Medical Surgical Nursing 2024-2025 PDF

Prepared BY Medical Surgical Nursing Faculty Members 2024-2025 Contents  Outline: ‫جدول المحتويات‬ UNIT 1: THE NATURE OF NURSING:...................................................

Prepared BY Medical Surgical Nursing Faculty Members 2024-2025 Contents  Outline: ‫جدول المحتويات‬ UNIT 1: THE NATURE OF NURSING:..................................................................3 The Nature of Nursing:..............................................................................................3 Historical Perspectives of Nursing.............................................................................4 Contemporary Nursing Practice...............................................................................11 UNIT 2: THE NURSING PROCESS......................................................................15 UNIT3: HEALTH BELIEFS AND PRACTICES...................................................24 Health, Wellness, and Illness...................................................................................26 Vital signs.................................................................................................................37 Pain assessment and management...........................................................................57 UNIT4: INTEGRAL COMPONENTS OF CLIENT CARE...................................69 Asepsis (Infection Prevention and Control)...........................................................71 Medications administration......................................................................................87 UNIT 5: PROMOTING PHYSIOLOGIC HEALTH..............................................96 Elimination...............................................................................................................96 Bowel elimination..............................................................................................96 Urinary elimination..........................................................................................104 Oxygenation...........................................................................................................117 Fluid, electrolyte, and acid base balance...............................................................127 References..............................................................................................................144 Contents  UNIT 1: THE NATURE OF NURSING: Learning objectives: ✓ Discuss historical factors and nursing leaders who influenced the development of nursing. ✓ Explain the importance of continuing nursing education. ✓ Identify the four major areas of nursing practice. ✓ Explain the relationship between research and evidence-based nursing practice. ✓ Recognize the nurse’s legal responsibilities with selected aspects of nursing practice. ✓ Discriminate between negligence and professional negligence or malpractice. The Nature of Nursing: Throughout its distinguished history, nursing has had a significant effect on people's lives. As rapid change continues to transform the profession of nursing and the health care system with which it is intricately linked, nurses embrace broader opportunities to influence human well-being. Today, nurses bring knowledge, leadership, spirit, and vital expertise to expanding roles that afford increased participation, responsibility, and rewards. However, nursing continues to evolve, underlying all is a time-honored, fervent, and profound commitment to caring. Historical Perspectives of Nursing & Contemporary nursing practice. Learning outcomes: after completing this lecture, student will be able to: Discuss historical and contemporary factors influencing the development of nursing. Identify the essential aspects of nursing. Identify four major areas within the scope of nursing practice. Describe the roles of nurses. Describe the expanded career roles and their functions. Contents  Historical Perspectives of Nursing Women’s roles Traditional female roles of wife, mother, daughter, and sister included in care and nurturing of family members. From the beginning of time, women have cared for infant and children. This, nursing could be said to have its roots in the home. Additionally, women, who is in general occupied a subservient and dependent role, were called on to care for others in the community who were ill. Thus, traditional nursing role has entailed humanistic caring, nurturing, comforting, and supporting. War: throughout history, wars have accentuated the need for nurses ▪ During the Crimean war (1854-1856), the inadequacy of care given to soldiers led to public outcry in Great Britain. The role Florance nightingale played in addressing this problem is well known. She was asked by Sir Sidney Herbert of British War Department to recruit a contingent of female nurses to provide care to the sick and injured in the Crimea. Nightingale and her nurses transformed the military hospitals by setting up sanitation practice, such as hand washing and washing clothing regularly. The mortality rate in the BarrackHospital in Turkey was reduced from 42% to 2%. ◼ The arrival of World War I resulted in American, British, and French Womenrushing to volunteer their nursing services. These Nurses endured harsh environments and treat injuries not seen before. ◼ Progress in health care occurred during World War I, particularly in the field of surgery. For example, there were advancement in the use of anesthetic agent, infection control, blood typing, and prosthetics. World War II casualties created an acute shortage of care givers, and Cadet Nurse Corps (A lifetime education free for high school graduates WHO qualify) was established in response to a marked shortage of nurses. Also at that time, Auxiliary health care workers became prominent. Practical nurses, aides, and technicians provided nursing care under supervision of nurses. Contents  ◼ During the Vietnam War, approximately 90% 0f 11000 American military women stationed in Vietnam were nurses. Most of them volunteered to go to Vietnam right after they graduated from nursing school. This made them the youngest group of medical personnel ever to serve in wartime. Societal Attitudes ◼ Before the mid-1800s, nursing was without education, organization, or social status. Society’s attitudes about nursing during this period are reflected in the writings of Charles dickens. Dickens reflected his attitude toward nursesthrough his character Sairy Gamp. She cared for the sick by neglecting them, stealing from them, and physically abusing them. These nurses greatly influenced the negative image and attitude toward nurses up to contemporary times. ◼ In contrast angel of mercy image arose in the latter part of the 19th century, largely because of the work of Florance Nightingale during the Crimean War. After Nightingale brought respectability to nursing profession, nurses were viewed as noble, compassionate, moral, religious, dedicated, and self- sacrificing. ◼ Another image arising in the early 19th century is the image of doctor’s handmaiden. This image evolved when women had yet to obtain the right to vote, and when the medical profession increasing use of scientific knowledge that, at that time, was viewed as a male domain. Contents Nursing leaders Florence nightingale’s (1820- 1910) ◼ She was born to a wealthy and intellectual family. She visited Kaiserswerth in 1847, where she received 3 months’ training in nursing. In 1853 she studied in Paris with the sisters of Charity. ◼ Her achievements in improving the standards for the care of war casualties in the Crimea earned her the title Lady with the lamp. ◼ Her efforts in reforming hospitals and in producing and implementing public health policies also made her an accomplished Political nurse. ◼ Through her contributions to nursing education – perhaps her greatest achievement – she is also recognized as Nursing’s first scientist- theorist for her work Notes on Nursing. ◼ She developed nightingale training school for nurses, which opened in 1860. The school servedas a model for other training schools. Its graduates traveled to other countries to manage hospitals and institute nurse-training programs. ◼ FOR MORE READING: ◼ PRESS HERE ◼ https://youtu.be/q9hB5QWcrCM?si=vOJYM_zEmjjK1qpE ◼ Contents  Clara Barton (1821-1912) ◼ She was a schoolteacher who volunteered as a nurse during the American civil war. ◼ Barton is noted for role in establishing the American Red Cross, which linked with the International Red Cross. Linda Richards (1841- 1930) ◼ She was American first trained nurse. ◼ She also initiated the practice of nurses wearinguniforms. ◼ She is credited for her pioneer work in psychiatric and industrial nursing. Mary Mahoney (1845- 1926) ◼ She was the first African American professionalnurse. ◼ She constantly worked for acceptance of African American in nursing and for the promotion of equalopportunities. ◼ The American nurses association gives a Mary Mahoney Award biennially in recognition of significant contributions in interracial relationships. Contents  Lillian Wald (1867- 1940) ◼ She is considered the founder of public health nursing. ◼ Wald and Mary Brewster were the first to offer trained nursing services to the poor on the New York slums. Their home provided nursing services, social services, and organized educational and cultural activities. Livinia Doch (1858- 1956) ◼ She was a feminist, prolific writer, and politicalactivist. ◼ She participated in protest movements for women’s rights. ◼ She campaigned for legislation to allow nurses rather than physicians to control their profession. Margaret Sanger (1879- 1966) ◼ A public health nurse in New York, has had a lasting impact on women’s health care. ◼ Imprisoned for opening the first birth control information clinic in America, she considered the founder of Planned Parenthood. Contents  Mary Breckinridge (1881-1965) ◼ A notable pioneer nurse established the frontier nursing service in 1918. ◼ She worked with the American Committee for distributing food, clothing, and supplies to ruralvillages and taking care of sick children. ◼ She started one of first midwifery training schools in the United States. Rufaidah bint Sa’ad ▪ In the Islamic world, Rufaidah is considered the first professional nurse. ▪ Rufaidah bint Sa’ad, from the Bani Aslam tribe in Medina. She lived at the time of Muhammed and was among the first people in Medina to accept Islam. Rufaidah received her training and knowledge in medicine from her father, a physician, whom she assisted regularly. ▪ After the Muslim state was established in Medina, she treated the ill in her tent set up outside the mosque. During times of war, she led a group of volunteers to the battlefield and would treat casualties and injured soldiers. ▪ Rufaidah is described as a woman possessing the qualities of an ideal nurse: compassionate, empathetic, a good leader and a great teacher, passing on her clinical knowledge to others she trained. Contents  Nursing in Egypt: - Mohammed Ali constitutes the first nursing school in Egypt. He employed French physician named Klot Bek for of health status in Egyptian soldier, he interested in country organization and offering all medical services, then established hospital beside solider camp in the village of Abou Zaabal. Klot Bek was the manager of this school, he employed many French and Italian teachers, the student was using books that translating from the French language to Arabic language. In 1888 during the era of (Tawfik Basha) recalled two English sisters