Nursing Process - FON-II Total Slides PDF

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 th...

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 To identify a client’s health status and actual or 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 individual’s airway, breathing status, and circulation during a cardiac arrest.  1. ASSESSMENT 4. Time-lapsed reassessment: Several months after initial assessment. To compare the client’s current health status with the data previously obtained COMPONENTS OF ASSESSMENT  1. ASSESSMENT Collection of data Data collection is the process of gathering information about a client’s health status. It includes the health history, physical examination, results of laboratory and diagnostic tests, and material contributed by other health personnel.  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 assessment 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 “double-checked” or verified to confirm that it is accurate and complete.  1. ASSESSMENT Documentation of data To complete the assessment phase, the nurse records client data. Accurate documentation is essential and should include all data collected about the client’s health status.  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: “a clinical judgment concerning a human response to health conditions/life processes, or a vulnerability for that response, by an individual, family, group, or community.”  2. DIAGNOSIS Diagnosing is to : 1.Analyza data 2. Identify health problems,risks and strengths 3. Formulate diagnostic statement  Status of the Nursing Diagnoses “Status refers to the actuality or potentiality of the diagnosis or the categorization of the diagnosis” (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 clients’preparedness to implement behaviors 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 label Risk for Infection to describe the client’s health status.  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) – statement of the patients response Etiology (E) – factors 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 PES format & includes: 1.Problem (P) – Statement of the patient’s response 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 describes a patient’s 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 The patient’s nursing The patient’s medical diagnosis change as the diagnosis remains the same client’s response change for as long as the disease process is present Nursing diagnosis relate to Nurses are obligated to carry the nurse’s independent 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 alleviate the client’s health problems. It is the process of formulating client goals and designing the nursing interventions required to prevent, reduce, or eliminate the client’s health problems. 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 obtain new information and evaluate the client’s 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 each client’s care plan.  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. Nurses frequently use Maslow’s hierarchy of needs 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 performs to improve patient’s health. 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 Determining the nurse’s need for assistance 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. 2. Determining the Nurse’s Need for Assistance 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 ensure the client’s privacy, for example by closing doors, pulling curtains, or draping the client.  Process of Implementing 4. Supervising Delegated Care If care has been delegated to other health care personnel, the nurse responsible for the client’s overall 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 findings 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 (a)the client’s progress toward achievement of goals/outcomes and (b)the effectiveness of the nursing care plan.  References kozier & Erb’s Fundamental of Nursing ,8th 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. Educational Platform  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 – creation, the meaning of life, afterlife Values have major influence on person's behavior and attitude and serve as broad guidelines in all situations Educational Platform  Conti…. A belief system is 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. These beliefs 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 as: “Beliefs about what is desirable or good and what is undesirable or bad” Values are ideals that guide or qualify your personal conduct, interaction with others, and involvement in your career. Like morals, 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 to something; our values are often reflected in the way we live our lives. example I value freedom of speech. A coherent set of values adopted and/or evolved by a person, organization, or society as 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. Educational Platform  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 Educational Platform  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 Educational Platform  Types of values 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. Values are highly influenced by a person’s family, 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 as 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 transparency then they will work hard to be transparent. Values are one important element that affect who we are and how we behave towards Educational Platform 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. Follow their employing or contracting bodies’ procedures when they have 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 dignity is 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. Educational Platform  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 justice is 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 Educational Platform  PROFESSIONAL BEHAVIORS  Demonstrates understanding of cultures, beliefs, and perspectives of others.  