FON 2nd Sam' all slides of 2k23_by_Samiii[1].pptx

ON 2nd Sam' all slides of 2k23_by_Samiii[1].pptx

1. Unit: 1 Nursing Process By : Ibne Amin Institute of Nursing Sciences, Khyber Medical University , Peshawar

2. Objectives 1. Define nursing process. 2. Describe the purposes of nursing process. 3. Identify the components of the nursing process 4. Discuss the requirements for effective use of the nursing process 5. Describe the functional health approach to the nursing process

3. Nursing Process The nursing process is a dynamic & modified form of scientific method used in nursing profession to assess client needs and create a course of action to address and solve patient problems. OR An organized sequence of problem-solving steps used to identify and to manage the health problems of clients. It is accepted for clinical practice established by the American Nurses Association

4. Purpose Of Nursing Process To identify a client’s health status and actual or potential health care problems or needs. To establish plans to meet the identified needs. To deliver specific nursing interventions to meet those needs. Purpose is to provide client care that is : Individualized Holistic Effective Efficient

5. Components Of Nursing Process The Nursing Process utilizes the following steps Assessment (data collection), Nursing diagnosis, Planning, Implementation Evaluation. Steps remain the same Applications and result are different

6. Components of Nursing Process

7. 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

8. 1. ASSESSMENT It involves Collection of data Organizing the data Validating the data Documenting the data Assessment is the systematic and continuous collection, organization, validation, and documentation of data (information).

9. 1. ASSESSMENT Types of assessment The four different types of assessments are; 1. Initial nursing assessment 2. Problem-focused assessment 3. Emergency assessment 4. Time-lapsed reassessment The ultimate Purpose of assessment is data collection

10. 1. ASSESSMENT 1. Initial nursing assessment: Performed within specified time after admission. To establish a complete database for problem identification. Eg: Nursing admission assessment

11. 1. ASSESSMENT 2. Problem-focused assessment : To determine the status of a specific problem identified in an earlier assessment. Eg: hourly checking of vital signs of fever patient

12. 1. ASSESSMENT 3. Emergency assessment: During emergency situation to identify any life threatening situation. Eg: Rapid assessment of an individual’s airway, breathing status, and circulation during a cardiac arrest .

13. 1. ASSESSMENT 4. Time-lapsed reassessment: Several months after initial assessment. To compare the client’s current health status with the data previously obtained

14. COMPONENTS OF ASSESSMENT

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

16. 1. ASSESSMENT Types of Data : Subjective data Objective data. 1. Subjective data Also referred to as symptoms or covert data, are clear only to the person affected and can be described only by that person. Itching, pain, and feelings of worry are examples of subjective data.

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

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

19. Methods Of Data Collection

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

21. 1. ASSESSMENT Validation of data The information gathered during the assessment is “double-checked” or verified to confirm that it is accurate and complete.

22. 1. ASSESSMENT Documentation of data To complete the assessment phase, the nurse records client data. Accurate documentation is essential and should include all data collected about the client’s health status.

23. 2. DIAGNOSIS Diagnosis is the second phase of the nursing process. In this phase, nurses use critical thinking skills to interpret assessment data to identify client problems. (NANDA) define or refine nursing diagnosis. The official NANDA definition of a nursing diagnosis is: “a clinical judgment concerning a human response to health conditions/life processes, or a vulnerability for that response, by an individual, family, group, or community.”

24. 2. DIAGNOSIS Diagnosing is to : 1.Analyza data 2. Identify health problems,risks and strengths 3. Formulate diagnostic statement

25. Status of the Nursing Diagnoses “Status refers to the actuality or potentiality of the diagnosis or the categorization of the diagnosis” (NANDA International, 2009, p. 44).The kinds of nursing diagnoses according to status are Actual Health promotion Risk Wellness. Possible Nursing Diagnosis Syndrome Nursing diagnosis

26. 1. Actual Diagnosis 1.An actual diagnosis is a client peoblem that is present at the time of Nursing assessment. Examples are ineffective breathing pattern and anxiety. It is based on the presence of associated signs and symptoms

27. 2. Health Promotion Diagnosis A health promotion diagnosis relates to clients’preparedness to implement behaviors to improve their health condition. These diagnosis labels begin with the phrase Readiness for Enhanced, as in Readiness for Enhanced Nutrition

28. 3. Risk Nursing Diagnosis A risk nursing diagnosis is a clinical judgment that a problem does not exist, but the presence of risk factors indicates that a problem is likely to develop unless nurses intervene. For example, all people admitted to a hospital have some possibility of acquiring an infection; however, a client with diabetes or a compromised immune system is at higher risk than others. Therefore, the nurse would appropriately use the label Risk for Infection to describe the client’s health status.

29. 4. Wellness Nursing Diagnosis It is clinical judgment about an individual, group or community in transition from a specific level of wellness to a higher level of wellness. Eg: Family coping: potential for growth related to unexpected birth of twins.

30. 5. Possible Nursing Diagnosis It describe a suspected problem for which current and available data are insufficient to validate the problem. eg: Possible social isolation related to unknown etiology. Eg: An elderly widow who lives alone is admitted to the hospital. The nurse notices that she has no visitors and is pleased with attention and conversation from the nursing staff .The nurse may write a nursing diagnosis of possible social isolation related to unknown etiology.

31. 6. Syndrome Nursing Diagnosis It is a cluster of nursing diagnosis that frequently go together and present a clinical picture. Eg: Chronic Pain syndrome Rape Trauma Syndrome Disuse syndrome (long term bed riddenpatients) Clusters of diagnoses associated with Disuse syndrome syndrome include Impaired Physical Mobility,Riskfor Impaired Tissue Integrity, Risk for Activity Intolerance, Risk for Constipation, Risk for Infection, Risk for Injury, Risk for Powerlessness, Impaired Gas Exchange, and so on .

32. Components of a Nursing Diagnosis A nursing diagnosis has three components: (1) The problem statement or Diagnostic Lable (2) The etiology (related factors & risk factors) (3) Signs & Symptoms or the defining characteristics

33. 1.Problem Statement (Diagnostic Label) It Describes the patient health status or response to health problems for which nursing therapy is given. The purpose of the diagnostic label is to direct the formation of client goals and desired outcomes. It may also suggest some nursing interventions. Eg: for example, Deficient Knowledge (Medications) or Deficient Knowledge (Dietary Adjustments). Similarly., Activity intolerance or Constipation etc

34. 2. Etiology (Related Factors & Risk Factors) The etiology component of a nursing diagnosis identifies causes of the health problem.These are causative factors that have influenced the clients actual or potential response to the healthproblem Eg: Activity intolerance related to generalized weakness or obesity or sedentary lifestyle. Constipation related to inadequate fluid intake or inadequate fiber intake.

35. 3. Defining characteristics (S/S) Defining characteristics are the cluster of signs and symptoms that indicate the presence of a particular diagnostic label or health problem. e.g Fluid volume deficit related to decreased oral intake manifested by dry skin and mucus membranes.

36. The Diagnostic Process The diagnostic process has three steps: Analyzing data Identifying health problems, risks, and strengths Formulating diagnostic statements.

37. Formulating Diagnostic statement Most nursing diagnosis are written as two part or three parts statements Basic Two Part Statements : It is also called PE format Problem (P) – statement of the patients response Etiology (E) – factors contributing to or probable cause of the response Example:Problem(P)relatedtoEtiology(E) Activity intolerance related to generalized weaknessorobesity

38. Formulating Diagnostic statement Basic Three Part Statements It is also called as PES format & includes: 1.Problem (P) – Statement of the patient’s response 2.Etiology (E) Factors contributing to or probablecausesoftheresponses 3.Signs & Symptoms (S) Defining characteristicsevidencedbytheclient Example: Problem related to etiology as evidentced by signs &symptoms Activity intolerance related to generalized weakness evidenced by fatigue

39. Difference between Nursing Diagnosis Medical Diagnosis Nursing Diagnosis It is a statement of nursing judgment and refers to a condition that nurses are licensed to treat. It is a statement of nursing judgment. It describe a patients physical, sociocultural, psychologic and spiritual responses to an illness or ahealthproblem Medical Diagnosis It is made by a physician and refers to a condition that only a physician cant reat. It is a statement of medical judgmen. Medical diagnoses refer to disease processes OR It describes a patient’s specific pathophysiologic responses to an illness.

40. Difference between Nursing Diagnosis Medical Diagnosis Nursing Diagnosis These responses vary among individuals The patient’s nursing diagnosis change as the client’s response change Nursing diagnosis relate to the nurse’s independent function Eg:Tepid sponging for fever Medical Diagnosis These responses are fairly uniform from one client to another The patient’s medical diagnosis remains the same for as long as the disease process is present Nurses are obligated to carry out physician prescribed treatment (dependent function). Eg: Tab. Paracetamol 500mg forfever

41. Difference between Nursing Diagnosis Medical Diagnosis Nursing Diagnosis Ineffective breathing pattern Activity intolerance Acute pain Disturbed body image Medical Diagnosis Asthma Cerebrovascular accident Appendicitis Amputation

42. Planning Planning is the third phase of the nursing process, in which the nurse and client develop client goals/ desired outcomes and nursing strategies to prevent, reduce or alleviate the client’s health problems. It is the process of formulating client goals and designing the nursing interventions required to prevent, reduce, or eliminate the client’s health problems. Planning involves decision making and problem solving.

43. Types Of Planning 1. Initial Planning : Planning which is done after the initial assessment. The nurse who performs the admission assessment usually develops the initial comprehensive plan of care. 2. Ongoing Planning : It is a continuous planning. As nurses obtain new information and evaluate the client’s responses to care, they can individualize the initial care plan further. It occurs at the beginning of a shift as the nurse plans the care to be given that day 3. Discharge Planning :The process of anticipating and planning for needs after discharge, is a crucial part of a comprehensive health care and should be addressed in each client’s care plan.

44. Planning Process It involves Prioritize problems/ diagnosis Formulate goals/desired outcomes Select Nursing intervension Write Nursing intervention

45. Planning Process 1. Setting priorities The nurse begin planning by deciding which nursing diagnosis requires attention first, which second, and so on. Nurses frequently use Maslow’s hierarchy of needs when setting priorities. Example: In this physiologic needs such as air, food and water are basic to life and receive higher priority than the need for security or activity

46. Maslow's Hierarchy of Needs

47. Planning Process 2. Establishing client goals/desired outcomes After establishing priorities, the nurse set goals for each nursing diagnosis. Goals may be short term or long term Client goals / desired outcomes: It is a specific and measurable behavior or response that reflects a clients highest possible level of wellness and independence in function.

48. Types of Goals Short Term Goals It is an objective that is expected to achieved / with in a short time, usually less than a week Example: Client will achieve comfort with in 24 hours post operatively Clientwill raise right arm to shoulder heightby Frida Long Term Goaals It is an objective that is expected to believe over a longer time frame, usually over weeksormonths Example: Client will adhere to post operative activity restrict Client will regain full use of right arm in 6 weeks ions for one month

49. Planning Process 3. Nursing interventions A nursing intervention is any treatment, that a nurse performs to improve patient’s health. OR These are the actions that nurses perform to achieve the clients goals

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

51. 4. IMPLEMENTATION In the nursing process, implementing is the action phase in which the nurse performs the nursing interventions. Implementing consists of doing and documenting the activities that are the specific nursing actions needed to carry out the interventions. The nurse performs or delegates the nursing activities for the interventions that were developed in the planning step and then concludes the implementing step by recording nursing activities and the resulting client responses.

52. Process of Implementing The process of implementing normally includes the following: Reassessing the client Determining the nurse’s need for assistance Implementing the nursing interventions Supervising the delegated care Documenting nursing activities.

53. Process of Implementing 1. Reassessing the Client Just before implementing an intervention, the nurse must reassess the client to make sure the intervention is still needed. 2. Determining the Nurse’s Need for Assistance When implementing some nursing interventions, the nurse may require assistance for one or more of the following reasons: The nurse is unable to implement the nursing activity safely or efficiently alone (e.g., ambulating an unsteady obese client). Assistance would reduce stress on the client (e.g., turning a person who experiences acute pain when moved). The nurse lacks the knowledge or skills to implement a particular nursing activity (e.g., a nurse who is not familiar with a particular model of traction equipment needs assistance the first time it is applied).

54. Process of Implementing 3. Implementing the Nursing Interventions It is important to explain to the client what interventions will be done, what sensations to expect, what the client is expected to do, and what the expected outcome is. For many nursing activities, it is also important to ensure the client’s privacy, for example by closing doors, pulling curtains, or draping the client.

55. Process of Implementing 4. Supervising Delegated Care If care has been delegated to other health care personnel, the nurse responsible for the client’s overall care must ensure that the activities have been implemented according to the care plan. Other caregivers may be required to communicate their activities to the nurse by documenting them on the client record, reporting verbally, or filling out a written form. The nurse validates and responds to any adverse findings or client responses. This may involve modifying the nursing care plan.

56. Process of Implementing 5. Documenting nursing activities. After carrying out the nursing activities, the nurse completes the implementing phase by recording the interventions and client responses in the nursing progress notes.

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

58. References kozier & Erb’s Fundamental of Nursing ,8 th edition( Audrey Berman ,Shirlee J. Synder). www.slideshare.com www.google.com

59. Critical Thinking Faculty: Ibne Amin INS, Khyber Medical University, Peshawar,

60. Objectives Relate the importance of critical thinking in nursing. Discuss definitions of, characteristics of, and skills used in critical thinking. Classify the three major factors that affect thinking. Assess ways to develop critical thinking skills especially as applied to nursing . Plan personal goals for developing critical thinking skills

61. Critical Thinking Critical Thinking: Careful and goal-directed thinking that is used to assess more complicated situations, identify actual and potential problems, and make decisions about an action plan. Critical thinking is the ability to think clearly and rationally about what to do or what to believe. It includes the ability to engage in reflective and independent thinking.

62. Critical thinking and clinical Reasoning The practice of nursing requires critical thinking and clinical reasoning . Critical thinking Is the process of intentional higher level thinking of defining a clients’ problem, examining, the evidence –based practice in caring for the client, and make choices in the delivery of care.

63. Critical thinking and clinical Reasoning Clinical reasoning: Is the cognitive process that uses thinking strategies to gather and analyze clients information , evaluate the relevance of the information , and decide on possible nursing to improve the clients physiological and psychosocial outcomes clinical reasoning requires the integration of critical thinking in the identification of the most appropriate interventions that will improve the clients condition.

64. Components of Critical Thinking A person will do the following : Ask questions to determine the reason why certain developments have occurred and to see whether more information is needed to understand the situation accurately. Gather as much relevant information as possible to consider as many factors as possible Validate the information presented to make sure that it is accurate (not just supposition or opinion), that it makes sense, and that it is based on fact and evidence

65. Conti.. Analyze the information to determine what it means and to see whether it forms clusters or patterns that point to certain conclusions. Draw on past clinical experience and knowledge to explain what is happening and to anticipate what might hap next, acknowledging personal bias and cultural influences. Maintain a flexible attitude that allows the facts to guide thinking and takes into account all possibilities.

66. Conti Consider available options and examine each in terms of its advantages and disadvantages. Formulate decisions that reflect creativity and independent decision making.