for learning student delivery and other obstetric disease. After the revolution of 1952, disunity of all foreigner teachers and starting in buildingmany nursing hospitals. During 1964 this program was replaced by another system of granting diploma in nursing after 3 years of teaching and after final exam was made for the student. The successful students had a chance for especially diploma in delivery and health visitors. Contents  Contemporary Nursing Practice An understanding of contemporary nursing practice includes a look at definitions of nursing, recipients of nursing, scope of nursing, setting of nursing practice, nurse practice acts, and current standards of clinical nursing practice. Definition of nursing Nightingale definition: Florence Nightingale defined nursing nearly 150 yearsago as (the act of utilizing the environment of the patient to assist him in his recovery). Nightingale considered a clean, well-ventilated, and quiet environment essential for recovery. Often considered the first nurse theorist, nightingale raised the status of nursing through education. Henderson definition of nursing: Virginia Henderson was one of the first modern nurses to define nursing. She wrote “The unique function of the nurse is to assist the individual, sick or well, in the performance of activities contributing ot health or its recovery”. In 1973 the American Nurses Association (ANA) described nursing practice as “direct, goal oriented and adaptable to the needs of the individual, the family and community during health and illness”. In 1980 the ANA changed his definition of nursing to this “Nursing is the diagnosis and treatment of human responses to actual or potential health problems” Contents  The most recent definition of professional nursing is much broader and states: Nursing is the protection, promotion, and optimization of health and abilities, preventions of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations”. Recipients of nursing Recipients of nursing are sometimes called consumers, sometimes patients, andsometimes clients. A consumer: is an individual, a group of people, or community that uses servicesor commodity. A patient: is a person who is waiting for or undergoing medical treatment and care. Usually, people become patients when they seek assistance because of illness or surgery. A client: is a person who engages the advice or services of another who is qualified to provide these services. The term client presents the receivers of health care as collaborators in the care, that is, as people who are also responsible for their own health. Scope of nursing practices Nurses provide care for three types of clients: individuals, families, and communities. Nursing practices involve four areas: 1. Promoting health and wellness Wellness is a process that engages in activities and behaviors that enhance quality of life and maximize personal potential. Nurses promote wellness in clients who are both healthy and ill. This may involve activities to enhance healthy lifestyles,such as improving nutrition and physical fitness, preventing accidents and injury in the home and workplace. 2. Preventing illness The goal of illness prevention programs is to maintain optimal health bypreventing disease. Nursing activities that prevent illness include immunizations, prenatal and infant care, and prevention of sexually transmitted disease. 3. Restoring health Restoring health focuses on the ill client, and it extends from early detection of disease through helping the client during the recovery period. Nursing activities include the following: Contents  Providing direct care to the ill person such as administering medication. Performing diagnostic and assessment procedures, such as measuring bloodpressure. Consulting with other health care professionals about client problems. Rehabilitating clients to their optimal functional level following physical ormental illness, injury, or chemical addiction. 4. Caring for dying This area of nursing practice involves comforting and caring for people of all ages who are dying. It includes helping clients live as comfortable as possible until death and helping support persons cope with death. Roles and functions of the nurse 1. Caregiver: the care giver role has traditionally included those activities thatassist the client physically and psychologically while preserving the client’s dignity. 2. Communicator: In the role of communicator, nurses identify client problems and then communicate these verbally or in writingto other members of health team. 3. Teacher: As a teacher, the nurse helps clients learn about their health and health care procedures they need to perform to restore health. 4. Client Advocate: A client advocate acts to protect the client. In this role thenurse may represent the client’s needs and wishes to other health professionals. They also assist clients in exercising their rights and help them speak up for themselves. 5. Counselor: counseling is the process of helping a client to recognize and cope with stressful psychological or social problems to develop improved interpersonal relationships, and to promote personal growth. It involves providing emotional, intellectual, and psychological support. The nurse focuses on helping the person develop new attitudes, feelings, and behaviors. 6. Change Agent: the nurse acts as a change agent when assisting clients to make modifications in their behavior. Nurses also often act to make changes in health care system, such as clinical care, if it is not helping a client to return to health. 7. Leader: A leader influences others to work together to accomplish a specific goal. 8. Manager: the nurse manages the nursing care of individuals, families, and communities. The nurse manager also delegates nursing activities to ancillary workers and other nurses, and supervises and evaluates their performance. Contents  9. Case manager: nurse case managers work with the multidisciplinary health care team to measure the effectiveness of the case management plan and to monitor outcome. 10. Researcher Consumer: Nurses often use research to improve client care. Nurses need to - have some awareness of the process of research as protect the right of human subjects, participate in the identification of significant research problems, be consumer of research finding. Contents  UNIT 3: THE NURSING PROCESS Learning objectives: Describe the phases of the nursing process. Identify major characteristics of the nursing process. Identify three methods of data collection and give examples of how each is useful. Identify the components of a nursing diagnosis. Compare nursing diagnoses, medical diagnoses. Identify essential guidelines for writing nursing care plans. Identify guidelines for implementing nursing interventions. Nursing Process Outlines: Definition of nursing process. Phases of nursing process. Characteristics of nursing process. Applying critical thinking to nursing process. Contents  Nursing process Introduction: The nursing process (NP) isa five-step clinical decision-making approach, whose purpose is to diagnose and treat human responses to actual and potential health problems. Nurses utilize a wholistic approach to care by providing each patient under their care with individualized care that focuses on the patient’s unique needs with the intention of solving the multiple problems that each patient faces. Definition nursing process is a critical thinking process that professionalnurses use to apply the best available evidence to caregiving and promoting human functions and responses to health and illness (American Nurses Association, 2010). Nursing process is a systematic method of providing care to clients. Purposes of nursing process: To identify a client’s health status and actual or potential health care problemsor needs. To establish plans to meet the identified needs. To deliver specific nursing interventions to meet those needs. Contents  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. ASSESSMENT Definition Assessment is the systematic and continuous collection, organization, validation, anddocumentation of data (information). Types of assessment, the four different types of assessments are; 1. Initial nursing assessment 2. Problem-focused assessment 3. Emergency assessment 4. Time-lapsed reassessment Contents  1. Initial nursing assessment: Performed within specified time after admission. To establish a complete database for problem identification.Eg: Nursing admission assessment 2. Problem-focused assessment: To determine the status of a specific problemidentified in an earlier assessment. Eg: hourly checking of vital signs of fever patient. 3. Emergency assessment: During emergency to identify any life- threatening situation. Eg: Rapid assessment of an individual’s airway, breathing status, and circulation during a cardiac arrest. 4. Time-lapsed reassessment: Several months after initial assessment. To compare the client’s current health status with the data previously obtained. Collection of data; Data collection is the process of gathering information about a client’s health status. It includes the health history, physical examination, results of laboratory and diagnostic tests, and material contributed by other health personnel. Types of Data; Two types: subjective data and objective data. 1. Subjective data, also referred to as symptoms or covert data are clear only to theperson affected and can be described only by that person. Itching, pain, and feelings of worry are examples of subjective data. 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 pressurereading is objective data. Sources of Data Sources of data are primary or secondary. 1. Primary: It is the direct source of information. The client is the primary sourceof data. 2. Secondary: It is the indirect source of information. All sources other than theclient are considered secondary sources. Family members, health professionals, records and reports, laboratory and diagnostic results are secondary sources. Methods of data collection the methods used to collect data are observation, Contents  interview, and examination. Observation: It is gathering data by using the senses. Vision, Smell and Hearing are used. Interview: An interview is a planned communication or a conversation with a purpose. Examination: The physical examination is a systematic data collection method to detect health problems. To conduct the examination, the nurse uses techniques of inspection, palpation, percussion, and auscultation. Organization of data; the nurse uses a format that organizesthe assessment data systematically. This is often referred to asnursing health history or nursing assessment form. Validation of data; the information gathered during the assessment is “double- checked” or verified to confirm that it is accurate and complete. Documentation of data; to complete the assessment phase, the nurse records client data. Accurate documentation is essential and should include all data collected about the client’s health status. DIAGNOSIS: After reviewing and validating a patient’s assessment, the next step of the nursing process is to form diagnostic conclusions to determine the patient’s problems and the level of care required. Diagnosis is the second phase of the nursing process. In this phase, nurses use critical thinking skills to interpret assessment data to identify client problems. North American Nursing Diagnosis Association (NANDA) define or refinenursing diagnosis. Definition the official NANDA definition of a nursing diagnosis is: “a clinical judgment concerning a human response to health conditions/life processes, orvulnerability for that response, by an individual, family, group, or community.” Status of the Nursing Diagnosis: The status of nursing diagnosis is actual, health promotion and risk. 1. An actual diagnosis is a client problem that is present at the time of the nursing assessment. 