Advocates for patients, particularly the most vulnerable,  Takes risks on behalf of patients and colleagues.  Mentors other professionals.  Plans care in partnership with patients.  Honors the right of patients and families to make decisions about health care,  Provides information so patients can make informed choices Educational Platform  PROFESSIONAL BEHAVIORS  Provides culturally competent and sensitive care.  Protects the patient's privacy.  Preserves the confidentiality of patients and health care providers.  Designs care with sensitivity to individual patient needs,  Provides honest information to patients and the public. Educational Platform  PROFESSIONAL BEHAVIORS  Documents care accurately and honestly.  Demonstrates accountability for own actions. Supports fairness and nondiscrimination in the delivery of care.  Promotes universal access to health care.  Encourages legislation and policy consistent with the advancement of nursing care and health care. Educational Platform Typical Value conflict and Sample Controvercies 1. Loyalty-honesty Should you tell your parents about your 2. Competition-Cooperation sester’s drug habit? 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. Security –excitement profession? 7. Generosity –material Is it desirable to give financial help to a success beggar? 8. Rationality –spontaneity Should you check the odds before placing a bet? 9. Tradition –novelty Should divorces be easily available? Educational Platform  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 Educational Platform  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 Educational Platform THANK YOU Educational Platform  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).Values Clarification: Ahandbook of practical strategies for teachers and students.New York: Hart. Fundamental of nursing by Erab & Koizer (6th edition) Educational Platform Self-concept /self Perception By: Ibne Amin (INS ),Khyber Medical university Educational Platform  Introduction Self Concept is 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. Educational Platform  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 Educational Platform  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 Dougles “1966”) Self-concept i s one’s mental image of oneself Self concept is the way we picture ourselves including our traits and values. Educational Platform  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 individual’s beliefs about his or her own personal attributes. It is basically the individuals image of the kind of person he or she is. Especially included in this are the awareness of being (What I am) and awareness of function (What I can do). Educational Platform  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 Educational Platform  The Role of the “Self” 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 Private, “Inner” Self Public, “Outer” Self Educational Platform  The ABCs of the Self The self concept includes 1.Cognitive aspect 2. Behavioral aspect 3. Affective aspect Educational Platform  COGNITIVE ASPECT: SELF SCHEMA Self schemas are “cognitive generalizations about the self, derived from past experience, that organize and guide the processing of self- related information” How do we come to know ourselves, develop a selfconcept, and maintain a stable sense of identity? Educational Platform  AFFECTIVE/EVALUATIVE ASPECT : SELF ESTEEM “self esteem reflects the perceived difference between an individual’s actual self concept (who I think I really am) and some ideal self image (who I would really like to be).” 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) Educational Platform  BEHAVIORALASPECT : SELF PERCEPTION 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. Educational Platform  Johari Window Known by self Unknown by Self Known by other OPEN ARENA BLIND SPOT FACADE Unknown byother HIDDEN UNKNOWN Educational Platform  Mechanism of Self Concept There are three mechanisms of self concept, Ideal Self} Real Self}………………Positive self concept 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 Educational Platform  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 Educational Platform Interrelationship of Components of Self-Concept Educational Platform Educational Platform  Components of Self-Concept 1.Self Identity A sense of personal identity is what sets one person apart as a unique individual. Identity includes a person’s name, gender, ethnic identity, family status, occupation, and roles. One’s personal identity begins to develop during childhood and is constantly reinforced and modified throughout life. Educational Platform  Components of Self-Concept 2.Body Image Body image is an attitude about one’s physical 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. Educational Platform  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-esteem when he or She receives positive Feed back from both Self and