67. Critical Thinking in Nursing Practice Nurses must use critical thinking skills in all practice settings—acute care, ambulatory care, extended care, and in the home and community. Regardless of the setting, each patient situation is viewed as unique and dynamic. The unique factors that the patient and nurse bring to the health care situation are considered, studied, analyzed, and interpreted. Interpretation of the information presented then allows the nurse to focus on those factors that are most relevant and most significant to the clinical situation. Decisions about what to do and how to do it are then developed into a plan of action.

68. Applying critical thinking to nursing practice Implementation of the nursing process provides nurses with a creative approach to thinking and doing to obtain, categorize, and analyze client data and plan actions that will meet the client’s needs. Nursing process: is a systematic, rational method of planning and providing individualized nursing care. The phases of the nursing process are assessing , diagnosing , planning , implementing , and evaluating

69. Applying critical thinking to nursing practice Problem Solving Problem solving: Process used when a gap is perceived between an existing state (what is occurring)& a desired state of what should be occurring. Throughout the problem-solving process the implementation of critical thought may or may not be required in working toward a solution (Wilkinson, 2012). The nurse carefully evaluates the possible solutions and chooses the best one to implement. Commonly used approaches to problem solving include trial and error , intuition, and the research process

70. Applying critical thinking to nursing practice Trial And Error: In trial and error , a number of approaches are tried until a solution is found. The use of trial- and-error methods in nursing care can be dangerous because the client might suffer harm if an approach is inappropriate. However, nurses often use trial and error in the home setting due to logistics, equipment, and client lifestyle .

71. Applying critical thinking to nursing practice Intuition Is a problem-solving approach that relies on a nurse’s inner sense. It is a legitimate aspect of a nursing judgment in the implementation of care. Intuition is the understanding or learning of things without the conscious use of the reasoning. It I also known as sixth sense, feeling, or suspicion.

72. Applying critical thinking to nursing practice Clinical judgment : In nursing is a decision-making process to ascertain the right nursing action to be implemented at the appropriate time in the client’s care. The nurse must first have the knowledge base necessary to practice in the clinical area and then use that knowledge in clinical practice. Clinical experience allows the nurse to recognize cues and patterns and begin to reach correct conclusions.

73. Applying critical thinking to nursing practice Research Process : is a formalized, logical, systematic approach to problem solving. The classic quantitative research process is most useful when the researcher is working in a controlled situation. Health professionals, often working with people. For example, unlike many experiments with animals in which the environment can be strictly regulated, the effects of diet on health in humans are complicated by a person’s genetic variations, lifestyle, and personal preferences. However, it is becoming increasingly important for nurses to identify evidence that supports effective nursing care. One critical source of this evidence is research.

74. Ways to Enhance Critical Thinking In Nursing There are many actions that can help a nurse to think critically. Five important actions are: Recognition Questioning Information gathering Evaluation Communication

75. Characteristics of Critical Thinkers Strive for understanding Are honest with themselves Base judgment on evidence Are interested in other people’s ideas Control their feeling/emotions Keep an open mind They are very observant Identify key issues and raise questions Obtain relevant facts Evaluate the findings from judgments

76. Skills used in critical thinking Analytical skills Communication Creativity Open Minded Problem solving 6.Identifying Biases

77. 1. Analytical Skills People with analytical skills can examine information, and then understand what it means, and what it represents. Asking thoughtful questions Data analysis Information seeking Interpretation Judgment Questioning evidence Recognizing differences and similarities

78. 2.Communication Often, you will need to share your conclusions with your employers or with a group of colleagues. You need to be able to communicate with others to share your ideas effectively. Assessment Collaboration Explanation Expressing opinions and ideas Presentation Teamwork Verbal communication Written communication

79. 3.Creativity Critical thinking often involves some level of creativity. You might need to spot patterns in the information you are looking at or come up with a solution that no one else has thought of before. All of this involves a creative eye. Cognitive flexibility Conceptualization Curiosity (interest) Imagination Making abstract connections Predicting Synthesizing (produce) Visionary (idealistic)

80. 4.Open Minded To think critically, you need to be able to put aside any assumptions or judgments and merely(simply) analyze the information you receive. You need to be objective, evaluating ideas without bias. Embracing different cultural perspectives Fair Humble Inclusive (wide range) Objective (neutral) Observation

81. 5. Problem Solving Problem solving is another important critical thinking skill that involves analyzing a problem, generating and implementing a solution, and assessing the success of the plan. Applying standards Attention to detail Clarification Collaboration (team work) Decision making Evaluation Innovative (advanced ) Logical reasoning

82. 6.Identifying Biases This skill can be exceedingly difficult, as even the smartest among us can fail to recognize biases. Strong critical thinkers do their best to evaluate information objectively. Think of yourself as a judge in that you want to evaluate the claims of both sides of an argument, but you’ll also need to keep in mind the biases each side may possess.

83. Factors That Affect Thinking Attitude Common Sense Nature Intelligence Mindset Wisdom Environment Stage of health Companions Lack of knowledge Lack of skills Lack of awareness Lack of confidence Dependency thinking Cognitive style

84. References Kozier & Erb’s Fundamental of Nursing Book, 8 th edition. Michael A Bettman FACRS “Self Esteem article” 1960. Thomas Fuller Ph.D/MCPR “Teaching and Learning” 1955. John Jackson M.D “of nursing research 6 th edition. Manual

85. CONCEPT OF VALUES AND BELIEF By: Ibne Amin Khyber Medical University ,Peshawar

86. Objectives At the end of this unit, learners will be able to:   1. Define value/belief pattern 2. Explain how behaviors related to values 3. Identify sources of professional nursing values 4. Apply cultural and developmental perspective when identifying values 5. Examine values conflict and resolution in nursing care situations

87. Introduction: Values are important in nursing and health care as they underpin all aspects of professional practice , including decision making , choose between alternatives , and resolve conflict . Values can be divided into three levels of expressions Beliefs values themselves Attitudes

88. Terminologies Value: Beliefs or attitudes about the worth of a person, object, idea or action. Belief: Beliefs are the assumptions we make about ourselves, about others in the world and about how we expect things to be. Attitude: Feelings toward a person, object or idea (e.g, acceptance, rejection, etc.)

89. Relevent terms Assumptions: Assumptions are beliefs that are regarded as so valuable and obviously correct that they are taken for granted and rarely examined or questioned. Honesty: A facet of moral character that connotes positive and virtuous attributes such as integrity, truthfulness, and straightforwardness, along with the absence of lying, cheating, or theft. Code : Any system of principles, rules or regulations relating to one subject. Conduct : The manner of guiding or carrying one's self, personal deportment, mode of action, behavior.

90. Relevent terms Decision : A choice or judgment Environment: The surroundings of, and influences on, a particular item of interest. Moral: Of or relating to principles of right and wrong in behavior, especially for teaching right behavior Attitude is the way a person expresses or applies their beliefs and values, and is expressed through words and behavior. example I get really upset when I hear about cruelty to children and animals, or I hate school

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

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

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

94. Types of Beliefs Commendatory ("I believe I am a good writer) Existentialism (Belief in God) Monotheism Polytheism Atheistic

95. Value They are also beliefs and are defined as: “Beliefs about what is desirable or good and what is undesirable or bad” Values are ideals that guide or qualify your personal conduct, interaction with others, and involvement in your career. Like morals, they Help you to distinguish what is right from what is wrong & Inform you on how you can conduct your life in a meaningful way . Value is a measure of the worth or importance a person attaches to something; our values are often reflected in the way we live our lives. example I value freedom of speech. A coherent set of values adopted and/or evolved by a person, organization, or society as a standard to guide its behavior in preferences in all situations

96. Types of Values Religious Value Personal Value Cultural Value Humanistic Optimistic Democratic Motivational Value

97. Types of values Religious values Religious values are ethical principles founded in religious traditions, texts and beliefs. In contrast to personal values, religious-based values are based on scriptures and a religion's established norms They help people determine which actions to take, and to make judgments about right or wrong and good or bad

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

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

100. Types of values Democratic Values They assert the sanctity of the individual. The right of people to be free from misuse of power. Use of fair and equitable treatment for all. Need for justice through rule of law. Motivational Values Internal and external Values that stimulate desire and energy in people to be continually interested and committed to a job, role or subject, or to make an effort to attain a goal

101. Types of values Motivational Value Achievement : personal success through demonstrating competence according to the social standards Hedonism: pleasure and sensuous gratification for oneself Stimulation: excitement, novelty and challenge in life Self Direction: independent thought and action choosing, creating, exploring Power: social status and prestige, control or dominance over the people and resources

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

103. Values Transmission Values are learned through observation and experience. We accumulate our values from childhood via teaching and observation of our parents, teachers, religious leaders, and other influential and powerful people. Values are highly influenced by a person’s family, sociocultural environment, and peer groups. For example, if a parent consistently demonstrates honesty in dealing, the child will probably begin to value honesty. Similarly, some cultures prefer folk treatment over new medicine which is learned from culture.

104. Values Influence on Behavior Values can have a positive influence on a person's behavior as he or she tries to emulate the conduct he or she holds as valuable. Values are one important element that affect who we are and how we behave towards others. Companies can influence a person's behavior with codes of conduct, ethics committees, and a punishment and reward system. Sometimes there will be a gap between a person's values and behavior. Organizational strategies, such as a reward system, can close that gap. If we deem something valuable then we do what we can to emulate that value. If a person values honesty, then they will strive to be honest. If a person values transparency then they will work hard to be transparent. Values are one important element that affect who we are and how we behave towards others

105. Professional values for nurses Be kind and considerate to those for whom they provide care, and to their carers and families Listen to, and work in partnership with those for whom they provide care Work constructively with colleagues to provide patientcentered care, recognising that multi-disciplinary teamwork, encouraging constructive challenge from all team members, safety-focused leadership and a culture based on openness and learning when things go wrong are fundamental to achieve high quality care. Follow their employing or contracting bodies’ procedures when they have concerns about the safety or dignity of people receiving care

106. Professional values for nurses Be open and honest with people receiving care if something goes wrong. Nurses ' professional values are acquired during socilizationinto nursing from codes of ethics , nursing experiences , teachers ,and peers . The American Association of Colleges of Nursing (AACN , 1998) identified five values essential for the professional nurse altruism , autonomy , humandignity , integrity , and social justice .

107. Professional values for nurses Altruism is a concern for the welfare and well-being of others. In professional practice, altruism is reflected by the nurse's concern for the welfare of patients, other nurses, and other health care providers. Autonomy is the right to self-determination. Professional practice reflects autonomy when the nurse respects patients' rights to make decisions about their health care. Human dignity is respect for the inherent worth and uniqueness of individuals and populations. In professional practice, human dignity is reflected when the nurse values and respects all patients and colleagues.

108. Cont Integrity is acting in accordance with an appropriate code of ethics and accepted standards of practice. Integrity is reflected in professional practice when the nurse is honest and provides care based on an ethical framework that is accepted within the profession. Social justice is upholding moral, legal, and humanistic principles. This value is reflected in professional practice when the nurse works to ensure equal treatment under the law and equal access to quality health care

109. PROFESSIONAL BEHAVIORS Demonstrates understanding of cultures, beliefs, and perspectives of others. Advocates for patients, particularly the most vulnerable, Takes risks on behalf of patients and colleagues. Mentors other professionals. Plans care in partnership with patients. Honors the right of patients and families to make decisions about health care, Provides information so patients can make informed choices

110. PROFESSIONAL BEHAVIORS Provides culturally competent and sensitive care. Protects the patient's privacy. Preserves the confidentiality of patients and health care providers. Designs care with sensitivity to individual patient needs, Provides honest information to patients and the public.

111. PROFESSIONAL BEHAVIORS Documents care accurately and honestly. Demonstrates accountability for own actions. Supports fairness and nondiscrimination in the delivery of care. Promotes universal access to health care. Encourages legislation and policy consistent with the advancement of nursing care and health care.

112. Typical Value conflict and Sample Controvercies Loyalty-honesty Competition-Cooperation Freedom of press- national security Equality-individualism Order-freedom of speech 6. Security –excitement 7. Generosity –material success Rationality –spontaneity 9 . Tradition –novelty Should you tell your parents about your sester’s drug habit? Do you support grading system? Is it wise to hold weekly presidential press conference? Are racial qoutas for employment fair? Shoud we imprison those with radical ideas? Should you choose a dangerous profession? Is it desirable to give financial help to a beggar? Should you check the odds before placing a bet? Should divorces be easily available?

113. Ethics The study of moral rules and principles that govern a person's behaviour or the conducting of an activity. Justice & Equality Respect for human dignity Relationships to patients The nature of health problems The right to self-determination Relationships with colleagues and others Privacy of patient's interests Conflict Resolution among Nurses Collaboration Professional boundaries

114. SUMMARY Values are learned and change in response to life situations as persons develops How value influence attitudes and how they together influence professional behavior. Most values are derived from four main sources that influence our personal and professional attitudes(Science ,Culture ,Religion and Experience) people arrive at their own values through Choosing , Prizing and then acting on them Values important in nursing settings as( values of health , health care , caring and nursing

115. References Tschudin, Verena ,RGN,...etc. .(1998).Ethics in Nursing. The caring relationship-2nd ed. British Library p(28-45). SimonS.B.,Howe.,L.W.@Kirshenbaum,H.(1995).Values Clarification: Ahandbook of practical strategies for teachers and students .New York: Hart. Fundamental of nursing by Erab & Koizer (6 th edition)

116. Self-concept /self Perception By: Ibne Amin (INS ),Khyber Medical university

117. Educational Platform

118. Introduction Self Concept is an individual conceptualization about how one thinks about himself or herself. It is a subjective sense of unconscious and conscious thoughts, attitude and perceptions. Self concept provides a frame of reference that effects the management of all situations and relationship with others. Educational Platform

119. Objectives At the end of this unit, learners will be able to: 1. Define self perception/ self concept pattern. 2. Describe the functions of self and self concept 3. Discuss how self concept develops through out the life span 4. Discuss factors that can effect self concept 5. Identify possible manifestation of altered self concept 6. Apply nursing process for a person with an altered self concept Educational Platform

120. Definition of Self Concept Self concept is an individuals identity about how one thinks about himself or herself. It means how one thinks or how one feels about himself or herself. (By Dougles “1966”) Self-concept i s one’s mental image of oneself Self concept is the way we picture ourselves including our traits and values. Educational Platform

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

122. Self-Concept /Self Perception Perception: the ability to see, hear, or become aware of something through the senses Self-Perception: is one's self-concept, self-knowledge, selfesteem, & self-assessments in order to define one's self-schemas Self-Schema: refers to the beliefs and ideas people have about themselves Self Concept: A self-concept is a reflection of the reactions of others towards an individual Educational Platform

123. The Role of the “Self” Self: A person's essential being that distinguishes them from others, especially considered as the object of introspection Capacity for self-reflection is necessary for self-understanding Private, “Inner” Self Public, “Outer” Self Educational Platform

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

125. COGNITIVE ASPECT: SELF SCHEMA Self schemas are “cognitive generalizations about the self, derived from past experience, that organize and guide the processing of self-related information” How do we come to know ourselves, develop a selfconcept, and maintain a stable sense of identity? Educational Platform

126. AFFECTIVE/EVALUATIVE ASPECT : SELF ESTEEM “self esteem reflects the perceived difference between an individual’s actual self concept (who I think I really am) and some ideal self image (who I would really like to be).” How do we evaluate ourselves, enhance our self-images, and defend against threats to our self-esteem? William James (1890) expressed the relationship this way. Self esteem= success/pretension Pretension (ideals against which individuals assess their actual self image) Educational Platform