2. A health promotion diagnosis relates to clients’ preparedness to improve their health condition. 3. A risk nursing diagnosis is a clinical judgment that a problem does not exist, but the presence of risk factors indicates that a problem may develop if adequatecare is not given. Components of a NANDA Nursing Diagnosis A nursing diagnosis has three components: Contents  1) The problem and its definition. 2) The etiology. 3) The defining characteristics. Formulating Diagnostic Statements, the basic three-part nursing diagnosisstatement is called the PES format and includes the following: 1. Problem (P): statement of the client’s health problem (NANDA label) 2. Etiology (E): causes of the health problem. 3. Signs and symptoms (S): defining characteristics manifested by the client. E.G: Acute pain related to abdominal surgery as evidenced by patientdiscomfort and pain scale. Problem: Pain Etiology: Surgery of abdomen Signs and symptoms: Pain scale and discomfort of patient Differentiating nursing Diagnosis from medical Diagnosis. Nursing diagnosis Medical diagnosis A nursing diagnosis is a statement of nursing judgment A medical diagnosis is made by a that made by nurse,by their education, experience, and physician expertise, are licensed to treat Nursing diagnoses describe the human. Medical diagnoses refer to disease response to an illness or a healthproblem processes Nursing diagnoses may change as theclient’s responses A client’s medical diagnosis remains the change same for as long as the disease is present Examples Ineffective breathing pattern Asthma Activity intolerance Hypertension Acute pain Appendicitis Contents  Planning Planning involves decision making and problem solving. It is the process of formulating client goals and designing the nursinginterventions required to prevent,reduce, or eliminate the client’s health problems. TYPES OF PLANNING 1. Initial Planning: Planning which is done after the initial assessment. 2. Ongoing Planning: It is a continuous planning. 3. Discharge Planning: Planning for needs afterdischarge. Planning process Planning includes. Setting priorities Establishing client goals/desired outcomes Selecting nursing interventions and activities Writing individualized nursing interventionson care plans. Setting priorities The nurse begins 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. Contents  Establishing client goals/desired outcomes. After establishing priorities, the nurse set goals for each nursing diagnosis.Goals may be short term or long term. Guidelines for writing nursing care plans: 1. Date and sign the plan: the date is written because it is essential for evaluation. 2. Use standardized medical or English symbols and key words rather than complete sentences to communicate your ideas. As ABO (blood group), I&O (intake and output) and so on. 3. Be specific about expected timing of an intervention. 4. Refer to the procedure books or other sources of information rather than including all the steps on a written plan. 5. Ensure that the plan containing intervention for ongoing assessment of theclient. 6. Include plans for the client's discharge and home care needs. The nurse begins discharge planning as soon as the client has been admitted. Nursing interventions A nursing intervention is any treatment that a nurse performs to improve patient’s health. Writing Individualized Nursing Interventions After choosing the appropriate nursing interventions, the nurse writes them on the care plan. Nursing care plan is written or computerized information about the client’s care. IMPLEMENTATION Implementation consists of doing and documenting the activities. The process of implementation includes Implementing the nursing interventions and Documenting nursing activities EVALUATION Evaluation is a planned, ongoing, purposeful activity in which the nurse determines THE FOLLOWING: a) The client’s progress toward achievement of goals/outcomes and b) The effectiveness of the nursing care plan. Contents  The evaluation includes: Identifying criteria and standards Collecting evaluation data Interpreting and summarizing finding Documenting finding Care plan revision What the nurse can do after evaluation? 1- Terminate plan of care. 2- Modify plan of care. 3- Continue plan of care. FOR MORE CLICK HERE: https://youtu.be/NJkc08bFIJI?si=DDNviwfMHjk589Y- Contents  UNIT4: HEALTH BELIEFS AND PRACTICES Health, Wellness, and Illness Learning objectives: ✓ Identify influences on clients’ definitions of health, wellness, and well-being. ✓ Describe stages of illness. ✓ Compare various models of health. Contents  Health, Wellness, and Illness Outlines: Introduction Concepts of health and wellness Models of health and wellness Variables influencing health status, beliefs, and practices:Health promotion, wellness, and illness prevention. Contents  Health, Wellness, and Illness Introduction: In the past, most people have viewed good health or wellness as the opposite or absence of disease. Health and disease are not in static conditions, rather they are vital concepts that are subject to continuous evaluation and changes. Some people think of health and wellness as the same thing or at the very least as accompanying one another. However, health may not always accompany wellbeing: a person who has a terminal illness may have a sense of well- being, conversely, another person may lack a sense of well- yet be in a state of good health. Concepts of health and wellness: Health: The WHO defines health as a state of complete physical, mental and social well- being and not merely the absence of disease. In 1980, the American Nurses Association (ANA) defined health as a dynamic state of being in which the developmental and behavioral potential of an individual is fully realized possible. In this definition, health is more than a state or the absence of disease, it includes striving toward optimal functioning. Wellness: is a state of wellbeing. It means engaging in attitudes and behaviors that enhance quality of life and maximize personal potential. It includes self- responsibility, a goal, a dynamic and growing process, daily decision making, stress management, physical fitness, preventive health care, emotional health and other aspects of health. Models of health and wellness: Because health is such a complex concept, various researchers have developed models or paradigms to explain health and, in some instances, its relationship to illness or injury. Models of health include the clinical model, the role performance model, the adaptive model, the eudaimonistic model, the agent–host–environment model, and health–illness scales.. Contents  A. Clinical Model: The narrowest interpretation of health occurs in the clinical model. Individuals are viewed as physiologic systems with related functions, and health is identified by the absence of signs and symptoms of disease or injury. It is considered the state of not being “sick.” In this model, the opposite of health is disease or injury. Many practitioners have used the clinical model in their focus on the relief of signs and symptoms of disease and elimination of malfunction and pain. b. Role Performance Model: Health is defined in terms of an individual’s ability to fulfill societal roles, that is, to perform his or her work. Individuals usually fulfill several roles (e.g., mother, daughter, friend), and certain individuals may consider nonwork roles the most important ones in their lives. According to this model, individuals who can fulfill their roles are healthy even if they have health problems. For example, a man who works all day at his job as expected is healthy even though he has migraines. It is assumed in this model that sickness is the inability to perform one’s work role. c. Adaptive Model In the adaptive model, health is a creative process; disease is a failure in adaptation, or maladaptation. The aim of treatment is to restore the ability of the individual to adapt, that is, to cope. According to this model, extreme good health is flexible adaptation to the environment and interaction with the environment to maximum advantage. The focus of this model is stability, although there is also an element of growth and change. d. Eudaimonistic Model The eudaimonistic model incorporates a comprehensive view of health. Health is seen as a condition of actualization or realization of an individual’s potential. Actualization is the apex of the fully developed personality, described by Abraham Maslow. In this model, the highest aspiration of individuals is fulfillment and complete development, which is actualization. Illness, in this model, is a condition that prevents self-actualization. It includes stabilizing and actualizing tendencies in their definition of health: “the realization of human potential through goal-directed behavior, competent self-care, and satisfying relationships with others while adapting to maintain structural integrity and harmony with the social and physical environments.” e.Agent-host- environment (ecologic) model: The agent–host–environment model of health and illness, also called the ecologic model. The Contents  model is used primarily in predicting illness rather than in promoting wellness, although identification of risk factors that result from the interactions of agent, host, and environment are helpful in promoting and maintaining health. The model has three dynamic, interactive elements: 1. Agent. Any environmental factor or stressor (biological, chemical, mechanical, physical, or psychosocial) that by its presence or absence (e.g., lack of essential nutrients) can lead to illness or disease. 2. Host. Individual(s) who may or may not be at risk of acquiring a disease. Family history, age, and lifestyle habits influence the host’s reaction. 3. Environment. All factors external to the host that may or may not predispose the individual to the development of disease. The physical environment includes climate, living conditions, sound (noise) levels, and economic level. Social environment includes interactions with others and life events, such as the death of a spouse. Because each of the agent–host–environment factors constantly interact with the others, health is an everchanging state. When the variables are in balance, health is maintained; when the variables are not in balance, disease occurs. Health–Illness Scales: Health–illness scales (grids or continua) can be used to measure an individual’s perceived level of wellness. Health or wellness and illness or disease can be viewed as the opposite ends of a health continuum. How individuals perceive themselves and how others see them in terms of health and illness will also affect their placement on the continuum. The ranges in which individuals can be thought of as healthy or ill are considerable. I- Dunn’s High-Level Wellness Grid Dunn (1959) described a health grid in which a health axis and an environmental axis intersect. The health axis ranges from wellness to death and the environmental axis from a very favorable environment to a very unfavorable one. The optimal quadrant is when individuals have both peak wellness and a favorable environment but individuals with poor health can be protected if they are in a favorable environment in which social institutions provide support. II- Illness–Wellness Continuum Various authors have proposed illness–wellness or illness– health continua. Many models illustrate Contents  arrows pointing in opposite directions and joined at a neutral point. Movement to one side of the neutral point indicates increasing levels of health and wellness for an individual. This is achieved through health knowledge, disease prevention, health promotion, and positive attitude. In contrast, movement to the opposite side of the neutral point indicates progressively decreasing levels of health. Some people believe that a health continuum is overly simplistic when the real concepts are more complex than a linear diagram suggests. An alternative depiction shows multiple levels of health in interaction with episodic illness. The factors influencing health are internal and external: I-Internal variables: A- Biological dimension: 1- Heredity or genetics: certain disease such as diabetes, cardiovascular disease, cancer, renal diseases, and some forms of mental retardation can be inherited. 