Introduction to Medical surgical for 2nd yrs Nursing stu today.pdf

Medical surgical part one for tvet nursing students

1. INTRODUCTION TO
MEDICAL SURGICAL NURSING
7/16/2024 By Husien S(Senior NP,RN) 1
RVU
For 2
nd
Year Level-IV Nursing students

2. Providing Nursing Care for Medical and Surgical
Health Problems
❑LEARNING OBJECTIVES
At the end of the module the learner will be able to:
➢Identify the impact of medical and surgical health problems
➢ Contribute to planning care for the client with medical and surgical
Health problems
➢ Contribute to multidisciplinary health care team in caring for clients in
the critical care environment
➢ Perform nursing interventions for medical and surgical health
problems
➢ Manage medical and surgical related disorders
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3. Identifying The Impact of Medical And Surgical
Health Problems
Introducing Medical Surgical Nursing
❖Definition
➢Medical –surgical nursing, involves the nursing care of adult
patients whose conditions or disorders are treated
medically/pharmacologically, or surgically.
➢Its also defined as the diagnosis and treatment of human responses of
individuals and groups to actual or potential health problems.
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4. Scope of Medical Surgical Nursing
✓The goal of medical-surgical nursing is to assist the individual
or group in promoting, restoring, or maintaining optimal health
✓The medical-surgical nurse is skilled in assessing, diagnosing,
and treating actual or potential alterations in functional ability
and lifestyle
✓Medical-surgical nursing services are provided to clients from
adolescence throughout the life span
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5. Scope of medical surgical nursing…
Medical-surgical nursing is practiced in a variety of
settings across the continuum of care; these settings
include, but are not limited to:
✓Acute And Sub Acute Care Facilities,
✓Home Care Agencies,
✓Ambulatory Care Clinics,
✓Outpatient Services,
✓Residential Facilities,
✓Skilled Nursing Facilities,
✓Private Practice,
✓Adult Day Care Agencies,
✓Primary Care And Specialty Practices,
✓Schools, Insurance Companies, And Private Companies
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6. Concept of Health And Illness
❖Health concept
➢Biomedical concepts: Health has been traditionally defined as
"absence of disease", and disease as deviation from a biochemical
concept" was based on the germ theory of disease, which dominated
medical thought at the turn of the 20
th
century.
➢Ecological concept
Health is a dynamic equilibrium between man & his environment,
and disease is maladjustment of the human organisms to the
environment.
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7. Concept of health and illness…..
Health concept…
➢The Nightingale Definition Of Health
Nightingale defined health as a state of “being well and using every
power the individual possesses to the fullest extent” (Nightingale,
1969)
➢The World Health Organization (WHO) definition
Health is a “state of complete physical, mental, and social well-being
and it is not merely the absence of disease and infirmity”.
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8. Model of Health And Illness
❖Host- agent-environment model
➢Health and illness depends on
interaction of host, agent and
environmental factors.
➢When the agent, host and
environment variables are in
equilibrium health is maintained.
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9. Model of health and illness….
❖The Health illness continuum
model
➢According to this model, health is a
constantly changing state, with high
level wellness and death being in the
opposite ends of a graduated scale,
or continuum.
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11. Model of health and illness….
❖ High-level wellness model
➢The function of one's maximum potential while maintaining
balance and purposeful direction in the environment.
➢The concept of high level of wellness can be applied to the
individual, family, community, environment, and society.
❖High-level wellness model viewed human beings in five aspects
1.Each individual is functioning as a total personality.
2.Each person possess dynamic energy.
3.Each person is at peace with inner and outer worlds.
4.Each person has a relationship between energy use and self
integration.
5.Each person has an inner world and an outer world.
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13. Model of health and illness….
❖ Health Belief Model
▪The health belief model is based on what people perceive, or
believe, to be true about them in relation to health.
▪This model is based on three components:
✓perceived susceptibility to a disease,
✓perceived seriousness of a disease and
✓perceived value of action.
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15. 15
Nursing Process
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16. What is nursing process?
❑Common Definitions
Nursing process is an organised, systematic and deliberate
approach to nursing in partnership with the patient and their
family with the aim of improving standards in nursing care