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

128. Johari Window Known by self Unknown by Self Known by other OPEN ARENA BLIND SPOT Unknown byother FACADE HIDDEN UNKNOWN Educational Platform

129. Mechanism of Self Concept There are three mechanisms of self concept, Ideal Self} Real Self}………………Positive self concept Public Self} Characteristics of a Positive Self-Concept Self-confidence Ability to accept criticism and not become defensive Setting obtainable goals Willingness to take risks and try new experiences Educational Platform

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

131. Interrelationship of Components of Self-Concept Educational Platform

132. Educational Platform

133. Components of Self-Concept 1.Self Identity A sense of personal identity is what sets one person apart as a unique individual. Identity includes a person’s name, gender, ethnic identity, family status, occupation, and roles. One’s personal identity begins to develop during childhood and is constantly reinforced and modified throughout life. Educational Platform

134. Components of Self-Concept 2.Body Image Body image is an attitude about one’s physical attributes and characteristics, appearance, and performance. Body image is dynamic because any change in body structure or function, including the normal changes of growth and development, can affect it. Educational Platform

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

136. Components of Self-Concept Educational Platform

137. Components of Self-Concept 4. Role Performance Role refers to a set of expected behaviors determined by familial, cultural, and social norms. The level of self-esteem is dependent upon the selfperception of adequate role performance in these various social roles. Stressors Affecting Role Performance Role Overload Role Conflict Whenever a person is unable to fulfill role responsibilities, self-concept is impaired. Educational Platform

138. Dimension of Self-Concept Self-knowledge — “Who am I?” Self-Expectation — “Who or what do I want to be?” Social Self – How person perceived by others? Self-Evaluation — “How well do I like myself?” Educational Platform

139. Self-knowledge Global Self : is the term used to describe the composite of all basic facts, qualities, traits, images and feelings one holds about oneself. It includes: 1 . Basic facts: sex, age, race, occupation, cultural background, sexual orientation 2. Person’s position with social groups 3. Qualities or traits that describe typical behaviours, feelings, moods and other characteristics (generous, hot-headed , ambitious, intelligent etc) Educational Platform

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

141. Social Self Social self is how a person perceived by others and society. The Self in a Social Context/background They focus on explaining an individual's actions within a group/society It investigates the question of how the personal self relates to the social environment Educational Platform

142. Self-Evaluation Self esteem is the evaluative and affective component of self concept The appraisal of oneself in relationship to others, events, or situations. Maslow’s Subsets of Esteem Needs: Self-esteem (strength, achievement, mastery, competence, ..) Respect needs or the need for esteem from others Educational Platform

143. Development of Self-Concept Self-concept evolves throughout life and depends to an extent on an individual’s developmental level. Formation of Self-Concept Infant learns physical self different from environment. If basic needs are met, child has positive feelings of self. Child internalizes others people’s attitudes toward self. Child or adult internalizes standards of society. Educational Platform

144. Stages in Development of Self Self-awareness (Newborn (28-Days)infancy=1year) Self-recognition (18 months) Toddler and Self-definition (3 years) Preschooler Self-concept (6 to7years) School Age Adolescence Adulthood Stages Educational Platform

145. DEVELOPMENT OF SELF-CONCEPT Various psychosocial theories have been developed to explain the development of self-concept. A discussion of Erikson’s theory of psychosocial development related to self-concept are follow. Erikson’s Theory Erikson’s (1963) psychosocial theory states that an individual’s development proceeds throughout life. Each of his eight developmental stages includes psychosocial tasks that need to be mastered. Educational Platform

146. Educational Platform

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

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

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

150. Activities/Helping Patients Maintain Sense of Self Communicate worth with looks, speech, and judicious touch. Acknowledge patient status, role, and individuality. Speak to patient respectfully. Offer simple explanations for procedures. Move patient’s body respectfully if necessary. Respect patient’s privacy and sensibilities. Acknowledge and allow expression of negative feelings. Help patients recognize strengths and explore alternatives. Educational Platform

151. Conti … The following are activities that the nurse can teach the client to engage in to increase one’s self-esteem: Taking good care of self Taking time to do enjoyable activities Spending time with people that make you feel good about yourself Learning something new Forgiving yourself Doing something nice for someone else Positive self-talk Giving yourself rewards Educational Platform

152. Self Concept and Nursing Process Assessment: Observe for behavior that suggest an alteration in the client’s self concept. Assess the client’s cultural background. Determine the client’s feelings and perceptions about changes in body image, self esteem or role Assess the quality of the clients relationship. Assess the client’s coping skills. Educational Platform

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

154. Self Concept and Nursing Process Decisional conflict. Ineffective coping. Fear Hopelessness Low self esteem Risk for loneliness Ineffective sexuality pattern Risk for self directed violence. Educational Platform

155. Self Concept and Nursing Process Planning: Select therapies that strengthen or maintain the client’s coping skills. Involve the client to ensure that realistic therapies are chosen. Minimize stressors affecting the clients self concept. Educational Platform

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

157. Health Promotion: The nurse may work with clients to help them develop healthy life style behaviors that contribute to positive self concept. To facilitate the client for adequate sleep and rest and stress reducing practices may make health self concept. E.g. Guided imaginary. Educational Platform

158. References Sandy L. Brook introduction to nursing self concept, 3 rd edition. Michael A Bettman FACRS “Self Esteem article” 1960. Thomas Fuller Ph.D/MCPR “Teaching and Learning” 1955. John Jackson M.D “Manual of nursing research 6 th edition. Bell state university school of nursing (2001). Clinical preceptor information, retrieved March 5, 2003. Educational Platform

159. Concept of Pain By: Zafar Iqbal/Ibne Amin Khyber Medical university

160. Introduction Pain is the fifth Vital sign and is regarded as a symptom of an underlying condition Pain is a complex experience consisting of physiological and a psychological response to a noxious stimulus. Pain is a warning mechanism that protects an organism by influencing it to withdraw from harmful stimuli; it is primarily associated with injury or the threat of injury. Pain is subjective and difficult to quantify, because it has both an affective and a sensory component

161. Objectives At the end of this unit, learners will be able to: Define the process of pain (physiological changes) Describe the different theories of pain theory. Differentiate between acute and chronic pain Discuss the non-pharmacologic interventions pain management. Identify pharmacologic interventions for pain management

162. Definition of Pain The International Association for the Study of Pain (IASP) defines pain as " an unpleasant sensory and emotional experience that is associated with actual or potential tissue damage , or described in terms of such damage.

163. Pain Process A nociceptor is a receptor of a sensory neuron (nerve cell) that responds to potentially damaging stimuli by sending signals to the spinal cord and brain. This process, called nociception, usually causes the perception of pain Distributed throughout the body (skin, viscera, muscles, joints, meninges) they can be stimulated by mechanical, thermal or chemical stimuli.

164. Pain Process There are four major processes: transduction, transmission, modulation, and perception

165. Transduction Transduction refers to the process by which a painful physical or chemical stimulus is transformed into a signal that can be carried (via transmission) to the central nervous system and perceived as pain.

166. Transmission Once transduction is complete transmission of pain begins, Painful stimuli produce nerve impulses that travel along efferent nerve fibers. A-delta fiber (fast myelinated ) Send sharp localized and distinct sensation C-fiber (Slow unmyelinated ) Slow impulses e.g needle stick,

167. Perception Perception of pain occurs when the pain impulse has been transmitted to the cortex and the person develops conscious awareness of the intensity, location, and quality of pain

168. Modulation Modulation of pain refers to activation of neural pathways that inhibit transmission of pain The periaqueductal gray (PAG), dorsolateral pontine tegmentum (DLPT), and rostroventral medulla (RVM) are the key regions of the brain involved in this descending pain modulation

169. Theories of Pain Several theoretical frameworks have been proposed to explain the physiological basis of pain, although none yet completely accounts for all aspects of pain perception. A number of theories have been postulated to describe mechanisms underlying pain perception. Some of which are:

170. Theories of Pain Intensive Theory ( Erb , 1874) Strong's Theory (Strong, 1895)  Specificity Theory (Von Frey, 1895) Pattern Theory( Goldschneider  (1920) Central Summation Theory (Livingstone, 1943) Sensory Interaction Theory ( Noordenbos , 1959) Gate Control Theory ( Melzack and Wall, 1965)

171. Gate Control Theory  Ronald Melzack and Patrick Wall proposed the Gate Control Theory in 1965. The gate control theory of pain asserts that non-painful input closes the "gates" to painful input, which prevents pain sensation from traveling to the central nervous system. Therefore, stimulation by non-noxious input is able to suppress pain.

172. Types of Pain There are several ways to categorize pain. One is to separate it into acute and chronic pain. Acute pain typically comes on suddenly and has a limited duration. It's frequently caused by damage to tissue such as bone, muscle, or organs, and the onset is often accompanied by anxiety or emotional distress. Chronic pain lasts longer than acute pain and is generally somewhat resistant to medical treatment. It's usually associated with a long-term illness, such as osteoarthritis

173. Types of Pain Pain is often classified by the kind of damage that causes it. The two main categories are pain caused by tissue damage, also called nociceptive pain , and pain caused by nerve damage, also called  neuropathic pain . A third category is psychogenic pain , which is pain that is affected by psychological factors

174. Types of Pain Somatic pain, visceral pain and Cutaneous is another classification of pain based on origin Somatic pain comes from the skin. muscles, and soft tissues, while visceral pain comes from the internal organs. Cutaneous pain : is caused by stimulation of the cutaneous nerve endings in the skin.

175. Non-pharmacological interventions Non-pharmacological pain therapy refers to interventions that do not involve the use of medications to treat pain. The goals of non-pharmacological interventions are to decrease fear, distress and anxiety, and to reduce pain and provide patients with a sense of control. The advantage of non-pharmacological treatments is that they are relatively inexpensive and safe

176. Non-pharmacological interventions Non-pharmacological therapies are typically categorized into: Physical (sensory) interventions Psychological interventions

177. Physical (sensory) interventions Physical (sensory) interventions typically are patient-specific and inhibit nociceptive input and pain perception. Some measures that can reduce pain intensity and improve the patient quality of life such as massage, positioning, hot and cold treatment, transcutaneous electrical nerve stimulation (TENS), acupuncture and progressive muscle relaxation

178. Psychological interventions Continuous pain may lead to development of maladaptive status and behavior that worsen day to day function, increase distress, or enhancing the experience of pain Most commonly used psychological interventions are: cognitive behavioral therapy, mindfulness-based stress reduction, acceptance and commitment therapy (ACT), meditation, guided imagery and biofeedback. Others: Spirituality and religion in pain management and music therapy.

179. Pharmacological interventions Pharmacological pain therapy refers to interventions that involve the use of medications to treat pain. A wide range of drugs are used to manage pain resulting from inflammation in response to tissue damage, chemical agents/pathogens (nociceptive pain) or nerve damage (neuropathic pain).

180. Pharmacological interventions W HO Analgesic Ladder Step 1-3 Originally developed by the World Health Organization (WHO) to improve management of cancer pain The 3 step WHO analgesic ladder is also used for providing stepwise pain relief for pain due to other causes.

181. Pharmacological interventions Non-opioid medications: Step 1 - WHO Analgesic ladder Mild to Moderate pain: Non-steroidal anti-inflammatory drugs (NSAIDs) Paracetamol also known as acetaminophen Aspirin also known as acetylsalicylic acid (ASA)

182. Pharmacological interventions Compound analgesics: Step 2 on the WHO analgesic ladder – mild to moderate pain Compound analgesics are a combination of drugs in a single tablet usually including codeine (a weak opiate) and aspirin or paracetamol . Examples include co- codamol and co- dydramol which contain codeine and paracetamol in various formulas (8/500, 10/500, 15/500, 30/500) where the first number refers to the amount of codeine and the second to paracetamol

183. Pharmacological interventions Opioid medications: Step 3 on the WHO analgesic ladder – severe pain Medications derived from morphine (or synthetic analogs)  mimic the body’s own analgesic system and are strongest and most effective painkillers currently available. Opioid medications include morphine, oxycodone, codeine, tramadol, buprenorphine, fentanyl and diamorphine (heroin)

184. Pharmacological interventions Adjuvants: The WHO analgesic ladder recommends that patients are prescribed additional medication to manage the symptoms of neuropathic pain. These drugs include tricyclic antidepressants and antiepileptic drugs Topical analgesics: Topical analgesics can provide localized pain relief and are used to treat acute and chronic pain, such as musculoskeletal and neuropathic pain, as well as muscle pain related to trauma. Topical analgesics include  rubefacients , topical NSAIDs and local anaesthetics .

185. Group Assignment ; Give brief description of the following Pain Management theories. Intensive Theory (Erb, 1874) Strong's Theory (Strong, 1895)  Specificity Theory (Von Frey, 1895) Pattern Theory(Goldschneider (1920) Central Summation Theory (Livingstone, 1943) Sensory Interaction Theory (Noordenbos, 1959) Note : Submit it before Monday , 22 nd Nov ,2021 at [email protected]

186. C oncept of Nutrition and Dietary Pattern Shabnam Faculty INS-KMU

187. Objectives At the end of this unit learners will be able to: Define nutrition/metabolic pattern. Review essential nutrients and examples of good dietary sources for each. Review normal digestion, absorption, and metabolism of carbohydrates, fats, and proteins. Discuss nutritional considerations across the life span list factors that can effect dietary pattern Describe manifestations of altered nutrition Explain nursing interventions to promote optimal nutrition and insta | husain.z.kmu

188. Nutrition-Metabolic pattern Pattern of food and fluid consumption relative to metabolic need and pattern. Nutrition: The science related to the food requirements of the body. insta | husain.z.kmu

189. Nutrition Nutrition is the intake of food, considered in relation to the body’s dietary needs. Good nutrition – an adequate, well balanced diet combined with regular physical activity – is a cornerstone of good health. Poor nutrition can lead to reduced immunity, increased susceptibility to disease, impaired physical and mental development, and reduced productivity . (WHO) insta | husain.z.kmu

190. Nutrition This field of study focuses on substances in foods that help living things to grow and stay healthy. The foods we eat provide energy and nutrients such as protein fat, Carbohydraye,vitamins, minerals and water. Nutrient Nutrients are chemical compounds in food that are used by the body to function properly and maintain health. Examples include proteins, fats, carbohydrates, vitamins, and minerals. insta | husain.z.kmu

191. Essential nutrients Essential nutrients for body growth are include: Protein Fats Carbohydrates insta | husain.z.kmu

192. Protein According to the Dietary Reference Intakes published by the USDA 10% - 35% of calories should come from protein. Used for building, growth or recovery of cells and tissues. Major constituent of hormones, enzymes and antibodies. Found in meat, fish, eggs, pulses etc. insta | husain.z.kmu

193. Fats According to the Dietary Reference Intakes published By the USDA 20% - 35% of calories should come from fat. Source of energy (1 gram of fat yields 9 k cales ). Component of cell membranes. Found in solid fats and liquid oils, in dairy products. Absorbing certain vitamins ( like vitamins A, D, E, K ) Providing cushioning for the organs. Fat is found in meat, poultry, nuts, milk products, butters and margarines, oils, fish, grain products. insta | husain.z.kmu