2- Sex: certain acquired and genetic diseases are more common in one sex than other as: A- Females most common disorders are osteoporosis, rheumatoid arthritis, systemic lupus erythematosus, thyroid disease, or uterine tumor. While B- most common disorders in males are stomach ulcer, abdominal hernia, respiratory diseases, heart diseases or testicular tumor. 3- Age: The distribution of disease varies with age as atherosclerotic heart disease is common in middle aged males, measles are common in children but rare in older people who have acquired immunity to them. B-Psychological (emotional) dimension: 1- Mind- body interactions can affect health status positively or negatively. Emotional responses to stress affect body function. As a student who is extremely anxious before a test may experience urinary frequency and diarrhea. Prolonged emotional distress may increase susceptibility to organic disease or precipitate it. Relaxation and biofeedback techniques are gaining wider recognition by individuals and health care professionals as people may learn biofeedback skills to reduce hypertension. 2- Self- concept: is how a person feels about self (self- esteem) and perceives the physical self (body image), needs, roles and abilities. It affects how people view and handle situations as anorexic woman who deprives herself of needed nutrients because she believes she is too fat even though Contents  she is well below an acceptable weight level. C-Cognitive (intellectual) dimension: 1- Life style: is a person general way of living that includes living conditions and individual patterns of behavior that are influenced by sociocultural factors and a personal characteristic. 2- Spiritual and religious beliefs can significantly affect health behavior as some fundamentalists believe that a serious illness is a punishment from God. II- External variables: A- Environment: Pollution of water, air and soil can affect life. Exposure to radiation can be hazardous to health as x-rays and the sun ultraviolet rays. B- Family and cultural beliefs: the family passes on patterns of daily living and lifestyles to offspring. As culture and social interactions influence how a person perceives, experiences and copes with health and illness. C- Social support networks: it influences the way the client defines and react illness,can also put the client at risk for specific diseases. Having a support network (family, friends or a confident) and job satisfaction helps people avoid illness. Support people also help the person confirm that illness exists. D- Economic variables (standard of living): Standard of living reflecting occupation, income and education is related to health, morbidity, and mortality. Hygiene, food habits and seeking health care advice and follow health regimens vary among high income groups as preventing illness. Health promotion, wellness, and illness prevention Health promotion, wellness strategies, and illness prevention activities as important forms of health care because they assist clients in maintaining and improving health. Levels of preventive care Health activities and nursing care occur at the primary, secondary, and tertiary level of prevention. 1- Primary Health Promotion and Illness Prevention Health promotion and disease or injury prevention. Contents  Examples of primary-level activities are immunization clinics, family planning services, providing poison-control information, and accident-prevention education. Other nursing interventions include teaching about a healthy diet, the importance of regular exercise, safety in industry and farms, using seat belts, and safer sex practices. 2- Secondary Health Promotion and Illness Prevention Early detection of disease with prompt diagnosis and treatment Examples of nursing activities at this level are: I. Assessing children for normal growth and development II. Encouraging regular medical, dental, and vision examination. III. Screenings (e.g., blood pressure, cholesterol, and skin cancer). IV. Direct nursing care interventions at the secondary level include administering medications and caring for wounds. 3- Tertiary Health Promotion and Illness Prevention Restoration and rehabilitation. It begins after an illness is diagnosed andtreated to reduce disability and to help rehabilitate patients to a maximum level offunctioning. Nursing activities on a tertiary level include: I. Teaching a patient with diabetes how to recognize and prevent complications. II. Using physical therapy to prevent contractures in a patient who has had a stroke or spinal cord injury. III. Referring a woman to a support group after removal of a breast because of cancer. Illness and disease Illness: is a highly personal state in which the person physical, emotional, intellectual, social, developmental, or spiritual functioning is thought to be diminished. It is not synonymous with disease and may or may not be related to disease. An individual could have a disease as a growth in the stomach and not feel ill. By the same token, a person can feel ill, that is, feel uncomfortable, and yet have no discernible disease. Contents  Disease: is an alteration in body functions resulting in a reduction of capacities or shortening of the normal life span. Illness and disease classification: there are many ways to classify illness anddisease. One of the most common is as acute or chronic. A- Acute illness is typically characterized by: 1- Severe symptoms of relatively short duration. 2- The symptoms often appear suddenly and subside quickly. 3- May or may not require intervention by health care professionals. 4- Some are serious as appendicitis may require surgical intervention but many ascold, subside without medical intervention. 5- Following it, most people return to their normal level of wellness. B-Chronic illness: is on that lasts for an extended period, usually 6 months or longerand often for the person life. - It usually has a slow onset and a period of remission (when the symptoms disappear) and exacerbation (when the symptoms reappear). - Ex. Of chronic illness are arthritis, heart and lung diseases and diabetes mellitus. Illness experience: Suchman (1972) describes five stages of illness. Not all clients' progress through each stage as the client who experiences a sudden heart attack is taken to the emergency room and immediately enters stages 3 and 4. Other clients may progress through only the first two stages and then recover. Stages are as follow: Stage I: symptom experience: A client is aware that something is wrong that leads to limitation in functioningbut doesn't suspect a specific diagnosis. Illness begins with vague, no specific symptoms that a person initially attempt to deny. Symptoms are described as a subjective (perceived by the patient) indication of organic psychic malfunctioning or change in the person condition that indicates some physical, Contents  mental state of disease.If the symptoms seem severe or life threatening, the client may seek care or deny symptoms exist. Stage II: Assumption of sick role: The individual now accepts the sick role and seeks confirmation from family and friends. Often people continue with self-treatment and delay contact with health care professionals as long as possible. During this stage, people may be excused fromnormal duties and role expectations. Emotional responses such as withdrawal, anxiety, fear, and depression are common depending on the severity of the illness, perceived degree of disability and anticipated duration of the illness. When symptomspersist or increase, the person is motivated to seek professional help. Stage III: Medical care contact: If the symptoms persist and become severe or require emergency care, the client motivated to seek professional health services. In this stage, the client seeks expert acknowledgement of the illness, its treatment, an explanation of the symptoms,the cause, course, and the implications of the illness for the future health. A health professional may determine they don't have an illness or that illness is present and may be life threatening. Then client may accept or deny this diagnosis, depending on variables that affect illness behavior. If the clients accept the diagnosis, they follow the physical treatment plan but if he denies the diagnosis, they consult several health care providers until they find who makes the desired diagnosis or until they accept the initial diagnosis. Stage IV: Dependent client role: After accepting the illness and seeking treatment, the client becomes dependent on the professional for help. People vary greatly in the degree of ease with whichthey can give up their independence. For some clients, illness may meet dependence needs that have never been met and thus provide satisfaction. Other people have minimal; dependence needs and do everything possible to return to independence functioning. A few may even try maintaining independence to the detriment of their recovery. Stage V: Recovery or rehabilitation: During this stage the client is expected to relinquish the dependent role and resume former roles and responsibilities. For people with acute illness, the time as an ill person is generally short and recovery is usually rapid. People who have long termillness and must adjust their lifestyle may find recovery more difficult. For clients with permanent disability, this final stage may require Contents  therapy to learn how to make major adjustment in functioning. Contents  UNIT 5: ASSESSING HEALTH Vital Signs Pain Assessment and Management Title: Vital Signs. Subject objectives: Describe factors that affect the vital signs, and accurate measurement of them. List characteristics that should be included when assessing vital signs. Describe methods of measuring vital signs. Identify the variations in normal body temperature, pulse, respiration, and blood pressure. Formulate nursing care plan to adult individuals with common problems relatedto vital signs. Formulate health education for patient with fever. For more information click here: https://youtu.be/gUWJ-6nL5-8?si=iO9g4cohdzZBLVum Contents  Outlines 1. Time to assess vital signs. 2. Body temperature. 3. Factors affecting the body’s heat production. 4. Regulation of body temperature. 5. Factors affecting body temperature. 6. Alteration in body temperature. Pulse: 1. Factors affecting pulse. 