others. Educational Platform Components of Self-Concept Educational Platform  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. Educational Platform  Dimension of Self-Concept Self-knowledge — “Who am I?” Self-Expectation — “Who or what do I want to be?” Social Self – How person perceived by others? Self-Evaluation — “How well do I like myself?” Educational Platform  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 2. Person’s position with social groups 3. Qualities or traits that describe typical behaviours, feelings, moods and other characteristics (generous, hot-headed , ambitious, intelligent etc) Educational Platform  Self-Expectation Involves the “ideal” self --- 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. Educational Platform  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 Educational Platform  Self-Evaluation Self esteem is the evaluative and affective component of self concept The appraisal of oneself in relationship to others, events, or situations. Maslow’s Subsets of Esteem Needs: 1. Self-esteem (strength, achievement, mastery, competence,..) 2. Respect needs or the need for esteem from others Educational Platform  Development of Self-Concept Self-concept evolves throughout life and depends to an extent on an individual’s developmental level. 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. Child internalizes others people’s attitudes toward self. 4. Child or adult internalizes standards of society. Educational Platform  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 Educational Platform  DEVELOPMENT OF SELF-CONCEPT Various psychosocial theories have been developed to explain the development of self-concept. A discussion of Erikson’s theory of psychosocial development related to self-concept are follow. Erikson’s Theory Erikson’s (1963) psychosocial theory states that an individual’s development proceeds throughout life. Each of his eight developmental stages includes psychosocial tasks that need to be mastered. Educational Platform 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 Educational Platform 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 Educational Platform  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 Educational Platform  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. Move patient’s body respectfully if necessary. Respect patient’s privacy and sensibilities. Acknowledge and allow expression of negative feelings. Help patients recognize strengths and explore alternatives. Educational Platform  Conti … The following are activities that the nurse can teach the client to engage in to increase one’s self-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 Educational Platform  Self Concept and Nursing Process Assessment: i. Observe for behavior that suggest an alteration in the client’s self concept. ii. Assess the client’s cultural background. iii. Determine the client’s feelings and perceptions about changes in body image, self esteem or role iv. Assess the quality of the clients relationship. v. Assess the client’s coping skills. Educational Platform  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 Educational Platform  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. Educational Platform  Self Concept and Nursing Process Planning: i. Select therapies that strengthen or maintain the client’s coping skills. ii. Involve the client to ensure that realistic therapies are chosen. iii. Minimize stressors affecting the clients self concept. Educational Platform  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. Educational Platform  Health Promotion: The nurse may work with clients to help them develop healthy life style behaviors that contribute to positive self concept. To facilitate the client for adequate sleep and rest and stress reducing practices may make health self concept. E.g. Guided imaginary. Educational Platform  References Sandy L. Brook introduction to nursing self concept, 3rd edition. Michael A Bettman FACRS “Self Esteem article” 1960. Thomas Fuller Ph.D/MCPR “Teaching and Learning” 1955. John Jackson M.D “Manual of nursing research 6th edition. Bell state university school of nursing (2001). Clinical preceptor information, retrieved March 5, 2003. Educational Platform 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 symptom of 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 as "an 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 describe mechanisms 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 asserts that non- painful input closes the "gates" to painful input, which prevents pain sensation from traveling to the central nervous system. Therefore, stimulation by non-noxious input is able to suppress pain.  Types of Pain There are several ways to categorize pain. One is to separate it into acute and chronic pain. Acute pain typically comes on suddenly and has a limited duration. It's frequently caused by damage to tissue such as bone, muscle, or organs, and the onset is often accompanied by anxiety or emotional distress. Chronic pain lasts 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 by nerve damage, also called neuropathic pain. A third category is psychogenic pain, which is pain that is affected by psychological factors  Types of Pain Somatic pain, visceral pain and Cutaneous is another classification of pain based on origin Somatic pain comes from the skin. muscles, and soft tissues, while visceral pain comes 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 manage pain resulting from inflammation in response to tissue damage, chemical agents/pathogens (nociceptive pain) or nerve damage (neuropathic pain).  