194. Carbohydrate Reference Intakes published by the USDA, 45% - 65% of calories should come from carbohydrate. Source of energy (1 gm yields 4 kcals). Helps in digestion and bowel function. All of the tissues and cells in our body can use glucose for energy. insta | husain.z.kmu

195. Carbohydrates can be stored in the muscles and liver and later used for energy. Fiber refers to certain types of carbohydrates that our body cannot digest. These carbohydrates pass through the intestinal tract intact and help to move waste out of the body. Carbohydrate present in foods; include bread, rice, cereals, pasta, potatoes, flour, porridge and chapattis insta | husain.z.kmu

196. Digestion of carbohydrate Carbohydrates are broken down to provide glucose for Energy. Digestion occurs by enzymes lining the wall of the small intestine. Once absorbed, galactose and fructose are metabolized further by the liver to produce glucose and minimal amounts of other metabolites. Most commonly, carbohydrate metabolism results in the production of glucose molecules which are the most efficient source of energy (ATP) for our muscles and our brains. insta | husain.z.kmu

197. Digestion of protein Proteins are decomposed to single amino acids by digestion in the gastro-intestinal tract. Digestion typically begins in the stomach when pepsinogen is converted to pepsin by the action of hydrochloric acid, and continued by trypsin and chymotrypsin(secreted by pancreas) in the small intestine. insta | husain.z.kmu

198. Digestion of fat Fats are mainly digested in the small intestine. The presence of fat in the small intestine produces hormone that stimulate the release of pancreatic lipase from the pancreas and bile from the liver which helps in the emulsification of fats into fatty acids and glycerol for absorption of fatty acids. Only freely dissolved monoglycerides and fatty acids can be absorbed. insta | husain.z.kmu

199. Nutritional consideration across life span insta | husain.z.kmu

200. Babies – birth to six months of age Breast milk is preferred to infant formula where possible, as it contains many protective and immunological factors that benefit the baby’s development. Breast milk generally supplies a baby with the required amounts of nutrients, fluids and energy up to about six months of age. It is recommended that infants be exclusively breastfed up to around six months of age. insta | husain.z.kmu

201. Food for babies – six to 12 months of age Avoid cow’s milk as a drink in the first 12months. Small amounts can be used in cereals and custards. All milk used should be pasteurized. insta | husain.z.kmu

202. Cont. Avoid whole nuts, seeds or similar hard foods to reduce the risk of choking. Feed babies during any illness and feed up after illness. Give ample liquids if your baby has diarrhea. Occasional exposure of the skin to sunlight is usually enough to provide a baby’s vitamin-D requirements. insta | husain.z.kmu

203. Food for young children Once a child is eating solids, offer a wide range of foods to ensure adequate nutrition. Young children are often selective with food, but should be encouraged to eat a wide variety of foods. If a child is gaining inappropriate weight for growth, limit energy-dense, nutrient-poor snack foods. Increase your child’s physical activity. Ensure your child has enough fluids, especially water. Fruit juices should be limited and soft drinks avoided. insta | husain.z.kmu

204. Food for children entering their teenage years The extra energy required for growth and physical activity needs to be obtained from foods that also provide nutrients, instead of just ‘empty calories. Milk, yoghurt and cheese (mostly reduced fat) should be included to boost calcium intake – this is especially important for growing bones. insta | husain.z.kmu

205. Conti… Adolescent girls should be particularly encouraged to consume milk and milk products. Takeaway and fast foods need to be balanced with nutrient-dense foods such as wholegrain breads and cereals, fruits, legumes, nuts, vegetables, fish and lean meats. insta | husain.z.kmu

206. Older teenagers and young adults Moving away from home, starting work or study, and the changing lifestyle that accompanies the late teens and early 20s can cause dietary changes Make a deliberate effort to keep physically active. Reduce the amount of fats and salt in the daily diet. Be careful to include foods rich in iron and calcium. Establish healthy eating habits that will be carried on into later life. insta | husain.z.kmu

207. Food for older people Many people eat less as they get older, this can make it harder to make sure your diet has enough variety to include all the nutrition you need. Recommendations include: Be as active as possible to encourage your appetite and maintain muscle mass. Remain healthy with well-balanced eating and regular exercise. insta | husain.z.kmu

208. If possible, try to spend some time outside each day to boost your vitamin D synthesis for healthy bones. Limit foods that are high in energy and low in nutrients such as cakes, sweet biscuits and soft drinks. Choose foods that are naturally high in fiber to encourage bowel health. Limit the use of table salt, especially during cooking. insta | husain.z.kmu

209. Eat foods that are nutrient dense rather than energy dense, including eggs, lean meats, fish, low-fat dairy foods, nuts and seeds, legumes, fruit and vegetables, wholegrain breads and cereals. insta | husain.z.kmu

210. Manifestations of altered nutrition Disturbed GI function Cardiovascular function Dry lips Bleeding gums Coated/ dry tongue Vision loss Obesity Underweight Altered bowel patterns Altered skin, teeth, hair, and mucous membrane Overweight insta | husain.z.kmu

211. Manifestations of altered nutrition Dehydration Fatigue Skin manifestations, include, poor wound healing Ulceration Dry skin Impact on activities of daily living General manifestations, Weight loss Muscle wasting Muscle weakness insta | husain.z.kmu

212. Assessment When conducting a nutrition assessment, check the patient for : Trouble chewing Swallowing disorders Weight history Height and weight Measurement Skin integrity Edema Electrolyte abnormalities Hand-grip strength (have the patient squeeze your hand). insta | husain.z.kmu

213. Nutritional-Metabolic Pattern Purpose The purpose of assessing the client's nutritional- metabolic pattern is to determine the client dietary habits and metabolic needs. The conditions of hair, skin, nails, teeth and mucous membranes are assessed. insta | husain.z.kmu

214. Subjective Data Guideline Questions Dietary and Fluid Intake Describe the type and amount of food you eat at breakfast, lunch, and supper on an average day Do follow any certain type of diet? Explain. What time do you usually eat your meals? insta | husain.z.kmu

215. CONT… Do you find it difficult to eat meals on time? Explain. What types of snacks do you eat? How often? Do you take any vitamin supplements? Describe. Do you consider your diet high in fat? Sugar? Salt? insta | husain.z.kmu

216. CONT… Do you find it difficult to tolerate certain foods? Specify. What kind of fluids do you usually drink? How much per day? Do you have difficulty chewing or swallowing food? When was your last dental exam? What were the result? Do you ever experience sore throat, sore tongue, sore gums? Describe insta | husain.z.kmu

217. CONT… Do you ever experience nausea and vomiting? Describe. Do you ever experience abdominal pains? Describe. Do you use antacids? How often? What kind? insta | husain.z.kmu

218. CONDITION OF HAIR & NAILS Describe the condition of your hair, nails? Do you have excessively oily or dry hair? Have you had difficulty with scalp itching or sores? Do you use any special hair or scalp care products? Have you noticed any changes in your nails? Color Cracking? Shape? Lines? insta | husain.z.kmu

219. CONDITION OF SKIN Describe the condition of your skin. How well and how quickly does your skin heal? Do you have any skin lesions? Describe? Do you have excessive oily or dry skin? Do you have any itching? What do you do for relief? insta | husain.z.kmu

220. METABOLISM What would you consider to be your "ideal weight"? Have you had any recent weight gains or losses? Have you used any measures to gain or lose weight? Describe. Do you have any intolerance to heat or cold? Have you noted any changes in your eating or drinking habits? Explain. insta | husain.z.kmu

221. OBJECTIVE DATA Assess the client's temperature, pulse, respirations, and height and weight. insta | husain.z.kmu

222. ACTUAL DIAGNOSIS Ineffective Thermo regulation. Fluid Volume Deficit Fluid Volume Excess Altered Nutrition: Less than body requirements Altered Nutrition: More than body requirements Subcutaneous fat loss Related to malnutrition insta | husain.z.kmu

223. ACTUAL DIAGNOSIS Ineffective Breastfeeding Interrupted Breastfeeding Ineffective Infant Feeding Pattern Impaired Swallowing Altered Protection Impaired Tissue Integrity Impaired Skin Integrity insta | husain.z.kmu

224. Nutrition and Metabolic Pattern  Number of meals per day. Break fast: _____________Lunch_________ Dinner__________ Snacks ______________________ Food Preference:(1) Like :_________________( 2) Dislikes__________________________ Amount of fluids per day: ________________Rout (I/V) _________Oral________________ Tube feeding __________________Any dietary restriction__________________________ Any fluid restriction________________________________________ Skin Turgor _________________Color______________Texture______________Edema_______ Hair:Texture______________________Distribution__________________________ Oral mucus membrane: _______________Gums_____________No of teeth_____________ Alignment: ___________________Dentures:________ Height_________ Weight________ Labs; HB____________ HCT_____________ WBC ______________ESR _________ RBC_____________Platelets____________PT_________ APTT _________INR ________ Albumin _____________ Na_____________ K __________Ca______ Mg___________ Others___________________ Nursing Diagnosis: __________________________________________________________ __________________________________________________________________________   insta | husain.z.kmu

225. Nursing intervention to provide optimal dietary health Nurses are often the ones who spend the most time with the patient. Therefore, their understanding of nutrition is critical. Educate the patient that : Modifiable risk factors such as unhealthy diet, physical inactivity, tobacco use and harmful use of alcohol are major causes of CVDs.(who) insta | husain.z.kmu

226. Interventions Daily measure weight. Determine daily caloric need. Teach the patient about importance of balanced diet. Monitor intake and output daily. Educate about importance of food to prevent from dehydration, and constipation. insta | husain.z.kmu

227. Interventions Give encouragement of individual to eat with others. Avoid excessive use of alcohol and caffeine etc. Give more protein and high fiber diet and avoid excessive carbohydrate and fats. insta | husain.z.kmu

228. Exercise? Discuss nutritional requirement for a patient with; Diarrhea Constipation Immobility Over weight insta | husain.z.kmu

229. Questions? insta | husain.z.kmu

230. ELIMINATION PATTERN By: Ibne Amin (INS ),Khyber Medical university

231. Objectives By the end of the session the students will be able to: Review the basic anatomy of digestive system Define elimination pattern Discuss common problem of bowel elimination Identify nursing care for common problem of fecal elimination Discuss common problems of urinary elimination Identify nursing intervention for common urinary problems Describe factors that can alter urinary function Discuss nursing care for alterations in elimination pattern insta | husain.z.kmu

232. Anatomy of Digestive System insta | husain.z.kmu

233. Anatomy of GIT. Human GI system is composed of; Mouth Pharynx Larynx Esophagus Stomach accessory organs. Small intestine Large intestine Anus . insta | husain.z.kmu

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

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

236. Bowel Elimination Large intestine (colon) is about 125-150 cm long It has seven parts: Cecum, ascending, transverse, and descending; sigmoid colon, rectum, and anus. The colon forms pouches called haustra (haustrum is singular) The large intestine is a muscular tube lined with mucous membrane The muscles are circular and longitudinal to facilitate peristaltic movements. insta | husain.z.kmu

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238. Types of Colon Movements Haustral Churning involves back and forth movement of chyme within the colon. Colon Peristalsis is relatively sluggish movement of the chyme along the colon. Mass Peristalsis is powerful muscular movement along the colon insta | husain.z.kmu

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

240. Characteristics of Feces Feces (Healthy People): Soft, brown, moist, and firmed. Distinct odor. Factors affecting the odor or appearance: Certain foods. Medications. Illness or infection. insta | husain.z.kmu

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

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

243. Factors Impairing Elimination Emotional anxiety Failure to heed defecation reflex, lack of time and privacy High carbohydrate, high fat diet Reduced fluid intake Immobility and inactivity Overuse of cathartics, narcotic analgesic Inability to squat because of immobility, musculoskeletal deformity; pain during defecation insta | husain.z.kmu

244. Alteration in Bowel Elimination Diarrhea : Liquid watery stools..deals with the consistency and frequency Constipation : Less then 3 times/week or what ever is less then the pt. Regular pattern of elimination Incontinence : Inability to control fecal discharge thru anal sphincter. Involuntary passage of stool Fecal Impaction: Mass of hardened feces in rectum…recognized by seepage Flatulence :- Gas, Abdominal Distention & Pain insta | husain.z.kmu

245. Assessing Elimination Status Usual pattern: -How often, When Changes in Bowels: Blood, Mucus Aids to Eliminate: - Laxatives Enemas Current Problems: Food Related, Meds Physical, Emotional, Artificial Orifices, Hemorrhoids (abnormally distended veins)..Colostomy insta | husain.z.kmu

246. Physical Assessment I nspection - Observe contour of abdomen and note visible peristalsis Auscultation - Listen for bowel sounds in all quadrants Percussion- Resonant or tympany over hollow organs…dullness over intestinal obstruction Palpation - Feel for masses, tenderness etc insta | husain.z.kmu

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

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

249. Nursing Interventions for Constipated Patients Increase fluid intake. Instruct the patient to drink fruit juices. Include fiber in the diet with foods. Administration of laxatives. Administration of Enema insta | husain.z.kmu

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

251. Nursing Interventions for Fecal Incontinence Give balanced meals Note time of incontinence Toilet pt 30 – 60 min before usual time of incontinence Begin bowel training program…supp every 3 days insta | husain.z.kmu

252. Nursing Interventions of Fecal Impaction Education/counseling/habit training Diet (fiber, lactose, fructose) Reduce caffeine intake Anal hygiene/skin care Digital removal of stool insta | husain.z.kmu

253. N.Interventions for Flatulence Decreasing flatulus by avoiding gas – producing food, exercise, moving in bed and ambulation Glycerin Suppository insta | husain.z.kmu

254. Plan and Implementation Promotion of regular bowel habits Promotion of normal defecation Digital removal of stool Maintenance of proper fluid/ food intake Promotion of regular exercise Promotion of comfort insta | husain.z.kmu

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

256. Urinary Elimination insta | husain.z.kmu

257. insta | husain.z.kmu

258. Anatomy of Renal system The renal system is composed of; 2 kidneys 2 ureters 1 urinary bladder 1 urethra insta | husain.z.kmu

259. Structure of kidney Kidneys are pairs of organ Shape : Bean shaped Size: 11cm long,6 cm wide, 3 cm thick Weight : 150 g. Location : The kidneys lie on the posterior abdominal wall, one on each side of the vertebral column. Position:  It is situated at T12-L3. (3) insta | husain.z.kmu

260. cont ’ Longitudinal section of the kidney shows following parts. Capsule Cortex. Medulla Hilum (3) insta | husain.z.kmu

261. insta | husain.z.kmu

262. insta | husain.z.kmu

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

264. Urination Micturation, voiding, and urination all refer to the process of emptying the urinary bladder Stretch receptors- special sensory nerve endings in the bladder wall that is stimulated when pressure is felt from the collection of urine – Adult: 250-450mL of urine – Children: 50-200mL of urine insta | husain.z.kmu

265. insta | husain.z.kmu

266. Factors affecting voiding Growth and development Psychosocial factors Fluid and food intake Medications Muscle tone and activity Pathologic conditions Surgical and diagnostic procedures insta | husain.z.kmu

267. Common Urinary Elimination Problems Urinary retention Urinary tract infections Urinary incontinence. insta | husain.z.kmu

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

269. Assessing Urinary Function Determine normal voiding pattern and frequency Appearance of urine Recent changes Past or current problems with urination (burning, urgency,etc). Presence of an ostomy Factors influencing elimination pattern. insta | husain.z.kmu