It is a holistic and interactive approach through which nursing
care provision is organised to achieve patient centred nursing
interventions
It is a systematic problem solving approach to client care.
It is an organized, systematic method of giving goal oriented,
humanistic care that is both effective and efficient.
Nursing process is the cornerstone of the nursing profession
N.B. Linda Hall first introduces the term nursing process in 1965
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17. Purpose of Nursing Process
1.To identify clients health care needs
2.To establish nursing care plan so as to meet those needs
3.To give scientific based, holistic, individualized care for the
patient;
4.An opportunity to work collaboratively with patients and others;
5.Achieve continuity of care and;
6.Encourages the health care team to observe and interact with the
patient, and not just the task they are performing such as a
administering an injection, dressing change, or a bed bath.
7.The process provides a roadmap that ensures good nursing care
and improves patient outcomes.
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18. Characteristics of the Nursing Process
✓Problem-oriented
✓Goal-oriented
✓Orderly, planned, systematic
✓Open to accepting new information during its application
✓Interpersonal
✓Permits creativity among nurses and clients
✓Universal;
✓It is applicable to individuals, families, and communities
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19. Benefits of the NP for the Patient
❖Access to quality nursing care
❖Continuity of care
❖Reduces the incidence of hospital stay
❖Patient participation reflects respect for human dignity
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20. Benefits of the NP for the Nurse
▪Consistent and systematic nursing education and care provision
▪Job satisfaction
▪Professional development
▪Avoidance of legal action
▪Meeting code of ethics and professional nursing standards
Speed up diagnosis and treatment of actual and potential health
problems
Promotes flexibility and independent thinking
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21. Nsg Vs Medical process
Nursing process
Deals with two types of health
problems
1. Human response for problems
2. Problems with structure and
function of organs or systems
requiring physicians’ orders
Uses the five step approach and
provides strict rules for how
each step is followed.
Medical process
▪Deals mostly with problems
with structure and function of
organs or systems.
▪Uses the five step approach but
has less precise rules for how
planning, implementation and
evaluation are done- e.g. Goals
are not clearly recorded during
planning.
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22. Phases of Nursing Process
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23. Components of the
NP
Components of the Nursing Process
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24. Nursing Process in the community
Assessment
Diagnosis
Planning
Implementation
Evaluation
Promote
Prevent
Maintain
Restore
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25. 25
ASSESSMENT
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26. Assessment
Assessment is the systematic collection of data (subjective and
objective data) to determine the patient’s health status and to
identify any actual or potential health problem .
It is the first step in the Nursing Process:
➢The assessment phase of the nursing process has the following
components:
✓ I. Subjective and objective data collection
✓II. Validation of data
✓III. Organizing data
✓IV. Documentation of data
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27. Cont…
❑Data collection
Nursing History from client as a primary source
A comprehensive physical examination that helps to identify
the client’s response to disease; to establish an initial data base
for later comparison, and to validate subjective data presented
by the client during the interview- Not toward identification of
disease;
Laboratory
Nursing Records
Relevant Literature
Input from family and significant others
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❑Sources of information:
❖Primary Source
✓information of assessment comes from the client
❖Secondary Source
✓includes family members, significant other health care
professionals, health records, and literature review
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29. 29
Two categories of data collected:
➢Subjective data – consists of client’s opinions, feelings about
what is happening. Only the client can tell you that he/she is
afraid or in pain. Sometimes the client can communicate through
body language: gesture, facial expressions and body posture. To
obtain subjective data you need sharp interviewing, listening and
observation skills
➢Objective data (precise, accurate measurements or clears
descriptions) – include all the measurable and observable pieces
of information about the client and his or her overall state of
health. This type of data is obtained by using the four physical
examination techniques (inspection , palpation , percussion ,and
auscultation).
7/16/2024 By Husien S(Senior NP,RN)