2. Pulse sites. Respiration: 1. Mechanics and regulation of breathing. 2. Factors affecting respiration. 3. Characteristic of respiration. 4. Alteration in breathing pattern. Blood pressure: 1. Determinant of blood pressure. 2. Factors affecting blood pressure. 3. Classification of Blood Pressure. Contents  Vital signs Introduction Vital signs include body temperature, pulse, respiration and blood pressure, these data are called vital signs because of it is importance. The ability to obtain accurate measurement is critical. because vital signs are an indication of basic body functioning. Measurement of vital signs is a quick &efficient way of monitoring a client's condition or identifying problems and evaluating the client's response to intervention. Time to assess vital signs. 1. During admission and discharge to a health care agency. 2. On a routine schedule as determined by agency policy. 3. Before and after invasive diagnostic procedure. 4. When a client has a change in health status or reports symptoms such as chestpain or feeling hot or faint. 5. Before and after any surgical procedure. 6. Before and after administration of medication that could affect the cardiovascular or respiratory system as digitalis. 7. Before and after any nursing intervention that could affect the vital signs asambulating a client who has been on bed rest. Body temperature Body temperature reflects the balance between heat produced and heat lostfrom the body, and it is measured in heat units called degree. There are two kinds of body temperature: core and surface temperature. Core temperature: is the temperature of the deep tissues of the body, such as abdominal cavity and pelvic cavity. It remains relatively constant. Surface temperature: is the temperature of the skin surface, subcutaneous tissue, and fat. It rises and falls in response to the environment changes. Contents  The body continually produces heat as a by-product of metabolism. When the amount of heat produced by the body equals the amount of heat lost, the person is in heat balance. Factors affecting the body’s heat production: 1. Basal metabolic rate (BMR) is the rate of energy utilization in the bodyrequired to maintain essential activities such as breathing. Metabolic rates decrease with age. In general, the younger the person, the higher the metabolic rate. 2. Muscle activity including shivering, increases the metabolic rate. 3. Thyroxine output: increased thyroxine output increases the rate of cellularmetabolism throughout the body. This effect is called chemical thermogenesis, the stimulation of heat production in the body through increased cellular metabolism. 4. Epinephrine, norepinephrine, and sympathetic stimulation / stress response. These hormones immediately increase the rate of cellular metabolism in many body tissues. 5. Fever increases the cellular metabolic rate and thus increases the body temperature future. Ways of heat loss: Heat is lost through four processes: radiation, conduction, convection, and evaporation. Radiation: - Exposure to a cold environment increases radiant heat loss. All objects with temperatures above absolute zero constantly lose heat through infrared heat rays. Covering the body with closely woven dark fabric can reduce radiant heat loss. Contents  Conduction: - is the transfer of heat from one object to another. The bodyloses a considerable amount of heat to the air through conduction. It can also loseheat to water during swimming or tepid baths. Convection: - is the loss of heat through air currents such as a fan. Evaporation: - causes heat loss as water is transformed to a gas. Examples of evaporation include diaphoresis (sweating) during strenuous exercise or when one is febrile. Temperature measurement: Normal body temperature when measured orally usually ranges between 36.5° and 37.5°C (97.6° and 99.6°F). This state of normal body temperature in a client is termed afebrile. Nurses are required to use both scales occasionally and convert between thetwo measurements. To convert Fahrenheit to Centigrade uses the formula: C= (F-32) X 5/9. EX. When Fahrenheit reading is 100.C= (100-32) X5/9 = 68 X 5/9 = 37.8. To convert Centigrade to Fahrenheit, use the formula: F=(C X 9/5) + 32 EX. When centigrade reading 40.F= (40 X 9/5) +32 = 72+32= 104. Regulation of body temperature Body temperature regulation requires the coordination of many body systems. For the core temperature to remain steady, heat production must equal heat loss. The hypothalamus, located in the pituitary gland in the brain, is the body’s built-in thermostat. When hypothalamus sense increase in body temperature impulses is sent to reduce body temperature by sweating and vasodilatation. If hypothalamus senses the body temperature is low signals are sent out to increase heat production by muscle shivering or heat conservation by vasoconstriction to maintain homeostasis (state of dynamic equilibrium). Factors affecting body temperature: 1. Age. The infant is greatly influenced by the temperature of the environment and must be protected from extreme changes. Many older people, particularly those over 75 years, are at risk of hypothermia for a variety of reasons, such as inadequate diet, loss of subcutaneous fat, lack of activity, and reduced thermoregulatory efficiency. Elderly is also sensitive to extremes in the environmental temperature due to decreased thermoregulatory controls. Contents 2. Diurnal variations (circadian rhythms). Body temperatures normally change throughout the day, varying as much as 1.0˚C between the early morning and thelate afternoon. The point of highest body temperature is usually reached between4:00 PM and 6:00 Pm, and the lowest point is reached during sleep between4:00 Am and 6:00 AM. 3. Exercise. Hard work or strenuous exercise can increase body temperature to as high as 38.3˚C to 40˚C measured rectally. 4. Hormones. Women usually experience more hormone fluctuations than men. In women, progesterone secretion at the time of ovulation raises body temperature by about 0.3˚C to 0.6˚C above basal temperature. 5. Stress. Stimulation of sympathetic nervous system can increase the productionof epinephrine and norepinephrine, thereby increasing metabolic activity and heat production. 6. Environment. Extreme in environmental temperatures can affect a person’s temperature regulatory systems. If the temperature is assessed in a very warm room and the body temperature cannot be modified by convection, conduction, or radiation, the temperature will be elevated. Similarly, if the client has been outside in cold weather without suitable clothing, the body temperature may below. Common site of measuring body temperature is: 1. Oral most accessible site, comfortable for patients, no need for position changes. 2. Rectal more reliable when oral temperature cannot be obtained. 3. Axillary considered safe but not very accurate. 4. Tympanic membrane 5. Skin/temporal artery. Contents  Contraindication of oral temperature: 1. Infants and children. 2. Unconscious patients. 3. Inflammation or surgery of mouth. 4. Persistent frequent coughing. Alteration in body temperature. Temperature elevations are frequently the first signs of illness the term pyrexia,febrile, and hyperthermia are used to describe a condition of having above normal temperature, elevating body temperature destroy invading bacteria. A very high fever,such as 41˚C is called hyperpyrexia, may damage normal body cells, therefore intervention is necessary. The client who has a fever is referred to as febrile; the one who doesn’t is afebrile. Types of fever 1- Constant fever. Body temperature remains elevated consistently and fluctuate very little. 2- Intermittent fever. Body temperature rise and fall; for example, body temperature is subnormal or normal in the morning and is elevated in the afternoon. 3- Remittent fever. Are like intermittent fever except doesn't return tonormal at all until the patient becomes well. Clinical Signs and Symptoms of Elevated Body Temperature Thirst Anorexia Flushed warm skin. Irritability or excessive sleepiness. Headache Glassy eyes or photophobia (sensitivity to light) or both Increased heart rate and respiratory rate. Increased perspiration. Contents  Disorientation, progressing to convulsions in infants and children. Nursing intervention for clients with fever Monitor vital signs at least every 4 hours. Monitor white blood cell count, hematocrit value, and other laboratory reportsfor indications of infection or dehydration. Remove excess blankets when client feels warm but provide extra warmth whenthe client feels chilled. Encourage fluids intake (e.g., 2500- 300 ml per day) if not contraindicated tomeet the increased metabolic demands and prevent dehydration. Measure intake and output Reduce physical activity to limit heat production. Administer antipyretic as doctors ordered. Provide oral hygiene to keep the mucus membranes moist. Provide bath to increase heat loss through conduction. Provide dry clothing and bed linens. Hypothermia It is a core body temperature below the lowest limit of normal. Death is a risk when the body temperature falls below 35C. Patient may intentionally place in hypothermia for a surgical procedure. The three physiologic mechanisms of hypothermia are (a) excessive heat loss. (b) Inadequate heat production as in patient with hypothyroidism and (c) impaired hypothalamic thermoregulation. The clinical signs of hypothermia Decreased body temperature, pulse, and respirations. Severe shivering Contents  Feeling of cold and chills Pale, cool, and waxy skin Hypotension Decreased urinary output. Lack of muscle coordination Disorientation Drowsiness progressing to coma. Nursing intervention for clients with hypothermia Provide a warm environment (close door and window) or eliminate drafts. Remove wet clothes and replace with dry ones. Cove patient with more warm blankets Keep limbs close to body. Cover the client scalp. Supply warm oral or intravenous fluids. Apply warming pads. Contents  Pulse Introduction Pulse is a rhythmic beating or vibrating movement in the body, it signifies the regular, recurrent expansion and contraction of an artery produced by the waves of pressure that are caused by the ejection of blood from the left ventricle of the heart as it contracts. Each pulse beat corresponds to a contraction of the heart. The pulse is a wave of blood created by contraction of the left ventricle of the heart. Cardiac output is the volume of blood ejected from the heart per minutes. It equals stroke volume multiply by the heart rate per minute. For example, 65 ml x 70 beats per minute = 4.55 L per minute. When an adult is resting the heart pumps about 5 liters of blood each minute. Stroke volume equal amount of blood ejected from the heart each beat. A peripheral pulse is a pulse located away from the heart, for example, in the foot or wrist. The apical pulse in contrast, is a central pulse, that is, it is located at the apex of the heart. It is also referred to as the point of maximal impulse (PMI). In a healthy person, the pulse reflects the heartbeat. However, in some types of cardiovascular disease, the heartbeat and pulse rates can differ. For example, a client’s heart may produce very weak or small pulse waves that are not detectable in aperipheral pulse far from the heart. Factors affecting pulse: 1- Age: as age increases, the pulse rate gradually decreases overall. 2- Gender: after puberty, the average male pulse rate is slightly lower than the females. 