270. Assessment Nursing history: Voiding pattern, description of urine for any changing. Urinary elimination problem. Presence of urinary diversion. Physical assessment: inspection, palpation, percussion and auscultation. insta | husain.z.kmu

271. Assessing Urine Color: transparent. Normal kidney produce urine at the rate of 40-60 ml/hr or 1500-2000 ml/day Sterility: no microorganism present. Glucose: not present. Blood: not present. Epithelial cell not present. Measuring urine output. Colleting urine specimen. insta | husain.z.kmu

272. Nursing Diagnosis Altered urinary elimination related to bladder neck obstruction. Stress incontinence related to relaxation of sphincter. Risk for infection related to urinary retention. Self esteem disturbances related to urinary incontinence. insta | husain.z.kmu

273. PLANNING Maintain normal voiding pattern. Regain normal urine output. Prevent infection. Maintaining normal urinary elimination: Promote fluid intake. Assisting with toileting. Preventing urinary tract infection: Increased fluid intake. Practice frequent voiding process... Strengthening pelvic floor muscles Manual bladder compression & Kegal exercise insta | husain.z.kmu

274. Managing Urinary Incontinence (UI) Bladder training- requires that the client postpone voiding, resist or inhibit the sensation urgency, and void according to a timetable rather than according to the urge to void. The goal is to lengthen the intervals between urination to correct the client’s habit of frequent urination Habit training- also referred to as timed voiding or scheduled toileting. There is no attempt to motivate the client to delay voiding is the urge occurs. Prompt voiding- supplements the habit training by encouraging the client to use the toilet and reminding the client when to void insta | husain.z.kmu

275. Managing Urinary Incontinence (UI) Pelvic Muscle Exercises (PME) Referred to as perineal muscle tightening or Kegel’s exercises Streghthen pubococcygeal muscles and can increase the incontinent female’s ability to start and stop the stream of urine insta | husain.z.kmu

276. Managing Urinary Incontinence (UI) • Positive reinforcements • Maintaining skin integrity • Applying external urinary devices insta | husain.z.kmu

277. Managing Urinary Retention Urinary catheterization insta | husain.z.kmu

278. References 1:Olowu WA, Niang A, Osafo C, Ashuntantang G, Arogundade FA, Porter J, et al. lancet global health, 2016. 2:https://www.webmd.com › Kidney Stones › News. 3:http:// www.newhealthadvisor.com /kidney-structure-and- function.html . 4: Porth , C., & Hannon, R. (2009).  Porth pathophysiology . Philadelphia, Pa.: Lippincott Williams & Wilkins.Mein insta | husain.z.kmu

279. Concept of Sleep & Rest By : Ibne Amin Lecturer , INS Khyber Medical University,Peshawar

280. Objectives 1. Define rest and sleep pattern 2. Define terms related to rest and sleep. 3. Compare the characteristics of sleep and rest. 4. Discuss the characteristics of two kinds of sleep. 5. Enumerate the functions of sleep. 6. Discuss factors affecting sleep. 7. Identify common sleep disorders. 8. Identify conditions necessary to promote sleep. 9. Discuss nursing process for a patient to promote sleep insta | husain.z.kmu

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

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

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

285. Sleep An altered state of consciousness in which the individual’s perception of and reaction to the environment is decreased. OR A physical and mental resting state in which a person becomes relatively inactive and unaware of the environment. Sleep is a partial detachment from the world, where most external stimuli are blocked from the senses. insta | husain.z.kmu

286. Compare the characteristics of Sleep & Rest. Sleep Sleep is a body-mind state in which we experience sensory detachment from our surroundings . Sleep is associated with a typical posture,such as lying down with eyes closed Sleep results in a decreased responsiveness to an external stimuli It’s a narrow term. Sleep is physical We need 7.5 hours of sleep per day Rest Rest is a condition in which the body is in a decreased state of activity without physical, emotional stress and freedom from anxiety. No typical posture required for rest In other resting conditions we are in contact with external stimuli It’s a broader term. Rest is spiritual We need 2 hours to 2-25 min rest per day insta | husain.z.kmu

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

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

289. Stages of Sleep Non Rapid Movement (NREM) About 75% to 80% of sleep during a night is NREM sleep. NREM sleep is divided into four stages, each associated with distinct brain activity and physiology. NREM –Non rapid eye moment Stage -I Stage -II Stage -III Stage-IV insta | husain.z.kmu

290. 1. Characteristics of NREM Stage I Stage I is the stage of very light sleep and lasts only a few minutes. During this stage, the person feels drowsy and relaxed, the eyes roll from side to side, and the heart and respiratory rates drop slightly. The sleeper can be readily awakened and may deny that he or she was sleeping. Relax and drowsy Profound and restfullness Floating sensation Eyes roll from sisde to side Usually last only a few minutes insta | husain.z.kmu

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

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

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

294. 1. Characteristics of NREM Stages III & stage IV Stages III and IVare the deepest stages of sleep, differing only in the percentage of delta waves recorded during a 30-second period. During deep sleep or delta sleep,the sleeper’s heart and respiratory rates drop 20% to 30% below those exhibited during waking hours. The sleeper is difficult to arouse. The person is not disturbed by sensory stimuli, the skeletal muscles are very relaxed, reflexes are diminished, and snoring is most likely to occur. Even swallowing and saliva production are reduced during delta sleep (Choudhary & Choudhary, 2009). These stages are essential for restoring energy and releasing important growth hormones insta | husain.z.kmu

295. 2.Characteristics of REM This sleep type usually recurs about every 90 minutes and lasts 5 to 30 minutes. Othername: PARADOXICAL Sleep. The EEG pattern resembles that of the “ awake” state. This is not as restful as NREM sleep. Most dreams take place during this period and the dreams are usually remembered or consolidated to memory. The brain is highly active with metabolic rate increasing as much as 20% . insta | husain.z.kmu

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

297. NREM VS REM Sleep NREM Slow eye movement Restful sleep Decrease metabolism Vital sign low Muscle tone maintained No vivid draems REM Rapid eye movement Not restful Increased metabolism Vital signs irregular Muscle tone depressed Dreams occur insta | husain.z.kmu

298. Sleep Cycles During a sleep cycle, people typically pass through NREM and REM sleep, the complete cycle usually lasting about 90 to 110 minutes in adults. In the first sleep cycle, a sleeper usually passes through all of the first three NREM stages in a total of about 20 to 30 minutes. Then, stage IVmay last about 30 minutes. After stage IV NREM, the sleep passes back through stages III and II over about 20 minutes. Thereafter, the first REM stage occurs, lasting about 10 minutes, completing the first sleep cycle. insta | husain.z.kmu

299. Sleep Cycles It is not unusual for the first REM period to be very brief or even skipped entirely. The healthy adult sleeper usually experiences four to six cycles of sleep during 7 to 8 hours . The sleeper who is awakened during any stage must begin a new at stage I NREM sleep and proceed through all stages to REM sleep. insta | husain.z.kmu

300. Sleep Cycle insta | husain.z.kmu

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

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

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

304. Factors Affecting sleep Both the quality and the quantity of sleep are affected by a number of factors. Factors that affects sleeps are: Age Illness Environment Lifestyle Emotional stress Stimulants and Alcohol Diet Smoking Motivation Medications insta | husain.z.kmu

305. Factors Affecting sleep Age Newborn: 16-18 hours /day Infants: 12-14 hours Toddlers: 10-12 hours Preschool: 11-12 hours School-Age: 8- 12 hours Adolescents: 8-10 hours Adult: 6-8 hours Elders: 6 hours insta | husain.z.kmu

306. Factors Affecting sleep Certain endocrine disturbances can also affect sleep. Hyperthyrodism lengthens presleep time making it difficult for a client to fall asleep.Hypothyroidism, conversely, decreases stage IV sleep. Elevated body temperatures can cause some reduction in delta sleep and REM sleep. The need to urinate during the night also disrupts sleep, and people who awaken at night to urinate sometimes have difficulty getting back to sleep. insta | husain.z.kmu

307. Factors Affecting sleep 2. Illness Illness that causes pain or physical distress (e.g., arthritis, back pain & low level of estrogen) can result in sleep problems. People who are ill require more sleep than normal, and the normal rhythm of sleep and wakefulness is often disturbed. Respiratory conditions can disturb an individual’s sleep. People who have gastric or duodenal ulcers may find their sleep disturbed because of pain, often a result of the increased gastric secretions that occur during REM sleep. insta | husain.z.kmu

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

309. Factors Affecting sleep In fact, some hospitals have instituted “quiet times” in the afternoon on nursing units where the lights are lowered and activity and noise are purposefully decreased so clients can rest or nap.Discomfort from environmental temperature (e.g., too hot or cold) and lack of ventilation can affect sleep. Light levels can be another factor. A person accustomed to darkness while sleeping may find it difficult to sleep in the light. Another influence includes the comfort and size of the bed. A person’s partner who has different sleep habits, snores, or has other sleep difficulties may become a problem for the person also. insta | husain.z.kmu

310. Factors Affecting sleep 4.Lifestyle Following an irregular morning and night time schedule can affect sleep. Moderate exercise in the morning or early afternoon usually is conducive to sleep, but exercise late in the day can delay sleep. The person’s ability to relax before retiring is an important factor affecting the ability to fall asleep. It is best, therefore, to avoid doing homework or office work before or after getting into bed. insta | husain.z.kmu

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

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

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

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

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

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

317. Factors Affecting sleep 10. Medications Some medications affect the quality of sleep. Most hypnotics can interfere with deep sleep and suppress REM sleep. Beta-blockers have been known to cause insomnia and nightmares. Narcotics, such as morphine, are known to suppress REM sleep and to cause frequent awakenings and drowsiness. Tranquilizers interfere with REM sleep. Although antidepressants suppress REM sleep, this effect is considered a therapeutic action insta | husain.z.kmu

318. Common Sleep Disorders. A knowledge of common sleep disorders can help nurses assess the sleep complaints of their clients and, when appropriate, make a referral to a specialist in sleep disorders medicine. Sleep disorders are typically categorized for the purpose of research as Dysomnias, Parasomnias, and Disorders associated with medical or psychiatric illness, Primary disorders can be divided into parasomnias and dyssomnias. Parasomnia sleep disorders cause abnormal activities during sleep, such as sleep terrors or sleep walking. Dyssomnia sleep disorders cause trouble falling asleep or staying asleep. insta | husain.z.kmu

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

320. Common Sleep Disorders The two main risk factors of insomnia are 1) Older age and 2) Female gender (National Sleep Foundation). Women suffer sleep loss in connection with hormonal changes (e.g., menstruation, pregnancy, and menopause). The incidence of insomnia increases with age, but it is thought that this is caused by some other medical condition. insta | husain.z.kmu

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

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

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

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

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

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

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

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

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

330. Parasomnias Bruxism. Usually occurring during stage II NREM sleep, this clenching and grinding of the teeth can eventually erode dental crowns, cause teeth to come loose, and lead to deterioration of the temporomandibular (TMJ) joint, called TMJ syndrome. Enuresis. Bed-wetting during sleep can occur in children over 3 years old. More males than females are affected. It often occurs 1 to 2 hours after falling asleep, when rousing from NREM stages III and IV. insta | husain.z.kmu

331. Parasomnias Periodic limb movement disorder (PLMD). In this condition, the legs jerk twice or three times per minute during sleep. It is most common among older adults. This kicking motion can wake the client and result in poor sleep. Sleeptalking. Talking during sleep occurs during NREM sleep before REM sleep. It rarely presents a problem to the person unless it becomes troublesome to others. Sleepwalking. Sleepwalking (somnambulism) occurs during stages III and IV of NREM sleep. It is episodic and usually occurs 1 to 2 hours after falling asleep. Sleepwalkers tend not to notice dangers (e.g., stairs) and often need to be protected from injury. insta | husain.z.kmu

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

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

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

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

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

337. Nursing Process for a Patient to Promote Sleep insta | husain.z.kmu

338. Assessment of Sleep Assessment of a client’s sleep includes: Sleep history Physical examination Sleep diary insta | husain.z.kmu

339. Sleep Rest Pattern No of hour’s sleep/24 hours: Home______________ Hospital __________ Naps Any problem to fall/stay a sleep___________ Use of tranquillizers___________ Any home remedy to induce sleep___________ insta | husain.z.kmu

340. Sleep Rest Pattern Evidence of lack of sleep_____ Quality of sleep______ Nursing diagnosis insta | husain.z.kmu

341. Sleep History When does client usually go to sleep? Bedtime rituals? Can client stay away during day? Taking any prescribed medications? insta | husain.z.kmu

342. Sleep History What is the usual sleeping pattern, specifically: sleeping and waking times hours of undisturbed sleep, etc. Bedtime rituals Use of sleep medications Sleep environment Changes in sleep pattern insta | husain.z.kmu

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

344. Nursing Diagnosis Readiness for enhanced sleep Insomnia related to anxiety Insomnia related to the disruption in the amount and quality of sleep Sleep deprivation related to jet lag Sleep deprivation related to nocturnal work hours Sleep deprivation related to prolonged periods of time without sleep insta | husain.z.kmu

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

346. Intervention The promotion of sleep and adequate rest depends on correcting any underlying problems, including pain and alcohol use, and then planning activities and routines that will enhance the duration and the quality of sleep. Some of these sleep promotion interventions and schedules include: Establishing and adhering to a regular sleep time and wake time for the client based on their patterns and needs Limiting the duration and frequency of day time naps The promotion of daily exercise insta | husain.z.kmu

347. Conti... The avoidance of alcohol, caffeine, heavy meals and exercise at least a couple of hours before bedtime The promotion of comfort using techniques such as white noise, dim lighting, pain management, stress reduction techniques, massage and the elimination of environmental noise insta | husain.z.kmu

348. Close window curtains if street lights shine through Close curtains between clients in semiprivate and larger rooms Reduce or eliminate overhead lighting: provide night light at the bedside or in the bathroom Close the door of the client’s room Perform only essential noisy activities during sleeping hours Conti... insta | husain.z.kmu

349. Reducing environmental distractions in Hospitals Close window curtains if street lights shine through Close curtains between clients in semiprivate and larger rooms Reduce or eliminate overhead lighting: provide night light at the bedside or in the bathroom Close the door of the client’s room Perform only essential noisy activities during sleeping hours insta | husain.z.kmu

350. Ensure that all carts wheels are well oiled Wear rubber soled shoes Keep required staff conversations at low levels: conduct nursing reports or other discussions in a separate area away from clients rooms Conti... insta | husain.z.kmu

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

352. References Kozier & Erb’s Fundamental of Nursing Book, 8 th edition. Potter and Perry (2005) “Fundamentals of nursing” published by most by an imprint of Elsevier, 6th edition. New Delhi. Page no 1068 – 1071  www.google.com insta | husain.z.kmu

353. THANK YOU insta | husain.z.kmu

354. Human Responses to Illness Faculty: Ibne Amin INS, Khyber Medical University, Peshawar,

355. Definition of Health Health: It is a complete state of physical, mental, and social well being and not merely the absence of disease or infirmity. (WHO,1948) Second definition of Health Potter & Perry (2014) define health as a “ dynamic state, in which the individual adapts to changes in internal and external environments to maintain a state of well-being”.