Pharmacological interventions WHO Analgesic Ladder Step 1-3 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 1 - WHO 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 – mild to moderate pain Compound analgesics are a combination of drugs in a 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 – severe pain Medications derived from morphine (or synthetic analogs) mimic the body’s own analgesic system and 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 include rubefacients, 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 , 22nd Nov ,2021 at [email protected] 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 the body’s dietary needs. Good nutrition – an adequate, well balanced diet combined with regular physical activity – is 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:  Protein  Fats  Carbohydrates  Protein According to the Dietary Reference Intakes published by the USDA 10% - 35% of calories should come from protein.  Used for building, growth or recovery of cells and tissues.  Major constituent of hormones, enzymes and antibodies.  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.  Source of energy (1 gram of fat yields 9 k cales).  Component of cell membranes.  Found in solid fats and liquid oils, in dairy products.  Absorbing certain vitamins ( like vitamins A, D, E, K )  Providing cushioning for the organs.  Fat 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.  Source of energy (1 gm yields 4 kcals).  Helps in digestion and bowel function.  All of the tissues and cells in our body can use glucose for energy.  Carbohydrates can be stored in the muscles and liver and later used for energy.  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.  Carbohydrate 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 in 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 Fats are mainly digested in the small intestine. The presence of fat in the small intestine produces hormone that stimulate the release of pancreatic lipase from the pancreas and bile from the liver which helps in the emulsification of fats into fatty acids and glycerol for absorption of fatty acids. Only freely dissolved monoglycerides and fatty acids can be absorbed. Nutritional consideration across life span  Babies – birth to six months of age Breast milk is preferred to infant formula where possible, as it contains many protective and immunological factors that benefit the baby’s development. 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 babies – six to 12 months of age Avoid cow’s milk as a drink in the first 12months. Small amounts can be used in cereals and custards. All milk used should be pasteurized.  Cont.  Avoid whole nuts, seeds or similar hard foods to reduce the risk of choking.  Feed babies during any illness and feed up after illness.  Give ample liquids if your baby has diarrhea.  Occasional exposure of the skin to sunlight is usually enough to provide a baby’s vitamin-D requirements.  Food for young children Once a child is eating solids, offer a wide range of foods to ensure adequate nutrition.  Young children are often selective with food, but should be encouraged to eat a wide variety of foods.  If a child is gaining inappropriate weight for growth, limit energy-dense, nutrient-poor snack foods. Increase your child’s physical activity.  Ensure your child has enough fluids, especially water.  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 nutrients, instead of just ‘empty calories. Milk, yoghurt and cheese (mostly reduced fat) should be included to boost calcium intake – this is especially important for growing bones.  Conti…  Adolescent girls should be particularly encouraged to consume milk and milk products.  Takeaway 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  Make a deliberate effort to keep physically active.  Reduce the amount of fats and salt in the daily diet.  Be careful to include foods rich in iron and calcium.  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:  Be as active as possible to encourage your appetite and maintain muscle mass.  Remain healthy with well-balanced eating and regular exercise.  If possible, try to spend some time outside each day to boost your vitamin D synthesis for healthy bones.  Limit foods that are high in energy and low in nutrients such as cakes, sweet biscuits and soft drinks.  Choose foods that are naturally high in fiber to encourage bowel health.  Limit the use of table salt, especially during cooking.  Eat foods that are nutrient dense rather than energy dense, including eggs, lean meats, fish, low-fat dairy foods, nuts and seeds, legumes, fruit and vegetables, wholegrain breads and cereals.  Manifestations of altered nutrition  Disturbed GI function  Obesity  Cardiovascular function  Underweight  Dry lips  Altered bowel patterns  Bleeding gums  Altered skin, teeth, hair,  Coated/ dry tongue  and mucous membrane  Vision loss  Overweight  Manifestations of altered nutrition  Dehydration  Impact on activities of  Fatigue daily living  Skin manifestations,  General manifestations, include, poor wound Weight loss healing  Muscle wasting  Ulceration  Muscle weakness  Dry skin  Assessment When conducting a nutrition assessment, check the patient for:  Skin integrity  Trouble chewing  Edema  Swallowing disorders  Electrolyte abnormalities  Weight history  Hand-grip strength (have  Height and weight the patient squeeze your  Measurement hand).  