3- Exercise: pulse rate normally increases with activity. The rate of increase in the professional athlete is often less than in the average person because of greater cardiac size, strength, and efficiency. 4- Fever: the pulse rate increases (a) in response to the lowered blood pressure that results from peripheral vasodilatation associated with elevated body temperature and (b) because of the increased metabolic rate. 5- Medications: Some medications decrease it and others increase it as digitalis slow heart rate, while epinephrine increase it. 6- Hypovolemia: blood loss increases the pulse rates. In adults the loss of blood volume results in an adjustment of the heart rate to increase blood pressure as the body compensate for the lost blood Contents  volume. Adults can usually lose up to 10% of their normal circulating volume without adverse effect. 7- Stress: in response to stress, sympathetic nervous stimulation increases theoverall activity of the heart. Stress increases the rate as well as the force of the heartbeat. Fear and anxiety as well as the perception of severe pain stimulate thesympathetic system. 8- Position changes: when a person assumes a sitting or standing, blood usually pools in the dependent vessels of the venous system that results in a transient decrease in the venous blood return to the heart and subsequent reduction in blood pressure and increase in heart rate. 9- Pathology: certain diseases such as some heart conditions or those that impair oxygenation can alter the resting pulse rate. 10- Metabolism: Certain diseases as chronic hyperthyroidism increase heart rate. Pulse sites 1- Temporal: Over temporal bone of head, above and lateral to eye 2- Carotid: at the site of the neck between the trachea and sternocleidomastoid muscle. 3- Apical: at the apex of the heart. In an adult this is located on the left side of the chest, about 8 cm to the left of the sternum and at the fourth, fifth or sixth intercostal space. Contents 4- Brachial: at the inner aspect of the bicep’s muscles at of the arm or medially toantecubital fossa. 5- Radial, where the radial artery runs along the radial bone or thumb side of theinner aspect of the wrist. 6- Femoral, where the femoral artery passes alongside the inguinal ligament. 7- Popliteal, where the popliteal artery passes behind the knee. 8- Posterior tibial on the medial surface of the ankle, where the posterior tibialartery passes behind the medial malleolus. 9- Pedal (Dorsalis pedis): over the bone of the foot, on imaginary line drawn fromthe middle of the ankle to the space between the big and second toes. Characteristic of pulse: Rate. In adults, the normal rate is 60 to 100 pulsations per minute. Adult pulse rates above 100 beats per minute are called tachycardia. Sympathetic nervous system activation may result in tachycardia rates. Tachycardia rates also may occur when the impulse for cardiac contraction comes from an abnormal site in the heart that stimulates the heart to beat faster. An abnormally slow pulse rate is called bradycardia. In adults, a pulse rate below 60 beats per minute is considered bradycardia. Rhythm. Normally, cardiac contractions occur at evenly spaced intervals, resulting in a regular rhythm. Infants and children often have increased pulse rates during inspiration and decreased rates during expiration. Heart disease, medications, or electrolyte imbalances may alter the heart’s normal rhythmic beating, causing an irregular pulse. A pulse with an irregular rhythm is referred to as dysrhythmia or arrhythmia. Quality (pulse volume):- Pulse quality generally refers to the strength of pulsation and may be rated on a numeric scale. It can range from absent to bounding. Contents  Document the pulse strength as bounding (4+); full or strong (3+); normal andexpected (2+); diminished or barely palpable (1+); or absent (0). Pulse volume variation Number type Description 0 Absent pulse None felt 1+ Thread pulse Difficult to feel; non palpable when only slight pressure applied 2+ Weak pulse Somewhat stronger than a thread pulse ,but not palpable when slight pressure applied 3+ Normal pulse Easily felt but not palpable when moderate pressure applied 4+ Bounding pulse Feels full and spring-like even under moderate pressure. Pulse deficit. The difference between the apical and radial pulse rates, this can confirmed by one nurse listening to apical pulse, and a second nurse palpating the radial pulse at the same time for full minutes using the same watch. Pulse deficit signifies that the pumping action of the heart is faulty or there is a peripheral vascularissue, this is often seen in atrial fibrillation. Nursing interventions for the patient with an abnormal pulse. 1- If pulse is weak or difficult to palpate. Perform complete assessment of allperipheral pulses. 2- Observe for other symptoms associated with altered tissue perfusion as pallor orcyanosis. 3- Observe for factors associated with decrease cardiac output as hemorrhage, orhypothermia. 4- If the pulse is weak or irregular assess apical pulse for a pulse deficit. 5- If pulse is below normal ask patient if he takes digoxin drug. 6- If pulse is above normal assess for related data as pain, fear, recent exercise, lowblood pressure or elevated body temperature. Respiration Contents  Respiration: is the act of breathing. Inhalation or inspiration refers to the intake of air into the lungs. Exhalation or expiration refers to breathing out or movement of gases from the lungs to the atmosphere. Ventilation is also used to refer to the movement of air in and out of the lungs. Internal respiration is exchange of gas at the tissue level caused by cellular oxidation and exchange that occur in the alveoli of the lung. External respiration is the breathing movement of the patient that is observed. There are basically two types of breathing: costal (thoracic) breathing and diaphragmatic (abdominal breathing). Costal breathing involves the external intercostal muscles and other accessory muscles, such as the sternocleidomastoid muscles. It can be observed by the movement of the chest upward and outward. Diaphragmatic breathing Involves the contraction and relaxation of the diaphragm, and it is observed by the movement of the abdomen, which occurs because of the diaphragm’s contraction and downward movement. Mechanics and regulation of breathing During inhalation, the following processes normally occur: the diaphragm contracts, the ribs move upward and outward, the sternum moves outward, thus enlarging the thorax and permitting the lungs to expand. During exhalation, the diaphragm relaxes, the ribs move downward and inward, and the sternum moves inward, thus decreasing the size of thorax as the lungsare compressed. A normal breathing is carried out automatically and effortlessly. Respiration is controlled by (a) respiratory center in the medulla oblongata and pons of the brain chemoreceptors located centrally in the medulla and peripherally in the carotid and aortic bodies. These centers and receptors respond to changes in the concentrations of oxygen, carbon dioxide, and hydrogen in the arterial blood. Factors affecting respiration. Exercise: increases rate and depth to meet the body’s need for additional oxygen andto rid the body of CO2. Contents  Acute Pain: Pain alters rate and rhythm of respirations; breathing becomes shallow. Anxiety: increases respiration rate and depth because of sympathetic stimulation. Smoking: Chronic smoking changes pulmonary airways, resulting in increased rateof respirations at rest when not smoking. Body Position: A straight, erect posture promotes full chest expansion. A stooped or slumped position impairs ventilatory movement. Lying flat prevents full chest expansion. Medications Opioid analgesics, general anesthetics, and sedative hypnotics depress rate anddepth. Bronchodilators slow rate by causing airway dilation. Neurological Injury Injury to brainstem impairs respiratory center and inhibits respiratory rate andrhythm. Hemoglobin Function Decreased hemoglobin levels (anemia) reduce oxygen-carrying capacity of theblood, which increases respiratory rate. Abnormal blood cell function (e.g., sickle cell disease) reduces ability ofhemoglobin to carry oxygen, which increases respiratory rate and depth. Characteristic of respiration: Normal breathing is almost invisible, effortless, automatic, and regular, also isnot audible except with the aid of a stethoscope. Rate: a) Bradypnea: slow than normal respiratory rate at rest. b) Normal: 14-20 cycle/minute. c) Tachypnea: rapid respiratory rate. Rhythm: regular or irregular Depth: deep, normal, and shallow. Alteration in breathing pattern: Contents  Bradypnea: Rate of breathing is regular but abnormally slow (less than 12breaths/min). Tachypnea: Rate of breathing is regular but abnormally rapid (greater than 20breaths/min). Hyperpnea: Respirations are labored, increased in depth, and increased in rate(greater than 20 breaths /min) (occurs normally during exercise). Apnea: Respirations cease for several seconds. Persistent cessation results inrespiratory arrest. Dyspnea: difficult and labored breathing during which the individual has a persistent,unsatisfied need for air and feels distressed. Orthopnea: ability to breathe only in upright sitting or standing positions. Cheyne-Stokes respiration: there is alternating periods of apnea and deep rapidbreathing. Kussmaul respiration : is deep rapidlabored breathing. Nursing intervention for patient with abnormal respirations: 1- If respiratory rate is abnormal report to health care provider. Contents  2- Observe for related signs and symptoms as cyanosis, dyspnea. 3- Consider possible effect of medication or anesthesia. 4- Assist patient to supported sitting position. 5- Provide Oxygen as ordered by health care provider. Blood pressure Arterial blood pressure is a measure of the pressure exerted by the blood as it flows through the arteries. There are two blood pressure measures. The systolic pressure is the pressure of the blood as a result of contraction of the ventricles, that is, the pressure of the height of the blood wave. The diastolic pressure is the pressure when the ventricles are at rest, diastolic pressure, and then is the lower pressure, present at all times within the arteries. E.g. BP: 130/ 80Pulse Pressure = 50 pulse pressure. Mean Arterial Pressure (MAP): MAP= 1/3 systolic + 2/3 diastolic e.g. BP:120/90MAP= 40 + 60 = 100 A normal pulse pressure is about 40 mm hg can be as high as 100 mm hg during exercise. Elevated pulse pressure occurs in arteriosclerosis. A low pulse pressure occurs in sever heart failure. Blood pressure is measured in millimeters of mercury (mm hg)and recorded as a fraction: systolic pressure over the diastolic pressure. Physiologic factors determine blood Pressure: Arterial blood pressure is the result of several factors: the pumping action ofthe heart, the peripheral vascular resistance (the resistance supplied by the blood vessels through which the blood flows), and the blood volume and viscosity. The pumping action of the heart When the pumping action of the heart is weak, less blood is pumped into arteries (lower cardiac output), and the blood pressure decreases. When the heart’s pumping action is strong and the volume of blood pumped into the circulation increases (higher cardiac output), the blood pressure increases. Hemodynamic factors affecting B.P.The peripheral vascular resistance Peripheral resistance can increase blood pressure. The diastolic pressure especially is affected. Some factors that create resistance in the arterial system are thecapacity of the arterioles Contents  and capillaries, the compliance of the arteries, and the viscosity of the blood. 