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

357. Copyright 2008 by Pearson Education, Inc. Dimensions of Wellness

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

359. Dimensions of Wellness Social Potential: Able to interact successfully with people in one’s environment, to develop and maintain intimacy with others, to develop respect and tolerance about different opinions and believes.

360. Dimensions of Wellness Emotional Potential: Ability to manage stress, expresses emotions appropriately and accepts limitations. Intellectual Potential: Ability to learn and use information effectively for personal development and meeting new challenges.

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

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

363. Concepts of illness and disease Disease Disease can be described as an alteration in body functions resulting in a reduction of capacities or shortening of the normal life span. OR A disease is a pathological condition that impairs normal body structure and functions. ... Illness is a broad term that is used to describe a person who is in a poor state of health . Illness is not always due to disease . Illness: the unique response of a person to a disease It is an abnormal, highly personal and subjective feeling in which individual’s physical, emotional, intellectual, social, developmental or spiritual functioning is thought to be diminished or impaired

364. Illness • “Illness is a condition characterized by a deviation from a normal health state which is manifested by physical & psychological symptoms.” – Kozier. • “Illness is a state in which a person’s physical, intellectual, emotional, social or spiritual functioning is diminished or impaired in comparison with the previous experience”. Potter & Perry.

365. Variables Affecting Illness Behaviour 1. Internal Variables. 2. External Variables.

366. Variables Affecting Illness Behaviour INTERNAL VARIABLES 1. Perception of symptoms. 2. Nature of illness. 3. Characteristics of person

367. Internal Variables Perception of symptoms It is the way of perceiving the symptoms of illness that influence illness If a person takes the symptoms not too seriously & takes adequate treatment, recovery will be quick, but if a person takes it very seriously , it may become life threatening or fatal for the person.

368. Internal Variables 2.Nature of illness Nature of illness also affects illness behaviour. Acute illness : Generally has a rapid onset of symptoms and lasts only for a relatively short time Examples: Appendicitis, Pneumonia, Diarrhea, Common Cold – Short duration – Mostly severe – Starts abruptly and subsides in relatively short period (less than 6 months) Chronic illness A broad term that encompasses many different physical and mental alterations . It is a permanent change It causes/is caused by irreversible alterations in normal A & P It requires special patient education for rehabilitation It requires a long period of care or support Examples: Diabetes Mellitus, COPD, Arthritis, CRF etc – Persist for more than six months – May affect functioning of body in any dimension – Up to the level of disability – Major health problem

369. Internal Variables 3. Characteristics of a person How a person responds to illness depends upon the adjusting, coping abilities. He may become well adjusted to illness or may get mentally disturbed

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

371. External Variables 1.VISIBILITY OF SYMPTOMS The visibility of symptoms affects body image as well as behaviour. The clients with visible symptoms are more likely to seek more assistance than clients without symptoms. E.g. A person with lip ulcer will seek medical help sooner than a person with sore throat because the lip sore has changed the physical look.

372. External Variables 2.SOCIAL GROUP Social group may assist the client in recognizing the threat of illness or support the denial of potential illness. The clients responds positively to social support.

373. External Variables 3.CULTURE & VALUES The culture & values teach the client how to remain healthy & also how to recognize the illness. 4.ECONOMIC VARIABLE The economic constraints may delay the treatment or may allow the client to carry out daily activities. Studies have shown that persons of low economic status have chronic illness.

374. External Variables 5.ACCESIBILITY OF HEALTH SERVICES. The proximity of health services has great influence on individuals in utilizing the same.

375. Types of Illnesses Acute Illness: Generally has a rapid onset of symptoms and lasts only for a relatively short time Examples: Appendicitis, Pneumonia, Diarrhea, Common Cold Chronic Illness: A broad term that encompasses many different physical and mental alterations . It is a permanent change It causes/is caused by irreversible alterations in normal A & P It requires special patient education for rehabilitation It requires a long period of care or support Examples: Diabetes Mellitus, COPD, Arthritis, CRF etc

376. Types of Illnesses Acute illness – Short duration – Mostly severe – Starts abruptly and subsides in relatively short period (less than 6 months) Chronic illness – Persist for more than six months – May affect functioning of body in any dimension – Up to the level of disability – Major health problem

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

378. Stages of Illness Behavior Edward suchman (1972) identified 5 stages of illness behavior. When a person experience illness ,he/she generally passes through five stages of illness behaviour. This pattern involves how a person seeks, finds & completes the health care. 1.Stage I : Symptom experience . 2.Stage II : Assumption of sick role. 3.Stage III : Medical care contact. 4.Stage IV : Dependent client care. 5.Stage V : Recovery & rehabilitation.

379. Stages of Illness Behavior STAGE I – SYMPTOM EXPERIENCE (manifestation /Signs) In the first stage, person feels that something is wrong but he is not able to diagnose the problem. Perception of symptoms includes awareness of physical change like pain, rashes, lump. At the end of this stage , he is able to make the decision that it is a symptom of an illness. Awareness of physical changes. Pain, rashes and lump etc

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

381. Stages of Illness Behavior STAGE III –MEDICAL CARE CONTACT At this stage, the client acknowledges the illness & seeks explanation of causes, duration of illness & it’s complications. Health professional may determine whether the client is ill or not. After knowing about illness some client seek medical treatment , but sometimes, they start denying the symptoms. Seek professional advice Accept or deny diagnosis Follow the treatment plan

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

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

384. Emotional Response To Illness • An emotion is a bodily state which involves feelings that may be consciously or unconsciously motivated. • How the emotions are expressed or experienced depends upon person's basic personality, perception, situation & also extent of support. • By knowing the emotional responses to illness, nurse can anticipate different reactions & can encourage the client & family to express the feelings in a constructive way.

385. Emotional Responses To Illness Fear. Over dependence & feeling of helplessness. Anxiety. Hope. Anger & hostility.

386. Emotional Responses To Illness 1.FEAR Fear is an emotional response characterized by expectation of harm or unpleasantness. Normally, the body reacts by attempting to avoid or withdraw from threat. Patient with fear expresses it freely but, few explanations from the nurse can alleviate the fear readily, on the other hand some are reluctant to express fears.

387. Emotional Responses To Illness 2.OVER DEPENDENCE During the period of illness, the dependence & feelings of helplessness usually increase up to the point they may be harmful for the client. Nurse can observe the over dependency in patient & can assist the client to decrease it in a manner compatible with patient’s capabilities.

388. Emotional Responses To Illness 3.ANXIETY Illness results in anxiety, & in anxious patients, insight is lacking. Anxiety leads to insomnia, diarrhoea, shift in Bp, fatigue & inadequate coping with disease condition. The nurse should have proper knowledge about anxiety level of the clients & should know the interventions to reduce anxiety.

389. Emotional Responses To Illness 4.HOPE Mostly people hope for the best & expect a long & healthy life. Physical & emotional equilibrium gets disturbed & even death may occur if a person gives up the will to live. Nurse can reinforce the hope & encourage the client for a continuous struggle .

390. Emotional Responses To Illness 5.ANGER & HOSTILITY • Anger is an emotion characteristically associated with frustrations & struggling with an unpleasant situation. • It is commonly seen when the goal is blocked or cannot be achieved, or the respect for self has lowered. • Hostility is an unfriendliness that is associated with a desire for aggression. Sarcasm, abusive remarks are the expression of hostility. • The over demanding, unreasonable aggressive & argumentative patients may express their hostility through their behaviour.

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

392. 1.Impact of illness on client. 1. Experience Behavioral And Emotional Changes (irritable, anger, withdrawal) (denial, Hopelessness, Powerlessness) (Lack of energy, fear) 2.Changes in Body Image Loss of special organ Loss of limb Severe scar 3. CHANGES IN SELF CONCEPT Loss of self esteem Loss of self concept

393. 1.Impact of illness on client. 4. Changes in life style Diet Activity Exercise Rest and sleep

394. Impact On The Family FACTORS : Member of the family who is ill. Seriousness and length of illness Cultural and social customs the family follows Role changes. Task reassigned and increased demands on time. Stress. Financial problems. Loneliness. Change in social customs.

395. Support During Illness Family Support Health Care Givers Support Complementary and Alternative Medicine Faith Healing Homeopathy

396. Models of Health and Illness The Agent-Host-Environment Model The Health–Illness Continuum The High-Level Wellness Model The Health Belief model The Health Promotion Model

397. The Agent-Host-Environment Model Agent-Host-Environment Model (Leavell and Clark) Agent: Agent is environmental factor or stressor, bacteria, virus, chemical substance Host: Host is living organism cable of being affected by the agent Environment: Environment is factors that are external to host that make illness more likely i.e: Lack of Sleep. Cold Temperature

398. The Health–Illness Continuum The Health–Illness Continuum Measures a person’s level of health Views health as a constantly changing state with high- level wellness and death on opposite sides of a continuum Illustrates the dynamic (ever-changing) state of health

399. The High-Level Wellness Model (Dunn) Encourages the nurse to care for the total person Involves functioning to one’s maximum potential while maintaining balance and a purposeful direction Regards wellness as an active state, oriented toward maximizing the potential of the individual, regardless of his or her state of health Incorporates the processes of being, belonging, becoming, and befitting Active State: More than good health (passive) maximizes the person’s potential. More total person focus encompasses all of the dimensions Being: Recognizing self as separate and individual Belonging: Being part of a whole becoming: Growing and Developing Befitting: Making personal choices to befit the self of the future

400. The High-Level Wellness Model (Dunn) Dunn(1959) described a health grid in which a health axis and an environmental axis intersect.The Health axis extends from peak wellness to death, & the environmental axis extends from very favourable to very unfavourable.The intersection of two axis forms four quadrants of health and wellness; 1:High level wellness in a favourable environment 2:Emergent high level wellness in an unfavorable environment 3:Protected Poor Health in a favorable environment 4:Poor health in an unfavorable environment

401. The Health Belief Model (Rosenstock) Concerned with what people perceive to be true about themselves in relation to their health Modifying factors for health include demographic, sociopsychological, and structural variables Based on three components of individual perceptions of threat of a disease Perceived susceptibility to a disease Perceived seriousness of a disease Perceived benefits of action

402. Health Promotion Model (Pender) Illustrates the “ multidimensional nature of persons interacting with their environment as they pursue health” Incorporates individual characteristics and experiences and behavior-specific knowledge and beliefs, to motivate health - promoting behavior Personal, biologic, psychological, and sociocultural factors are predicative of a certain health-related habit Health-related behavior is the outcome of the model and is directed toward attaining positive health outcomes and experiences throughout the lifespan

403. Health Promotion Model (Pender) Example: Used to predict how a person is likely to incorporate health promotion behaviors into their lifestyle. Smoking: If parents smoke children more likely to smoke Primary prevention—e.g., Diet, Exercise

404. Level of prevention Primary prevention—e.g., Diet, Exercise, Immunizations Secondary prevention—e.g., Screenings, Mammograms, Family Counseling Tertiary prevention—e.g., Medications, Surgical Treatment, Rehabilitation

405. References Kozier & Erb’s Fundamental of Nursing Book, 8 th edition. Michael A Bettman FACRS “Self Esteem article” 1960. Thomas Fuller Ph.D/MCPR “Teaching and Learning” 1955. John Jackson M.D “of nursing research 6 th edition. Manual

406. Concept of Sexuality By: Zafar Iqbal/Ibne Amin Khyber Medical university

407. Introduction Sexuality has been a consistent focus of curiosity, interest, and analysis to humankind Sexuality encompasses all those thoughts, feelings, and behaviors connected with sexual gratification and reproduction, including the attraction of one person to another. It is a key factor in our principal relationships and the formation of our families. It is also a common source of problems. insta | husain.z.kmu

408. Objectives At the end of this unit, learners will be able to: Review the Anatomy and physiology of the male and female reproductive system Describe normal sexual pattern Relate sexuality to all stages of life cycle Identify factors that effects sexual functioning Describe common risks and alteration in sexuality Understand the nursing process as it relate to sexual functioning insta | husain.z.kmu

409. Male Reproductive System Male reproductive system consist of: External organs & Internal organs An adult male manufactures over 100 million sperm cells each day. Testosterone , is a hormone that is responsible for the development of the secondary sex characteristics. of men such as the beard, deep voice, and masculine body shape. insta | husain.z.kmu

410. Female Reproductive System Female reproductive system consist of: External organs & Internal organs Estrogen is responsible for the development of the secondary sexual characteristics of a mature woman. Estrogen continues to be secreted throughout the reproductive age of the female, regulates menstrual period in female, eggs production occur prior to birth. insta | husain.z.kmu

411. Why to Study Reason for studying human sexuality is that we may face various personal and social problems involving sexuality, such as, sexually transmitted diseases, unwanted pregnancies, and sexual harassment insta | husain.z.kmu

412. Sexuality pattern Sexuality is a state or quality of being sexual including the collective characteristics that distinguish male and female. It comprises of: Sexual identity Sex role Sexual performance and Social norms. insta | husain.z.kmu

413. Sexual or Gender identity Anatomical state of being male and female, results from genetic and hormonal influence It is sense of one's self as male or female Characteristic develop 8 month to 3 years of life insta | husain.z.kmu

414. Sex role: This is expression of one's own gender through behavior, feeling, attitude. Culturally defined as feminine and masculine role. insta | husain.z.kmu

415. Sexual orientation: It is a feeling of sexual attraction towards sexual partner Heterosexual: "romantic or sexual attraction to persons of the opposite sex“ Bisexual : is sexual orientation involving physical or romantic attraction to both males and females. Homosexual : an enduring pattern to experience sexual, or romantic attractions to people of the same sex insta | husain.z.kmu

416. Social Norms: Each society has their own and different norms regarding premarital sex, sexual consent and many other sexual behaviors Mostly influenced by Religion & Culture insta | husain.z.kmu

417. Sexual Reproductive pattern Sexual reproduction is a union that results in increasing genetic diversity of the offspring. Reproduction is only one component of sexuality insta | husain.z.kmu

418. Normal Sexual pattern Four stages of sexual responsiveness excitement platuae Orgasm resolution insta | husain.z.kmu

419. Normal Sexual pattern Excitement Phase : is the first stage of the human sexual response cycle. It occurs as the result of any physical or mental stimulation that leads to sexual arousal Platuae Phase : is the period of sexual excitement prior to orgasm. Orgasm Phase : is the conclusion of the plateau phase of the sexual response cycle. It is accompanied by quick cycles of muscle contraction in the lower pelvic muscles, which surround both the anus and the primary sexual organs. Resolution Phase : occurs after orgasm and allows the muscles to relax, blood pressure to drop and the body to slow down from its excited state. insta | husain.z.kmu

420. Abnormal Sexuality Sexual behavior that is destructive to oneself or others, that is markedly constricted, that cannot be directed toward a partner, that excludes stimulation of the primary sex organs, and that is inappropriately associated with guilt or anxiety. insta | husain.z.kmu

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

422. Sexuality to all stages of life cycle Adolescence is a phase of transition during which major developments of sexuality takes place. Puberty is reached during adolescence, which is a major landmark in the development of sexuality. Adolescent sexuality development can be better explained with the bio-psycho-social model. Biological factors, psychological factors, as well as social factors have equal importance in determining, the development of sexuality in adolescents Other than the biological, psychological, and social factors, many more factors such as political, legal, philosophical, spiritual, ethical, and moral values significantly influence the sexuality development insta | husain.z.kmu