30. Cont…
➢Subjective data: consists the client’s opinions, feelings about
what is happening.
To obtain subjective data you need sharp interviewing,
listening, and observation skills.
E.g. "I feel sick to my stomach."
"I have a stabbing pain in my side."
"I feel like nobody likes me."
307/16/2024 By Husien S(Senior NP,RN)

31. Cont…
➢Objective data: include all the measurable and observable
pieces of information about the client and his or her overall
state of health.
➢Objective data are concrete, observable information such as:
- vital signs, laboratory studies, and changes in physical
appearance
Example: Blood pressure of 110/70 mmHg.
Rash on right arm
Urinated 150 ml clear urine
The term objective means that only precise, accurate
measurements or clear descriptions are used.
N.B. S- S = Subjective data are Stated.
O-O = Objective data are Observable.
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32. Cont…
❖Method of data collection
1.Observation: is an assessment tool that relies on the use of
the five senses (sight, touch, hearing, smell and taste) to
discover information about client.
2.Health interview: the health interview is a way of soliciting
information from the client.
➢This interview may also be called a nursing history.
3.Physical examination: done from head to toe or on
particular body area depending on the clients condition
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33. Cont…
Validating data
➢Data validation focuses up on making sure that your data are
factual.
➢Validating the data with the client helps the nurse to avoid
making incorrect inferences.
Validating data helps you to avoid:
➢Missing pertinent information
➢Misunderstanding situation
➢Jumping to conclusion or focusing in the wrong direction.
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34. Cont…
Organizing (Clustering) Data
Based on
➢Human needs
➢Functional health pattern (Gordon)
➢ Body systems
Documentation data
Importance of documentation of data are:
➢Communication
➢For evaluation
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35. DIAGNOSIS
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36. Nursing diagnosis
Nursing diagnosis is a clinical judgment about an individual, family
or community response to actual or potential health problems.
It tells us the health care needs of the patient
Nursing diagnosis are those problems for which nurses can legally
prescribe definitive interventions independently.
Type of Nursing Diagnosis:
✓Actual Nursing Diagnosis
✓Risk nursing diagnosis
✓Possible Nursing Diagnosis
✓Wellness Nursing Diagnosis
✓Syndrome nursing diagnosis
367/16/2024 By Husien S(Senior NP,RN)

37. Types of nursing diagnosis
1.Actual Nursing Diagnosis
▪Represents a problem that has been validated by the presence of
its characteristics.
E.g. Impaired physical mobility ,fatigue ,ineffective breathing
pattern.
2.Risk nursing diagnosis
▪It is a clinical judgment that an individual , family ,community is
more vulnerable (able) to develop the problem .
▪E.g. Risk for deficient fluid volume
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38. Cont….
3.Possible Nursing Diagnosis
▪Are statements describing a suspected problem requiring
additional data .
E.g. Possible chronic low self-esteem
4.Wellness Diagnosis
▪It is a clinical judgment about individual , group , or community
in transition from specific level of wellness to a higher level .
E.g. Readiness for enhanced health maintenance ,Readiness for
enhanced self- esteem.
5.Syndrome nursing diagnosis
▪A cluster of an actual or risk nursing diagnosis suspected to be
present according to certain events or situations.
E.g. Post trauma syndrome
387/16/2024 By Husien S(Senior NP,RN)

39. Parts of Nursing Diagnosis
1.Problem (diagnostic label)-statement that describes the health
problem of the patient clearly & concisely.
2.Etiology(Related factors) -the reason that identifies the
physiological , psychological ,social ,spiritual & environmental
factors related to the problem.
3.Defining characteristics (s/s )- The subjective & objective data
that signal the existence of the problem.
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40. Cont…
NB: To write a diagnostic statement for an actual nursing diagnosis
,link the problem(P) and etiology (E) by using “related to” and
link the etiology (E) with defining characteristics (S) by using “
as evidenced by” or “as manifested by ’’
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41. Cont…
1. An actual nursing diagnosis has 3 parts statement ( P + E + S)
E.g. Pain related to surgical incision as evidence by verbal
comments ,body posture…
2.Risk nursing diagnoses are two parts (P + E)
E. g. Risk for injury related to lack of awareness of hazards
3.Possible nursing diagnoses has two-part statements consisting of:
▪ The “related to” data that lead the nurse to suspect the diagnosis.
E.g Possible disturbed body image related to isolating behaviors post
surgery
4.Diagnostic statements for wellness nursing diagnoses has one-
part containing the diagnostic label.
E.g Readiness for enhanced family process
Readiness for enhanced nutrition
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42. Cont…
5.Syndrome nursing diagnoses usually are one- part diagnostic
statements with the contributing factors contained in the
diagnostic label.
Example
▪ Rape- trauma syndrome
▪ Disuse syndrome
▪ Post -trauma syndrome
▪ Relocation stress syndrome
▪ Impaired environmental Interpretation syndrome
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43. 43
PLANNING
7/16/2024 By Husien S(Senior NP,RN)