1- Cardiac output: It is volume of blood ejected from left ventricle and pumpedby the heart during one minute as the cardiac output increase, when the volume increases (as rapid intravenous infusion) more blood is pumped against arterial wall causing elevation in blood pressure. When blood volume decrease (ashemorrhage or dehydration), the blood pressure decreases because of decreased fluid in the arteries. 2- Arterial diameter: The smaller the vessel lumen size the greater the peripheral resistance the greater the blood pressure. Normally, the arterioles are in a state of partial constriction. Increased vasoconstriction, such as occurs with smoking, raise the blood pressure, where decreased vasoconstriction lowers the blood pressure. 3- Arterial compliance (elasticity): If the elastic and muscular tissues of thearteries are replaced with fibrous tissue, the arteries lose much of their ability to constrict and dilate leads to increase blood pressure. This condition, most common in middle-aged and elderly adults, is known as arteriosclerosis. 4- Viscosity of the blood: The more viscous the blood the higher the blood pressure. That is, when the proportion of red blood cells to the blood plasma is high. This proportion is referred to as the hematocrit. The viscosity increases markedly when the hematocrit is more than 60% to 65%. Factors affecting blood pressure: 1. Age. Newborns have a mean systolic pressure of about 75 mm hg. The pressure rises with age, reaching a peak at the onset of puberty, and then tend to decrease somewhat. In elders, elasticity of arteries is decreased- the arteries are more rigid. This produces an elevated systolic pressure. Because the walls no longer retract as flexibly with decreased pressure, the diastolic pressure may also be high. 2. Exercise. Physical activity increases the cardiac output and hence the blood pressure; thus 20 to 30 minutes of rest following exercise is indicated before the resting blood pressure can be reliably assessed. 3. Stress. Stimulation of the sympathetic nervous system increases cardiac output and vasoconstriction of the arterioles, thus increasing the blood pressure; however, sever pain can Contents  decrease blood pressure greatly by inhibiting the vasomotor center and producing vasodilatation. 4. Race. African American males over 35 years have higher blood pressures than European American males of the same age. 5. Gender. After puberty, females usually lower blood pressure than males of the same age; this difference is thought to be due to hormonal variations. After menopause, women have higher blood pressures than before. 6. Medication. Some medications directly or indirectly affect blood pressure. Before blood pressure so asks the patient is receiving antihypertensive or other cardiac medications, which lower blood pressure. Another class of medications affecting blood pressure is opioid analgesics, which can lower it. Vasoconstrictorsand an excess volume of intravenous pressure fluids increase it. 7. Diurnal variations. Pressure is usually lowest early in the morning, when the metabolic rate is lowest, then rises throughout the day and peaks in the late afternoon or early evening. 8. Disease process. Any condition affecting the cardiac output, blood volume, blood viscosity, and or compliance of the arteries has a direct effect on the bloodpressure. Classification of Blood Pressure Diastolic BP Category Systolic BP MM HG MM HG Normal < 120 And < 80 Prehypertension 120-139 Or 80-89 Stage 1 Hypertension 140–159 Or 90–99 Stage 2 Hypertension 160 Or 100 From the seventh report of the joint national committee for the detection, evaluation, and treatment of high blood pressure by national institute of health, national heart, lung, and blood institute, 2004 Contents  Hypertension A blood pressure that is persistently above normal is called hypertension. A single elevated blood pressure reading indicates the need for reassessment. Hypertension cannot be diagnosed unless an elevated blood pressure is found when measured twice at different time. It is usually a symptomatic and is often a contributing factor to myocardial infraction. An elevated blood pressure of unknown cause is called primary hypertension. An elevated blood pressure of known cause iscalled secondary hypertension. Individuals with diastolic blood pressures of 80 to89 mm hg or systolic blood pressures of 120 to 139 mm hg should be considered pre- hypertensive and, without intervention, may develop cardiac disease. When systolic and diastolic blood pressures fall into different categories, the higher category should be used to classify blood pressure level. For example, 160/80 mmHg would be stage2 hypertension. Factors associated with hypertension: - include thickening of arterial walls, which reduces the size of arterial lumen and inelasticity of the arteries as well as suchlifestyle factors ass cigarette smoking, obesity, heavy alcohol consumption, lack of physical exercise, high blood cholesterol levels, and continued exposure to stress. Follow up care should include lifestyle changes conducive to lowering the blood pressure as well as monitoring the pressure itself. Contents  Life style modification to prevent and manage hypertension Modification Recommendation Weight reduction Maintain normal body weight (body mass index 18.5–24.9 kg/m2). (Dietary Approaches to Stop Consume a diet rich in fruits, vegetables, and low- Hypertension through eating plan fat dairy products with a reduced content of saturated and total fat. Dietary sodium reduction Reduce dietary sodium intake to no more than 100 mmol/day (2.4 g sodium or 6 g sodium chloride). Physical activity Engage in regular aerobic physical activity such as brisk walking (at least 30 min/day, most days of the week). Limit consumption to no more than 2 drinks per day Moderation of alcohol consumption in most men and to no more than 1 drink per day in women and lighter-weight people. Contents  Hypotension Is a blood pressure that below normal, that is, a systolic reading consistently between 85- and 110-mm hg in an adult whose normal pressure is higher than this. Factors associated with hypotension general anesthesia, bleeding, severe burn, postural change, and dehydration. Orthostatic hypotension is a blood pressure that falls when the client sits or stands. It is usually the result of peripheral vasodilatation in which blood leaves the central body organs, especially the brain, and move to the periphery, often causingthe person to feel faint. Nursing intervention for the patient with hypotension 1. Report finding to health care provider. 2. If an abnormal blood pressure reading is obtained, measure blood pressure onthe other arm. 3. Be certain size of cuff is appropriate. 4. Compare your current reading with the patient base line. 5. Observe for symptoms as weak, thready pulse and confusion. 6. Place client in supine position and limit activity. 7. Assist the client to slowly sit or stand. Support the client in case of faintness. Contents  Pain assessment and management. Subject objectives: - 1. Describe the concept of pain. 2. Describe types of pain and how to assess it. 3. Formulate health education for patient with pain. 4. Synthesize clinical evidence to solve problems related to patient. Outlines: Importance of pain assessment and management. Types of pain. Pathophysiology of pain. Factors influencing pain response. The Nurse’s role in assessment and care of patients with pain. Characteristics of pain instruments for assessing the perception of pain. Pain Management Strategies. Application of nursing process for patients with pain. Contents  Pain Pain is defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage. It is the most common reason for seeking health care. Pain occurs as the result of many disorders, diagnostic tests, and treatments; it disables and distresses more people than any single disease. Importance of Pain Assessment and Management Pain management is considered such an important part of care that it is referred to as “the fifth vital sign” to emphasize its significance. Identifying pain as the fifth vital sign suggests that the assessment of pain should be as automatic as taking a patient’s blood pressure and pulse. Anatomy of the Pain Pathway: Transduction: Conversion of a noxious stimuli (chemical, mechanical, or thermal) into electrical energy Transmission: Electrical stimulus is sent to the dorsal horn of the spinal cord and synapse at the 2nd order neuron Modulation: Inhibition vs amplification of signal (facilitated by EAA) Perception: Conscious awareness of pain as a culmination of previous processes in the context of the individuals’ experiences. Contents  The Gate Control Theory of Pain is a mechanism, in the spinal cord, in which pain signals can be sent up to the brain to be processed to accentuate the possible perceived pain, or attenuate it at the spinal cord itself. The 'gate' is the mechanism where pain signals can be let through or restricted. One of two things can happen, the gate can be 'open' or the gate can be 'closed': If the gate is open, pain signals can pass through and will be sent to the brain to perceive the pain. If the gate is closed, pain signals will be restricted from travelling up to the brain, and the sensation of pain won't be perceived. If someone experiences a painful (noxious) stimulus, the application of a non -noxious (soothing or light rubbing) stimulus can help activate the gate control mechanism, and reduce the pain. Contents  Physiology of pain: Pain acts as a signal, alerting us to potential tissue damage, and leads to a wide range of actions to prevent or limit further damage. Physiologically, pain occurs when sensory nerve endings called nociceptors (also referred to as pain receptors) meet a painful or noxious stimulus. The resulting nerve impulse travels from the sensory nerve ending to the spinal cord, where the impulse is rapidly shunted to the brain via nerve tracts in the spinal cord and brainstem. The brain processes the pain sensation and quickly responds with a motor response to cease the action causing the pain. Nociceptive Pathways: The classic nociceptive pathway involves three types of neurons: Primary sensory neurons in the peripheral nervous system, which conduct painful sensations from the periphery to the dorsal root of the spinal cord. Secondary sensory neurons in the spinal cord or brainstem, which transmit the painful sensation to the thalamus. Tertiary sensory neurons, which transmit the painful sensation from the thalamus to the somatosensory areas of the cerebral cortex. Types of Pain: pain can classify by Origins into: (1) Cutaneous (or superficial) pain usually involves the subcutaneous tissue. It produces sharp pain with a burning sensation. (2) Deep somatic pain is diffused or scattered and originates in tendons, ligaments, bones, blood vessels, and nerves. (3) Visceral pain: is poorly localized and originates in body organs in the thorax, cranium, and abdomen. (4) Psychogenic pain: it is a pain where no physical pathology has been found or where the pain appears to have a greater psychological basis than a physiological one. Contents  Pain can classify by category or onset and duration into: 1. Acute Pain It characterized by generally rapid in onset, varies in intensity from mild to severe, the cause is usually clear. It is usually easy to ‘see’ the pain, such as an injury or infection, it lasts few days or weeks until healing has occurred as acute pain from a broken leg. It may be associated with anxiety and fear. 2. Chronic Pain It characterized by constant or intermittent and it interferes with normal functioning.It lasts for more than three months, or beyond normal healing time. It is a persistent pain that can disrupt sleep, mood, and normal living. The cause is not always clear. Chronic pain may start with an injury or infection, or there may be an ongoing cause of pain (e.g. arthritis). 