Nutritional-Metabolic Pattern Purpose  The purpose of assessing the client's nutritional- metabolic pattern is to determine the client dietary habits and metabolic needs.  The conditions of hair, skin, nails, teeth and mucous membranes are assessed.  Subjective Data Guideline Questions Dietary and Fluid Intake  Describe the type and amount of food you eat at breakfast, lunch, and supper on an average day  Do follow any certain type of diet? Explain.  What time do you usually eat your meals? CONT…  Do you find it difficult to eat meals on time? Explain.  What types of snacks do you eat? How often?  Do you take any vitamin supplements? Describe.  Do you consider your diet high in fat? Sugar? Salt? CONT…  Do you find it difficult to tolerate certain foods? Specify. What kind of fluids do you usually drink? How much per day?  Do you have difficulty chewing or swallowing food?  When was your last dental exam? What were the result?  Do you ever experience sore throat, sore tongue, sore gums? Describe CONT…  Do you ever experience nausea and vomiting? Describe.  Do you ever experience abdominal pains? Describe.  Do you use antacids? How often? What kind? CONDITION OF HAIR & NAILS  Describe the condition of your hair, nails?  Do you have excessively oily or dry hair?  Have you had difficulty with scalp itching or sores?  Do you use any special hair or scalp care products?  Have you noticed any changes in your nails? Color  Cracking? Shape? Lines? CONDITION OF SKIN  Describe the condition of your skin.  How well and how quickly does your skin heal?  Do you have any skin lesions? Describe?  Do you have excessive oily or dry skin?  Do you have any itching? What do you do for relief? METABOLISM  What would you consider to be your "ideal weight"?  Have you had any recent weight gains or losses?  Have you used any measures to gain or lose weight? Describe.  Do you have any intolerance to heat or cold?  Have you noted any changes in your eating or drinking habits? Explain. OBJECTIVE DATA  Assess the client's temperature, pulse, respirations, and height and weight.  ACTUAL DIAGNOSIS  Ineffective Thermo regulation.  Fluid Volume Deficit  Fluid Volume Excess  Altered Nutrition: Less than body requirements  Altered Nutrition: More than body requirements  Subcutaneous fat loss Related to malnutrition ACTUAL DIAGNOSIS  Ineffective Breastfeeding  Interrupted Breastfeeding  Ineffective Infant Feeding Pattern  Impaired Swallowing  Altered Protection  Impaired Tissue Integrity  Impaired Skin Integrity 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  Nurses are often the ones who spend the most time with the patient. Therefore, their understanding of nutrition is critical.  Educate 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  Daily measure weight.  Determine daily caloric need.  Teach the patient about importance of balanced diet.  Monitor intake and output daily.  Educate about importance of food to prevent from dehydration, and constipation.  Interventions  Give encouragement of individual to eat with others.  Avoid excessive use of alcohol and caffeine etc.  Give more protein and high fiber diet and avoid excessive carbohydrate and fats.  Exercise? Discuss nutritional requirement for a patient with;  Diarrhea  Constipation  Immobility  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 Educational Platform Anatomy of Digestive System Educational Platform  Anatomy of GIT. Human GI system is composed of; Mouth Pharynx Larynx Esophagus Stomach accessory organs. Small intestine Large intestine Anus. Educational Platform  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. Educational Platform  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 Educational Platform  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. Educational Platform Educational Platform  Types of Colon Movements Haustral Churning involves 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 Educational Platform  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 Educational Platform  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. Educational Platform  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. Educational Platform  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 Educational Platform  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 Educational Platform  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 rectum…recognized by seepage Flatulence:- Gas, Abdominal Distention & Pain Educational Platform  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 Educational Platform  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 organs…dullness over intestinal obstruction Palpation- Feel for masses, tenderness etc Educational Platform  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 Educational Platform 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, commode Educational Platform 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 Educational Platform  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. Educational Platform  Nursing Interventions for Fecal Incontinence Give balanced meals Note time of incontinence Toilet pt 30 – 60 min before usual time of incontinence Begin bowel training program…supp every 3 days Educational Platform  Nursing Interventions of Fecal Impaction Education/counseling/habit