44. Planning
➢It is the third step of nursing process.
➢It provides the direction for nursing intervention.
➢The planning phase is where goals and outcomes are formulated that
directly impact patient care based on evidence based practice (EBP).
Types of Planning
❑Initial Planning:
✓It is done by the nurse who conducts the admission assessment.
❑Ongoing Planning:
✓It is done by all the nurses who work with the client.
❑Discharge Planning:
✓It is the process of anticipating and planning for needs after discharge.
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45. Cont…
Planning Goal Directed Care
▪Setting realistic goal
▪Goals should be SMART (Specific Measurable, Attainable,
realistic and time bounded).
➢ Short term goal- can be meet relatively quickly (i.e less than a
week)
➢Long term goals- may take a week and more or months or
more.
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Developing a Nursing Care Plan
❖Informal nursing care plan – is a strategy for action that exist in
the nurse’s mind
❖Formal nursing care plan – written or computerized guide that
organizes information about the client’s care
❖Standardized care plan – a formal plan that specifies the nursing
care for groups of clients with common needs
❖Individualized care plan – tailored to meet the unique needs of a
specific client
7/16/2024 By Husien S(Senior NP,RN)

47. Nursing care plan (planning)…
In writing the nursing care plan, the nurse should think about:
❑Who is it for?
❑ What are the short term and long term goals?
❑How can you determine that you have reached the goals?
(measurable)
❑ How will the patient know he/she has achieved the goals?
(realistic)
❑ Who is involved in the delivery of the care? (The patient (and
family), yourself, the nursing team, medical staff,
multidisciplinary team, labs, investigations, procedures etc)
✓nursing centered, and it identifies the scope and depth of the
nursing practice
477/16/2024 By Husien S(Senior NP,RN)

48. Nursing care plan (planning)…
Priority setting
Nursing diagnoses are ranked in order of importance.
Survival needs or imminent life threatening situations takes the
highest priority.
For example, the needs for air, water and food are survival needs.
➢Nursing diagnostic categories that reflect these high-priorities
needs include Ineffective Airway Clearance and deficient fluid
volume.
➢During setting criteria, consider the following points:
✓Actual problems take precedence over potential concerns.
✓Airway should always be given highest priority.
✓Clients with unstable condition should be given priority over
those with stable conditions.
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49. Nursing care plan (planning)…
Priority setting …
❖Priority 1. - Life threatening problems and those interfering
with physiologic needs. (Ex. Problems with respiration,
circulation, nutrition, hydration, elimination, temperature
regulation, physical comfort);
❖Priority 2. - Problems interfering with safety and security (ex.
Environmental hazards, fear)
❖Priority 3. - Problems interfering with love and belonging (ex.
Isolation or loss of a loved one)
❖Priority 4. - Problems interfering with self esteem (ex.
Inability to wash hair, perform normal activities)
❖Priority 5. - Problems interfering with the ability to achieve
personal goals.
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50. 50
IMPLEMENTATION
7/16/2024 By Husien S(Senior NP,RN)

51. Implementation
▪ A step of nursing process in which a planned nursing action is
carried out and documented.
Types of nursing implementation :
1.Direct care intervention :
▪Performed through intervention with patient and includes both
physical and psychological nursing action also include
both(laying of hands) or supportive and counseling in nature.
2.Indirect care intervention
▪ A treatment performed away from the patient include
management of patient environment.
3.A community intervention
▪Targeted to promote and preserve the health of populations.
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52. EVALUATION
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53. Evaluation
Nursing Care Evaluation
❑Nursing evaluation is the regular review of the effect of nursing
interventions and the treatment regimen on the patient’s health status
and expected health outcomes.
During this phase
✓Collect data regarding your client progress
✓Measure goal attainment
✓Revise or modify care plan if necessary
The following questions should be considered:
✓Have the goals of the nursing care plan been achieved? If not, why
not?
✓Were the goals realistic?
✓Was the patient committed to the goals?
✓Was there enough time to achieve the goals?
✓Did other problems arise that impeded progress?
✓Were interventions consistently performed as prescribed?
537/16/2024 By Husien S(Senior NP,RN)