3. Cancer-Related Pain Pain associated with cancer may be acute or chronic. Pain in patients with cancer can be directly associated with the cancer (eg, bony infiltration with tumor cells or nerve compression), a result of cancer treatment (eg, surgery or radiation), or not associated with the cancer (eg, trauma). However, most pain associated with cancer is a direct result of tumor involvement. Pain can classify by location Pain can also be categorized according to location (eg, pelvic pain, headache, chest pain). This type of categorization aids in communication about and treatment of the pain. For example, chest pain may suggest acute coronary syndrome (ACS). Pain can classify by etiology Pain can also be categorized by etiology. As burn pain, back pain, headache, and stomach. Contents  Manifestation of pain: 1- Physiologic responses: observable physiological signs of acute pain include changes in blood pressure, heart rate, respiratory rate, and metabolic responses as increase blood pressure due to over activity of the sympathetic nervous system, diaphoresis, and pallor, muscle tension for body especially of face, nausea and vomiting if pain is severe. 2- Behavioral responses: - Verbal responses: they are the most dependable indicators of pain as moaning, crying. Nonverbal responses: they often give a clue about pain location. Common nonverbal responses include rubbing painful areas, rigid body position, restlessness, clenched teeth and fists. Factors Influencing Pain Response 1. Experience It is tempting to expect that people who had multiple or prolonged experiences with pain will be less anxious and more tolerant of pain than those who have had little experience with pain. 2. Anxiety and Depression Anxiety that is relevant or related to the pain may increase the patient’s perception of pain. In this case, the anxiety may result in increased pain. Anxiety that is unrelated to the pain may distract the patient and may decrease the perception of pain. 3. Culture Beliefs about pain and how to respond to it differ from one culture to the next. The nurse must react to the person’s perception of pain and not to the person’s behavior, because the behavior may differ from the nurse’s cultural expectations. 4. Gender In some studies, women consistently reported higher pain intensity, pain unpleasantness, frustration, and fear, compared to men. Men and women are thought to be socialized to respond differently and differ in their expectations about pain. The Nurse’s Role in Assessment and Care of Patients with Pain Assessment Contents  A broad definition of pain is, “whatever the person says it is, existing whenever the experiencing person says it does”. Patients are the best authority on the existence of their own pain. In assessing a patient with pain, the nurse reviews the patient’s description of the pain and other factors that may influence pain, as well as the patient’s response to pain relief strategies. Characteristics of Pain Pain assessment begins by careful patient observation, noting overall posture and presence or absence of overt pain behaviors. Characteristics of Pain include: 1. Intensity The intensity of pain ranges from none to mild discomfort to excruciating. The reported intensity is influenced by the person’s pain threshold ( the smallest stimulus for which a person reports pain), and pain tolerance (the maximum amount of pain a person can tolerate). 2. Timing The nurse questions about the onset, duration, relationship between time and intensity (eg, at what time the pain is the worst), and changes in rhythmic patterns. 3. Location Having the patient point to the area of the body involved best determines the location of pain. This is especially helpful if the pain radiates (referred pain). 4. Quality The nurse asks the patient to describe the pain in his or her own words without offering clues. For example, the nurse asks the patient to describe what the pain feels like. If the patient cannot describe the quality of the pain, the nurse can suggest words such as burning, aching, throbbing, or stabbing. 5. Personal Meaning Pain means different things to different people; as a result, patients experience pain differently. It is important to ask how the pain affects the person’s daily life. Some people with pain can continue to work or study, whereas others may be disabled by their pain. 6. Aggravating and Alleviating Factors The nurse asks the patient what, if anything, makes the pain worse and what makes it better and asks specifically about the relationship between activity and pain. Contents  7. Instruments for Assessing the (Intensity) Perception of Pain Several pain assessment tools may be used to document the need for intervention. A. Visual Analogue Scales and Other Intensity Scales Visual analogue scales (VASs) are useful in assessing the intensity of pain. One version of the scale includes a horizontal 10-cm line with anchors (ends) indicating the extremes of pain. The patient is asked to place a mark indicating where the current pain lies on the line. The left anchor usually represents “none” or “no pain,” whereas the right anchor usually represents “severe” or “worst possible pain.” To score the results, a ruler is placed along the line, and the distance the patient marked from the left or low end is measured and reported in millimeters or centimeters. Some patients (eg, children, elderly patients, visually or cognitively impaired patients) may find it difficult to use an unmarked VAS. In those circumstances, ordinal scales, such as a simple descriptive pain intensity scale or a 0-to-10 numeric pain intensity scale, may be used. B. Faces Pain Scale–Revised Contents  This instrument has six faces depicting expressions that range from contented to obvious distress. The patient is asked to point to the face that most closely resembles the intensity of his or her pain. Management of Patients With Pain Pharmacologic intervention and non-pharmacologic interventions of pain: I-pharmacological intervention: (a) Analgesic Administration There are three general classes of drugs used for pain relief: Nonnarcotic analgesics (eg, aspirin, acetaminophen, nonsteroidal anti-inflammatory agents) Narcotic analgesics or opioids (morphine, codeine, meperidine, methadone). Adjuvant analgesics (anticonvulsants, antidepressants, and others) (b) Local Anesthesia: Anesthetic agents may be applied topically to the skin or mucous membranes or injected into the body to produce a temporary loss of sensation. (c) Neurosurgery 1- Neurectomy: is a partial or total excision of a peripheral or cranial nerve to relieve localized pain 2- Cordotomy is a surgical resection of the spinal and cerebral tracts carrying painful impulses and is used for advanced disease and intractable pain. 3- Sympathectomy is a severing of the sympathetic afferent nerve pathways that is used primarily for casualties, phantom pain, and pain due to vascular disorders. Contents II-Non-pharmacologic interventions / Activities to promote comfort: Massage, which is generalized cutaneous stimulation of the body, often concentrates on the back and shoulders. A massage does not specifically stimulate the non-pain receptors in the same receptor field as the pain receptors, but it may have an impact through the descending control system. Massage also promotes comfort because it produces muscle relaxation. Thermal Therapies Ice and heat therapies may be effective pain relief strategies in some circumstances; however, their effectiveness and mechanisms of action need further study. Proponents believe that ice and heat stimulate the non-pain receptors in the same receptor field as the injury. For greatest effect, ice should be placed on the injury site immediately after injury or surgery. Ice therapy after joint surgery can significantly reduce the amount of analgesic medication required. Ice therapy may also relieve pain if applied later. Care must be taken to assess the skin before treatment and to protect the skin from direct application of the ice. Ice should be applied to an area for no longer than 15 to 20 minutes at a time and should be avoided in patients with compromised circulation. Long applications of ice may result in frostbite or nerve injury. Transcutaneous Electrical Nerve Stimulation Transcutaneous electrical nerve stimulation (TENS) uses a battery-operated unit with electrodes applied to the skin to produce a tingling, vibrating, or buzzing sensation in pain. It has been used in both acute and chronic pain relief and is thought to decrease pain by stimulating the non-pain receptors in the same area as the fibers that transmit the pain. This mechanism is consistent with the gate control theory of pain and explains the effectiveness of cutaneous stimulation when applied in the same area as an injury. Distraction Distraction involves focusing the patient’s attention on something other than the pain, may be the mechanism responsible for other effective cognitive techniques. Distraction is thought to Contents  reduce the perception of pain by stimulating the descending control system, resulting in fewer painful stimuli being transmitted to the brain. Distraction techniques may range from simple activities, such as watching TV or listening to music, to highly complex physical and mental exercises. The stimulation of sight, sound, and touch is likely to be more effective in reducing pain than is the stimulation of a single sense. Relaxation Techniques Skeletal muscle relaxation is believed to reduce pain by relaxing tense muscles that contribute to the pain. A simple relaxation technique consists of abdominal breathing at a slow, rhythmic rate. The patient may close both eyes and breathe slowly and comfortably. A constant rhythm can be maintained by counting silently and slowly with each inhalation (“in, two, three”) and exhalation (“out, two, three”). When teaching this technique, the nurse may count out loud with the patient at first. Slow, rhythmic breathing may also be used as a distraction technique. Guided Imagery Guided imagery is using one’s imagination to achieve a specific positive effect. Guided imagery for relaxation and pain relief may consist of combining slow, rhythmic breathing with a mental image of relaxation and comfort. The nurse instructs the patient to close both eyes and breathe slowly in and out. With each slowly exhaled breath, the patient imagines muscle tension and discomfort being breathed out, carrying away pain and tension and leaving behind a relaxed and comfortable body. With each inhaled breath, the patient imagines healing energy flowing to the area of discomfort. Usually, the patient is asked to practice guided imagery for about 5 minutes, three times a day. Several days of practice may be needed before the intensity of pain is reduced. Hypnosis Hypnosis, which has been effective in relieving pain or decreasing the amount of analgesic a