training Diet (fiber, lactose, fructose) Reduce caffeine intake Anal hygiene/skin care Digital removal of stool Educational Platform  N.Interventions for Flatulence Decreasing flatulus by avoiding gas – producing food, exercise, moving in bed and ambulation Glycerin Suppository Educational Platform  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 Educational Platform  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. Educational Platform Urinary Elimination Educational Platform Educational Platform  Anatomy of Renal system The renal system is composed of; – 2 kidneys – 2 ureters – 1 urinary bladder – 1 urethra Educational Platform  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) Educational Platform  cont’ Longitudinal section of the kidney shows following parts. Capsule Cortex. Medulla Hilum (3) Educational Platform Educational Platform Educational Platform  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. Educational Platform  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 urine – Adult: 250-450mL of urine – Children: 50-200mL of urine Educational Platform Educational Platform  Factors affecting voiding Growth and development Psychosocial factors Fluid and food intake Medications Muscle tone and activity Pathologic conditions Surgical and diagnostic procedures Educational Platform  Common Urinary Elimination Problems Urinary retention Urinary tract infections Urinary incontinence. Educational Platform  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 Hypospadias is a birth (congenital) defect in which the opening of the urethra is on the underside of the penis Educational Platform  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. Educational Platform  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. Educational Platform  Assessing Urine Color: transparent. Normal kidney produce urine at the rate of 40-60 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. Educational Platform  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. Educational Platform  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 Educational Platform  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 between urination to correct the client’s habit of 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 Educational Platform  Managing Urinary Incontinence (UI) Pelvic Muscle Exercises (PME) Referred to as perineal muscle tightening or Kegel’s exercises Streghthen pubococcygeal muscles and can increase the incontinent female’s ability to start and stop the stream of urine Educational Platform  Managing Urinary Incontinence (UI) Positive reinforcements Maintaining skin integrity Applying external urinary devices Educational Platform  Managing Urinary Retention Urinary catheterization Educational Platform  References 1:Olowu WA, Niang A, Osafo C, Ashuntantang G, Arogundade FA, Porter J, et al. lancet global health, 2016. 2:https://www.webmd.com › Kidney Stones › News. 3:http://www.newhealthadvisor.com/kidney-structure-and-function.html. 4: Porth, C., & Hannon, R. (2009). Porth pathophysiology. Philadelphia, Pa.: Lippincott Williams & Wilkins.Mein Educational Platform Educational Platform 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 Educational Platform  Rest and sleep pattern Sleep is a basic human need; it is a universal biological 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. Educational Platform Educational Platform  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 Educational Platform  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. Educational Platform  Sleep An altered state of consciousness in which the individual’s 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. Educational Platform  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. It’s a narrow term. 4. It’s a broader term. 5. Sleep is physical 5. Rest is spiritual 6. We need 7.5 hours of sleep per 6. We need 2 hours to 2-25 min day rest per day Educational Platform  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. Educational Platform  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) Educational Platform  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. NREM –Non rapid eye moment Stage -I Stage -II Stage -III Stage-IV Educational Platform  1. Characteristics of NREM Stage I Stage I is the stage of very light sleep and 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 Educational Platform  Characteristics of NREM Stage II Stage II is the stage of light sleep during 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 Educational Platform  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 Educational Platform  1. Characteristics of NREM STAGE 4 -this is the deepest sleep or delta sleep. It is the stage where the heart rate and respiratory rate drop 20-30% 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 Educational Platform  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 sleeper’s heart and respiratory rates drop 20% to 30% 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 Educational Platform  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 resembles that of the “ awake” state. This is not as 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%. Educational Platform  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 RR are increased and IRREGULAR. This sleep period becomes longer as the night progresses Educational Platform  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 Educational Platform