423. Sexuality to all stages of life cycle Sigmund Freud had proposed his theory of psychosexual development, where he described about – oral phase, anal phase, phallic phase, latency phase, and genital phase as the landmark steps of psycho-sexual development. During these phases, different body parts behave as most erotogenic and the individual attempts to explore or stimulate these erotogenic zones in order to get gratification He emphasized that a child's personality is formed by the ways which his parents managed his sexual and aggressive drives. insta | husain.z.kmu

424. Freud’s Psychosexual Stages Stage: Oral (0-18 months) Anal (18-36 months) Phallic (3-6 years) Latency (6 to puberty) Genital (puberty on) Focus: Pleasure centers on the mouth-sucking, chewing, biting Pleasure focuses on bowel and bladder elimination; coping with demands for control Pleasure zone is the genitals; coping with incestuous sexual feelings Dormant sexual feeling Maturation of sexual interest. insta | husain.z.kmu

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

426. Sexuality to all stages of life cycle Sexuality in older age  concerns the sexual drive, sexual activity, interests, orientation, intimacy, self-esteem, behaviors, and the social perceptions concerning sexuality in older age. Older people engage in a variety of sexual acts from time to time for a variety of reasons. Desire for intimacy does not disappear with age, yet there are many restrictions placed on the elderly preventing sexual expressions and discouraging the fulfillment of sexual needs. Sexuality in older age is often considered a taboo yet it is considered to be quite a healthy practice; however, this stigma can affect how older individuals experience their sexuality. While the human body has some limits on the maximum age for reproduction, sexual activity can be performed or experienced well into the later years of life insta | husain.z.kmu

427. Factors Affecting Sexuality Quality of relationship Cognition and perception Culture, value and believe Self concept Previous experience Environment Pregnancy Illness and diseases life circumstances Personality traits Biological makeup insta | husain.z.kmu

428. Risks and Alteration in Sexuality General health status (Chronic diseases) Sexual abuse Sexual dysfunction Impotence and ejaculatory dysfunction Dyspareunia insta | husain.z.kmu

429. Nursing Care Process Assessment: History; About existent sexual problem Type and quality of relation among partners Level of knowledge Drug and other illness PLISSIT model insta | husain.z.kmu

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

431. insta | husain.z.kmu

432. Nursing Care Process Nursing Diagnosis Ineffective sexuality pattern. Sexual dysfunction Rape trauma syndrome insta | husain.z.kmu

433. Nursing Care Process Nursing Diagnosis Ineffective sexuality pattern. Sexual dysfunction Rape trauma syndrome insta | husain.z.kmu

434. Nursing Care Process Goal: The person will resume previous sexual activity The person will have alternative sexual activity insta | husain.z.kmu

435. Nursing Care Process Nursing Interventions : Establish trusting relationship Maintain privacy Active listening Clarify the patient that sexuality does not mean only intercourse Discuss alternative methods insta | husain.z.kmu

436. References Craven, R. F., & Hirnle , C. J. (2006). Fundamentals of nursing: Human health and function . (5th.ed.)p.1176-1262 New York: Lippincott. Cox, H. C. et. al.(2002). Clinical application of nursing diagnosis. Philadelphia: Lippincott Estes,M . E. Z. (2000) Health assessment & Physical examination (2 nd ed.). Delmar. Katz, A. (2000). Birds do it, Bees do it, Lets talk about it. AWHONN lifelines, 4( 5) 40-41 Harkreader , H. & Hogan, M. A. (2004) Fundamental of nursing : caring and clinical Judgment (2 nd ed.). Sunders insta | husain.z.kmu

437. Loss, Death, and Grieving By : Ibne Amin Lecturer , INS Khyber Medical University,Peshawar

438. Objectives 1. Assess the physiologic signs of death. 2. Identify beliefs and attitude about death in relation to age. 3. Discuss the various ways of helping the dying patient meet his/her physiological, spiritual and emotional needs. 4. Discuss care of the body after death. 5. Discuss the legal implications of death. 6. Describe how a nurse meets a dying patient’s needs of comfort. 7. Discuss important factors in caring for the body after death. 8. List changes that occur in the body after death.

439. Objectives 9. Define terms related to loss and grieving. 10. Discuss Kubler-Ross’ theory to assess grieving behaviors. 11. Identify common manifestations of grief 12. Discuss the effects of multiple losses on the grief process 13. Apply the nursing process to grieving clients.

440. Introduction Birth and death are two aspects of life, which will happen to everyone. Dying and death are painful and personal experiences for those that are dying and their loved ones caring for them. Death affects each person involved in multiple ways, including physically, psychologically, emotionally, spiritually, and financially.

441. Definition Death is defined as “The irreversible cessation of all vital functions especially as indicated by permanent stoppage of the heart, respiration, and higher brain function” Death is the cessation or permanent termination of all the biological functions that sustain a living organism. Dying means “approaching death”

442. Physiologic signs of death The four main characteristic changes are ; Loss of muscle tone Slowing of the circulation Changes in the vital signs Sensory impairment. The following guidelines for physicians as indications of death. Total lack of response to external stimuli No musscular movement(esp breathing) No reflexes Flat encephalogram.

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

444. Conti…. 12 to 18 years; May still hold concept from previous developmental stages, may seem to reach “adult’’ perception of death but be emotionally unable to accept it. 18 to 45 years ; Has attitude towards death influenced by religious and cultural beliefs. 45 to 65 years; Accepts own mortality. encounters death of parents and some peers experiences. 65 years +; Fears prolonged illness, sees death as having multiple meanings,(eg,freedom from pain, reunion with already deceased family

445. Dying Patients We may help the dying patient meet his/her Physiological Needs Spiritual Needs Emotional Needs

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

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

448. Emotional support Compassion (desire to help) Responsiveness to emotional needs Maintain a positive attitude Expressing empathy Attending wishes Being present.

449. Physical Changes After Death Pupils- Fixed and dilated Algor Mortis- Rapid cooling of the body Rigor Mortis- Stiffening of the body, develops 2-4 hours after death Livor Mortis- Purple discoloration of skin in dependent areas

450. Care After Death Death declaration/ Death certificate by physician. Autopsy(written permission) Customs & principles are kept in mind. Positioning- body straitened & arms laid at the side. Eyes are closed as in sleep. Dentures are removed & prop chin in position with bandaging. Remove all appliances used for patient care( e.g - catheter tubing's etc..)

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

452. Legal aspects of death Federal and state law require that institutions develop policies and procedures for certain events that occur after death. 1.Requesting organ or tissue donation 2. Autopsy 3.Certifying and documenting the occurrence of a death. 4.Providing safe and appropriate post mortem care.

453. Legal aspects of death Death must be certified by a physician In unusual death,an autopsy(postmortem examination)may be required. Request family member consent and signature for autopsy. Several reasons for a death becoming a case for the coroner: Death by suspicious means or not under a doctor’s care Death resulting from an accident Client has been hospitalized for less than 24 hours Dying Persons’ Bill of Rights Passive euthanasia California Law (1976)- “Right to Die” bill California Natural Death Act

454. Loss Loss occurs when a valued person, object, or situation is changed. OR Loss can be defined as the undesired change or removal of a valued object ,person or situation Loss is a universal experience that occurs throughout the lifespan.

455. Types of loss 1. Actual Loss can be recognized by others including the person sustaining the loss, ex: a person losing a limb, spouse, valued object, job etc. 2.Perceived loss felt by the person but is intangible to others loss of your youth, financial dependence, loss of confidence or prestige. 3. Anticipated loss the person displays loss and grief behaviors for loss that has yet to take place. EX: families with terminally ill patients and serves to lessen the impact of actual loss

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

457. Loss & Grieving LOSS Something of value is gone GRIEF Total response to emotional experience related to loss BEREAVEMENT Subjective response to by loved ones MOURNING Behavioral response

458. Functions of Grief To make the outer reality of the loss in to an internally accepted reality To lessen the emotional attachment to the lost person or object To make it possible for the bereaved person to become attached to other people or objects

459. Types Of Grief ANTICIPATORY GRIEF NORMAL OR COMMON GRIEF COMPLICATED GRIEF DISENFRANCHISED GRIEF

460. Common Grief Reactions A grief reaction is a set of psychological and somatic (body) symptoms that results from extreme sorrow or loss. These reactions fall into four different categories: Thought Patterns Physical Sensations Emotions Behaviours.

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

462. Stages Of Grief Kubler-Ross, in extensive research with terminally ill patients, identified five stages of feelings and behaviours that individuals experience in response to a real, perceived or anticipated loss. Kubler-Ross Stages of Grieving (1969) Denial Anger Bargaining Depression Acceptance

463. Kubler-Ross Stages of Grieving 1. Denial and Isolation Denial is a conscious or unconscious refusal to accept facts, information, reality, etc., relating to the situation concerned. It's a defence mechanism and perfectly natural.

464. Kubler-Ross Stages of Grieving 2.Anger Anger can manifest in different ways. People dealing with emotional upset can be angry with themselves, and/or with others, especially those close to them. “Why me?” and It’s not fair!” are comments often expressed during anger stage

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

466. Kubler-Ross Stages of Grieving 4. Depression During this stage, the full impact of the loss is experienced. The sense of loss is intense and feelings of sadness and depression prevail. This is a time of quiet desperation and disengagement from all association with the lost entity.

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

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

469. Nursing Implications Hospice care , attention to family and individual psychosocial issues ,and symptom and pain management are all part of the nurse's responsibilities. The nurse must also be concerned with ethical considerations and quality-of-life issues that affect dying people

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

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

472. References Kozier & Erb’s Fundamental of Nursing Book, 8 th edition. Potter and Perry (2005) “Fundamentals of nursing” published by most by an imprint of Elsevier, 6th edition. New Delhi. Page no 1068 – 1071  www.google.com

473. Stress and coping By: Ibne Amin/Zafar Iqbal (INS ),Khyber Medical university

474. Objectives At the end of this unit learners will be able to: 1.Discuss the stress and coping 2. Identify different stressors and different types of stress 3. List the different Symptoms of Stress. 4. Identify different techniques of stress management.

475. Stress Stress is a person response to stressor such as an environmental condition or a stimulus. OR Mind and body response or reaction to a real or imagined threat, event or change. OR Stress is condition in which the person experience changes in the normal balance state.

476. Stress Stressor - ----as any event or stimulus that cause the individual to experience stress. Coping strategies , coping response, coping mechanism-----person response to stress

477. Stress Stress can result from both positive and negative experiences........ Examples ; A bride preparing for her wedding A graduate preparing to start new job A husband concern about caring of his wife and family Diagnosis of cancer Lossing of special object ,person or any other things all experiences stress reactions.

478. Stress Coping "The cognitive and behavioral efforts to manage specific internal demands ( infection ,feeling of depression) or external demands ( move to another city ,death in family ) that are appraised as exceeding the resources of a person". Folkman and Lazarus(1991) OR When a person faces stressors ,then the responses of the person are reffered as coping strategies ,coping responses or coping mechanisms.

479. Indicators of stress Physiological indicators Psychological indicators

480. Stress indicators 1. Physiological indicators The physiological sign & symptoms of stress result from the activation of sympathetic and neuroendocrine systems of the body Clinical manifestations lists physiological indicators of stress

481. Clinical Manifestation Of Stress Pupils dilates Sweat production Heart rate increase Cardiac output increase Skin is pailed ( because of constriction of peripheral blood vessels) Sodium and water retention increase which increase blood volume

482. Clinical Manifestation Of Stress/Physiological indicators Rate and depth of respiration increase (because of dilation of bronchioles) Urinary output decrease Mouth may be dry Paristalsis of intestine decrease Muscles tension increase

483. Psychological Indicators Anxiety Fear Anger Depression Uncounsious Ego Mechanism

484. Psychological Indicators 1. Anxiety: Common reaction to stress A state of mental uneasiness ,apprehension, or a feeling of helplessness related to an impending or anticipated unidentified threat to self or significant relationships. Four levels of anxiety Mild Anxiety Moderate Anxiety Severe Anxiety Panic

485. Psychological Indicators 2. FEAR An emotion or feeling of apprehension aroused by impending or seeming danger ,pain or another percieved threat

486. Psychological Indicators Anxiety and Fear differ in four ways 1. The source of anxiety may not be identified 2. Anxiety is related to mainly future, to an anticipated event ,fear is related to past ,present and future 3. Anxiety is Vague, whereas fear is definite 4. Anxiety results from psychological or emotional conflicts ,fear results from a specific physical or psychological entity.

487. Psychological Indicators 3.Anger An emotional state consisting of a subjective feeling of animosity or strong displeasure

488. Psychological Indicators 4. Depression A common reaction to events that seem overwhelming or negative An extreme feeling of saidness ,dispair ,dejection ,lack of worth ,or emptiness

489. Psychological Indicators 5. Unconscious Ego Mechanisms Unconscious psychological adaptive mechanism or mental mechanisms that develop as the personality attempts to defend itself ,establish compromises among conflicting impulses and calm inner tentions

490. Coping Pattern The cognitive and behavioral efforts to manage specific external or internal demands that are appraised as exceeding the resources of the person OR A natural or learned way of responding to a changing environment or specific problem or situation

491. Types of coping Problem- focused coping Emotion-Focused coping Long term coping strategies Short term coping strategies Adoptive coping Maladaptive coping Care-giver burden

492. Types of coping 1. Problem- focused coping Refers to efforts to improve a situation by making changes or talking actions (Lozarus 2006) 2. Emotion-focused coping Include thoughts and actions that relieve emotional destress Doesn't improve the situation but the person often feels better (Lozarus 2006)

493. Types of coping 3. Long term coping strategies Can be constructive and practical In certain situations talking with others and trying to find out more about the situation are long term strategies Other long term Coping strategies include Lifestyle pattern e.g. Eating a healthy diet Exersicing regularly Decision making

494. Types of coping 4. Short term coping strategies Can reduce stress to a tolerable limit temporarily but are ineffective ways to permennently deal with reality. These may even have destructive or detrimental effect on the person Examples; Using Alcohol Using drugs

495. Types of coping 5. Adaptive coping Helps the person to deal effectively with stressful events and minimizes distress associated with them Effective coping result in adaptations 6. Maladaptive coping Can cause unnessasary distress for the person and others associated with the person or stressfull events Ineffective coping result In maladaptation

496. Types of coping 7. care giver Burden Reaction to a long term stress is seen in family members who undertake the Care of a person in the home for long time period Produces responses such as chronic fatigue , sleeping difficulties and high blood pressure

497. Factors affecting copping pattern during hospitalization Many factors can affect the copping pattern of patient,family members and nurses in hospital. Following are the main factors which affect the copping pattern during hospitalization.

498. Conti… Anxiety: Anxiety is an emotion characterized by feelings of tension, worried thoughts and physical changes like increased blood pressure. Anxiety in hospital: Depression and anxiety are common in hospitalized patients especially those waiting for surgery and with chronic or hard-to-treat conditions. Psychological disorders are not only related to a poor adjustment to hospitalization distress, but is associated with adverse events and unsatisfactory outcomes. Hospitalization exacerbates patients' emotions, and increases feelings of depression and anxiety. By this way copping is affected by admitted into hospital.

499. Conti .. Fear: More prosaic issues might result in the fear of hospitals, such as smells, sick roommates , and a complete lack of privacy. Media reports surrounding medical mishaps often result in fear among patients. The fear from doctor or nurse during the intervention steps by applying nursing processs affect the copping

500. Conti … Example of fear. The most common examples of fear a  nurse  encounter are patient in the community, a patient may also have fear during diagnostic testing in an outpatient setting, or during hospitalization. The nurse’s role is to identify when patients are experiencing fear and must find ways to help them in a respectful way to face these feelings. The nurse must also learn to distinguish when fear becomes persistent and pervasive that it affects the individual’s ability to perform his or her activities of daily living. Referral to a reliable support system and programs increase the chances of successfully managing, treating, and overcoming phobias and other fears.

501. Conti… Possibility of fear for nurse: the possibility of harming a patient is their biggest fear. “We are the gatekeepers of health. For family: Family member of the patient are also at fear condition because there may be chance of paralysis or even death may be cause of their patient .

502. Conti… Sleep: Unfortunately, the hospital environment is often poorly conducive to sleep . Pain, anxiety, medication effects, medical interventions, environmental noise and light, and the acute illness itself all contribute to decreased quality and quantity of sleep in hospitalized patients.then the patient cannot mannage such stress . Sleep loss in the hospital is associated with worse health outcomes, including cardio-metabolic derangements and increased risk of delirium

503. Conti. Isolation from parents : to separate the child frome parents and admitted them into hospital it will affected the copping of the childs mostly .it this stages child are totally dependent to their parents . Change in nutrition The following factors can also contribute to malnutrition: teeth that are in poor condition, or dentures that do not fit properly, which can make eating difficult or painful. a physical disability or other impairment that makes it difficult to move around, cook or shop for food. living alone and being These all are including in changing the copping of clints.

504. Conti… Economic :the lower economy level and poverty can affect copping of patient and their family . some time when patient require surgery of heart and other serious surgery but they cannot afford and sustain their cost that s way the copping pattern is affected . Social culture : the Clint of various culture are admitted into hospital . They affect decisions about a patient's treatment and who makes the decisions. Cultural differences create problems in communication, rapport, physical examination and treatment compliance and follow through. The special meaning of medicines and diet requires particular attention.

505. Nursing Management of stress Assessing Nursing assessment of clients stress and coping pattern includes;Nursing History & Physical Examination. During Nursing History the nurse have to poses questions ,,i.e Client perceived stressors or stressful incidents Manifestations of stress Past coping strategies Present coping strategies

506. Nursing Management of stress During physical examination the Nurse observe for ; Verbal and cognitive manifestations Indicators of stress such as,Nail biting,Nervousness,Weight changes Stress related health problems such as, Hypertension Hyperthyroidism Dyspnea

507. Nursing Management of stress 2.Nursing diagnosis Anxiety related to unconscious conflict's about essential goals and values of life , threat to self concept , positive or negative self talk ,or physiological factors (E.g hyperthyroidism ,dysrhythmias ,dyspnea )

508. Conti.. Planning The overall clients goals for individual experiencing stress related responses are; Decrease or resolve anxiety Increase abality to manage or cope with stressful events or circumstances Improve role performance

509. Nursing Management of stress Implementation Although stress is a part of daily life ,it is also highly individualize Some methods help to reduce stress will be effective for one person Other methods are appropriate for a different person A Nurse who is sensitive to clients needs and reactions can choose those methods of interventions that will be most effective for each individuals

510. Nursing Management of stress Several health promotion strategies are often appropriate as interventions for clients with stress related Nursing daignosis Among these are; Physical exercise (relief mention,feeling of well being, relaxation)

511. Nursing Management of stress Optimal Nutrition (balanced diet) Adequate rest and sleep (sleep restore bodies energy levels and is essential aspect of stress management) Time management (people who manage their time effectively usually experience less stress because they feel more in control of their circumstances)

512. Nursing Management of stress Evaluation How does the cleint perceive the problems? Is there an underlying problem not identified? Have new stressors occur that interfare with successful Coping? Were existing coping strategies sufficient to meet intended outcomes?

513. Nursing Management of stress How does the client perceive the effctiveness of new coping strategies? Did the client implement new coping strategies properly? Did the client access and use available resources? Have family members and significant others provided effective support?

514. Stress Management for Nurses Nurses like client's are susceptible to experiencing anxiety and stress Nursing practice involves many stressors I.e; Increasing severity of client illness Adjusting to various work shifts Inadequate support from supervisors Caring for dying client etc Although most Nurses cope effectively with physical and emotional demands of nursing But some Nurses become overwhelmed and develop Burnout

515. Stress Management for Nurses BURNOUT A complex syndrome of behavior The Nurses with Burnout manifests physical and emotional depletion A negative attitude and self concept Feeling of helplessness and hopelessness

516. Stress Management for Nurses STEPS TO REDUCE STRESS FOR NURSES Plan daily relaxation programs to reduce tention ( I.e read novels ,listen to music or other favorite activities) Establish regular exercise program Learn to accept failure's Seek counseling if indicated Support each others as a team Take time to relax Eat properly Lern something New

517. References Kozier & Erb’s Fundamental of Nursing Book, 8 th edition. Potter and Perry (2005) “Fundamentals of nursing” published by most by an imprint of Elsevier, 6th edition. New Delhi. Page no 1068 – 1071  www.google.com

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

519. Parentral Medication Para: outside enteron: intestine (i.e. beside the intestine) These are the preparations which are given other than oral routes. Parenteral administration is injection or infusion by means of a needle or catheter inserted into the body. Parenterals are sterile solutions or suspension of drug in aqueous or oily vehicle. Parenteral drugs are administered directly in to the veins, muscles or under the skin , or more specialized tissues such as spinal cord.

520. Parenteral Routes Parenteral administration involves injecting a medication into body tissues. The following are the four major sites of injection: 1. Intradermal (ID): Injection into the dermis just under the epidermis. 2. Subcutaneous (SC): Injection into tissues just below the dermis of the skin. 3. Intramuscular (IM): Injection into a muscle. 4. Intravenous (IV): Injection into a vein.

521. Parenteral Routes

522. Parenteral Routes Some medications are administered into body cavities.These additional routes include 5. Intra-arterial 6. Intracardiac 7. Intrathecal 8. Intracisternal 9. Peridural 10.Intraarticular 11.Intracerebral 12. Intrapleural 13. Intraosseous 14. Intraperitoneal

523. Intradermal Injections An intradermal (ID) injection is the administration of a drug into the dermal layer of the skin just beneath the epidermis. Usually only a small amount of liquid is used, for example 0.1ml. This method of administration is frequently used for allergy testing and tuberculosis(TB) screening. Use a tuberculin or small hypodermic syringe for skin testing. The angle of insertion for an intradermal injection is 5 to 15 degrees (Syringe is positioned at 5˚-15˚ angle. ) Needle used is a short (3/8 inch) length, gauge (25-27G). Create small bubble like.

524. Intradermal Injections It is an injection given into the dermal layer(the top few layers of the skin. ) of the skin for some purposes : – Local Anesthesia – Diagnostic Tests – Immunizations (BCG vaccine) After injecting the medication, a small bleb resembling a mosquito bite appears on the surfaceoftheskin

525. Intradermal Injection Procedure Check the 5 Right then : 1.Wash hand and Take equipment to the patient's side. 2.Explain procedure to patient. 3.Locate the site of injection, and Cleanse the skin with a spirit swab, allow the area to dry. 4.Remove needle cap and holds syringe at 10˚-15˚ angle from skin with bevel up and Inject the solution. 5.Remove the needle quickly but gently at the same angle used for injection. 6.Wipe with dry cotton ball but do not press or massage the injection site. 7.Chart the data and time of the administration of the drug. 8.Take care of the equipment & return to their places.

526. Subcutaneous Injections The injection of the drug under the skin into the fatty layer, but not into the muscle. Absorption of the drug is rapid. Eg; insulin The subcutaneous injection sites include The outer posterior aspect of the upper arms The abdomen The anterior aspects of the thighs The scapular areas of the upper back The upper ventral or dorsal gluteal areas.

527. Subcutaneous Injections Subcutaneous (SC; SQ ;Sub Q): The injection is given under the skin Need to be isotonic Upto 2 ml is given Using ½ to 1 inch 23 gauge needle or smaller needle Given: Vaccines Insulin Scopolamine Epinephrine

528. Subcutaneous Injections Kinds of drugs commonly administered: 1. Vaccines 2. Preoperative medications 3. Narcotics 4. Nnsulin 5. Heparin • Only small volumes (0.5 to 1.5 mL) of medicationsare given subcutaneously. • The angle of insertion for a subcutaneous injection is 90 or 45 degrees.

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

530. Intramuscular Injection Drugs are injected deeply into muscle tissue. If the drug is in aqueous (water) solution, absorption is rapid. However, if the drug is in an oily liquid or in the form of a suspension, it can prolong the release of the drug. It is injecting of drug into a body's system via the muscles . Used to administer : Some antibiotics Vitamins or iron Some Vaccines (DTP) Needle used is (1-1.5 inch)length, gauge(19-22G). Volume usually 2-5 ml are injected. Inject the needle at an angle of 90˚ .

531. Intramuscular Injection Striated muscle fibre 0.5 to 2 ml sometimes upto 4 ml 1 to 1.5 inch & 19 to 22 gauge needle is used Preferably isotonic Principle sites: Gluteal (buttocks) (Ventrogluteal , Dorsoglutea) Deltoid (upper arms) Vastus lateralis (lateral thigh) Rectus Femoris Given: Solutions Emulsions Oils Suspension Care must be taken with deep IM injections to avoid hitting a vein, artery, or nerve

532. Intramuscular Injection Procedure Check the 5 Right then : 1.Wash hand and Take equipment to the patient's side. 2.Explain procedure to patient. 3.Locate the site of injection, and Cleanse the skin with a spirit swab, allow the area to dry. 4.Remove needle cap and holds syringe at 90˚ angle then Inject the needle . 5.Draw back the plunger to check you are or aren't in the blood vessel (Blood return should not be seen) then inject the solution. 6.Remove the needle quickly but gently at the same angle used for injection and massage the area with alcohol swab. 7.Chart the data and time of the administration of the drug. 8.Take care of the equipment & return to their places.

533. Intravenous Injections Fast-acting route because the drug goes directly into the bloodstream Often used in the emergency department and in critical care areas Commonly used For fluid and electrolyte replacement To provide necessary nutrition to the patient who is critically ill Needle used is (1-1.5 inch)length, gauge(16-20 G). Intravenous (IV) injections are administered at an angle of 15˚-20˚

534. Intravenous Injections For adults, the veins on the arm are: Basilic vein Median cubital vein Dorsal veins Median vein Radial vein Cephalic vein On the foot, the veins are; Great saphenous vein Dorsal plexus Given: Aqueous solutions Hydro alcoholic solutions Emulsions Liposome

535. Intravenous Injection Procedure Check the 5 Right then : 1.Wash hand and Take equipment to the patient's side. 2.Explain procedure to patient. Expose the arm and apply tourniquet 3.Ask pt. To open and close his fist. 4.Palpate the vein and clean with alcohol swab the site of the injection 5.Remove needle cap and holds syringe at 15˚-20˚ angle. 6.Puncture the vein and draw back (Blood return should be seen(. 7.Once you know that you are in the vein, release the tourniquet and gently lower the angle of the needle then inject the solution very slowly. 8.Remove the needle quickly but gently at the same angle used for injection and apply pressure over the area to prevent bleeding.. 9.Chart the data and time of the administration of the drug. 10.Take care of the equipment & return to their places

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

537. Complications During IV Therapy • Circulatory Overload ; the intravascular fluid compartment contains more fluid than normal. This occurs when infusion is too rapid or excess volume is infused. This manifests as dyspnoea, cough, frothy sputumandgurglingsoundsonaspiration. • Embolism; obstruction of the blood vessels by travelling air emboli or clot of the blood. Itisfata

538. General requirements of parenteral preparations Stability Sterility Free from Pyrogens Free from foreign particles Isotonicity Specific gravity Chemical purity

539. Equipment To administer parenteral medications, nurses use syringes and needles to withdraw medication from ampules and vials.

540. Equipments Needles Available in different gauges – the smaller the number, the larger the gauge (inside diameter) Length – long enough to penetrate the appropriate layers of tissue Syringes Barrel Plunger With or without needle Calibrated in milliliters or units

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

542. Needles Most needles are made of stainless steel, and all are disposable. A needle has three parts: 1.The hub, which fits onto the tip of a syringe 2. The shaft, which connects to the hub 3. The bevel, the tip of the needle The hollow bore of the needle shaft is known as the lumen.

543. Needle Size-is Designated By Length And Gauge The length of a needle is measured in inches from the juncture of the hub and the shaft to the tip of the point. Needle lengths range from 3/8 inch to 3 1/2 inches; some special use needles are even longer. The gauge of a needle , used to designate the size of the lumen, ranges from 27 (the finest) to 13 (the largest). The smaller the number, the larger the gauge (inside diameter).

544. Needle Size-is Designated By Length And Gauge Smaller the number, the larger the Guage,the inside diameter.

545. Conti… The gauge varies from 18 to 30.Use longer needles for IM injections and a shorter needle for subcutaneous injections.

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

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

548. Syringes Syringes have three parts: The tip, which connects with the needle The barrel, or outside part, on which the scales are printed The plunger, which fits inside the barrel

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

550. Types Of Syringes Standard - comes in 3ml,5 and 10ml Insulin -designed specially for use with the ordered dose of insulin Tuberculin-narrow syringe , use to administer small or precise doses such as pediatric dosages. Should be used for doses of 0.5ml or less Pre-filled Single dose Syringe Autoinjectors

551. Cannula A cannula is a flexible tube that can be inserted into the body. A venous cannula is inserted into a vein, for the administration of intravenous fluids, for obtaining blood samples and for administering medicines.

552. Types Of Cannula Types of cannula are IV cannula pen-like model. IV cannula with wings model. IV cannula with injection part model. IV cannula y-type model. Butterfly Canula

553. Pen like Model Canula

554. Canula with Wings Model

555. Canula with Injection Portal Model

556. Y-Type Model of IV Canula

557. Parenteral Drug Packaging Ampule – glass or plastic container that is sealed and sterile (open with care) Vial – small bottle with rubber diaphragm that can be punctured by needle

558. Advantages of the Parenteral Route The IV route is the fastest method for delivering systemic drugs Preferred administration in an emergency situation It can provide fluids, electrolytes, and nutrition. Patients who cannot take food or have serious problems with the GI tract

559. Advantages of the Parenteral Route It provides higher concentration of drug to bloodstream or tissues Advantageous in serious bacterial infection. IV infusion provides a continuous amount of needed medication Infusion rate can be adjusted. To provide more or less medication as the situation dictates Drug action can be prolonged by modifying the formulation

560. Disadvantages of the Parenteral Route Traumatic injury from the insertion of needle Potential for introducing: Toxic agents Microbes Pyrogens Impossible to retrieve if adverse reaction occurs Injected directly into the body Correct syringe, needle, and technique must be used Rotation of injection sites with long-term use

561. Disadvantages of the Parenteral Route Sensitivity or allergic reaction at the site of injection Prevents scarring and other skin changes Can influence drug absorption More expensive and costly to produce Trained person is required. Require specialized equipment, devices, and techniques to prepare and administer drugs Requires strict control of sterility & non pyrogenicity than other formulation

562. References Fundamental of nursing by Erab & Koizer (6 th edition)

563. THANK YOU