O.U Medico-Surgical Nursing 1 PDF

NATIONAL OPEN UNIVERSITY OF NIGERIA
SCHOOL OF SCIENCE AND TECHNOLOGY
COURSE CODE:NSS 321
COURSE CODE TITLE:MEDICO-SURGICAL NURSING I

NSS 321 MEDICO-SURGICAL NURSING
I
COURSE
GUIDE
NSS 321
MEDICO-SURGICAL NURSING I
Course Team Dr. Clara Agbedia (Developer/Writer) - DELSU

Prof. O.C. Nwana (Programme Leader) - NOUN
Simeon K.Olubiyi (Coordinator) - NOUN
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National Open University of Nigeria

Headquarters
14/16 Ahmadu Bello Way
Victoria Island
Lagos
Abuja Office
No. 5 Dar es Salaam Street
Off Aminu Kano Crescent
Wuse II, Abuja
Nigeria
e-mail: centralinfo@nou.edu.ng
URL: www.nou.edu.ng
Published By:
First Printed 2009
ISBN: 978-058-343-2
All Rights Reserved
Printed by:
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CONTENTS PAGE
Introduction ………………………………………………………… 1
The Course………………………………………………………….. 2
Course Aims ………………………………………………………… 2
Course Objectives ………………………………………………….. 2
Working through the Course ………………………………………. 3
Course Material ………………………………………………..…… 3
Study Units …………………………………………………………. 3
Text Books and References ………………………………………… 4
Assessment ………………………………………………………… 4
Tutor-Marked Assignment ………………………………………… 4
Final Examination and Grading …………………………………… 4
Summary …………………………………………………………… 4
Introduction
Nursing is a profession that serves the needs of society in the area of

health. The practice of nursing addresses a range of health problems,
both actual and potential, requiring of its practitioners a specialised body
of knowledge and skills to meet client needs and a value system that
recognises the client as an autonomous human being with rights. As a
profession, nursing has served a vital role within the health care system
through history.
The rapid changes in health, technological advances, knowledge

explosion, demographic changes and advance medical science, demand
that nurses be educationally prepared to provide or plan care across the
continuum of setting – from hospital or clinic to home or community
and during all phases of illness.
The course you are about to study is Medico-Surgical Nursing, and is

taught in four parts, namely Medico-Surgical nursing I, II, III, IV.
Medico-Surgical Nursing I lays the foundation for the other three Med-
surgical courses. Medico-Surgical Nursing 1 deals with the basic
concepts of health and illness, ways in which the body defends and
responds physiologically to disease states, the use of the nursing process
as a framework in providing comprehensive care to patients, basic
nursing concepts, principles and practices of rehabilitation and
conditions that threaten body’s adaptation mechanism. You will also
gain understanding of the varied diagnostic measures used in medical-
surgical nursing. At the end of Medico-Surgical II, you should be able to
identify clients/patients suffering from specific medical or surgical
conditions, formulate and implement nursing care plans based on the
needs of individuals. You will also learn how to manage patients before,
during and after diagnostic and nursing procedures.
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Medical-Surgical III, is designed in such a way that you will continue to

learn to identify clients/patients suffering from specific medical or
surgical conditions. Continue to utilise the nursing process in the care of
patient health problems. Formulate and implement nursing care plans
based on the needs of individuals. Manage patients before, during and
after specific diagnostic and nursing procedures. Demonstrate
understanding of emergency and disaster nursing care. Demonstrate the
ability to perform a simple surgical wound-dressing and skill in use of
various nursing equipments.
The Course
Medico-Surgical Nursing I is divided into three modules.
Module 1 lays the foundation for Medico-Surgical Nursing practices

and provides you with knowledge of general concepts in medical-
surgical practice. Basic concepts and terminologies in Medico-Surgical
Nursing are discussed with special reference to health-illness
continuum. It also deals extensively with the use of the nursing process
as a framework for nursing practice. An overview of selected nursing
theories and models are included. You need to understand the uses of
this essential tool in nursing as well as the concept of evidence-based
practice.
Module 2 deals with nursing history and physical examination of

patients. It also focuses on common concepts in the practice of medical-
surgical nursing. These include quality assessment fluid and electrolyte
distribution and imbalances, shock, pain, infection, disease and
neoplasm.
Module 3 deals with the challenges of surgical nursing. The unit on

surgical patient deals with pre-operative nursing of a patient undergoing
surgery with special emphasis on general assessment, preparation and
intervention for patient experiencing surgery. The final unit deals with
tools that enhance nursing practice, accountability, pain and pain
management are discussed. Diagnostic measures in medical-surgical
condition are also discussed.
Course Aim
The goal of this course (Medico-Surgical Nursing) is to provide you

with the necessary knowledge of the art and science of adult medico-
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surgical nursing and the therapeutic skills needed for effective

management of systemic disorders in the body.
Course Objectives
This course is set to assist you achieve the following objectives:
1. Understand the basic concept and terminologies in Medical Surgical

Nursing.
2. Understand the concept and Philosophy of rehabilitation.
3. Understand the use of nursing process in the care of client/patient.
4. Understand the problems associated with body defence mechanism.
5. Learn the diagnostic measures in medical surgical conditions.
6. Explain the role of the nurse in pre-operative care of a surgical
patient.
7. Learn the pre-operative management of the surgical patient.
Working through the Course
This course requires extensive reading. The contents of this material

also require a lot of time to study. Despite the great effort to make it
comprehensible, the effort required of you is still tremendous. You are
therefore advised to avail yourself of the tutorial sessions opportunity to
compare notes with your peers.
The Course Material
You will be provided with the following materials:
Course Guide
Study Units.
Study Units
The study units covered on this course are:
Module 1 General Introduction to the Course
Unit 1 Framework of Nursing Practice

Unit 2 Nursing Process
Unit 3 Application of the Nursing Process
Module 2 Medical-Surgical Conditions
Unit 1 Fluid and Electrolyte Distribution
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Unit 2 Fluid and Electrolyte Imbalances

Unit 3 Acid-Base Imbalance
Unit 4 Inflammation
Unit 5 Shock
Unit 6 Neoplasms
Unit 7 Pain
Module 3 Diagnostics and Investigations of Medical–Surgical

Conditions
Unit 1 Diagnostic and Laboratory Investigation in Medical-

Surgical Conditions
Unit 2 Clinical Observations
Unit 3 Pre-operative intervention
Unit 4 Post Operative Nursing Care
Text Books and References
In addition, the course comes with a list of recommended textbooks,

which though are not compulsory for acquisition, are indeed, valuable
supplements to the course material.
Barbara Kozier, Glenora Erb. [No date]. Fundamentals of Nursing.

Concepts and Procedures. (2nd ed.)
Brunner & Suddarth. Medical Surgical Nursing. (10th ed) Lippincott

Wilkins, 2004.
Schultz, A. Predicting and Preventing Pressure Ulcers in Surgical

Patients AORN Journal 81; Issue No. 986 – 1006, 2005.
Assessment
There are two components of assessment for this course. The Tutor-
Marked Assignment (TMA) and the end of course examination.
Tutor-Marked Assignment
The TMA is the continuous assessment component of your course. It

accounts for 30% of the total score. You will be given four TMAs to
answer. Three of these must be answered before you are allowed to sit
for the course examination. The TMAs would be given to you by your
facilitator and returned after you have done the assignment.
Final Examination and Grading
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This examination concludes the assessment for the course. It constitutes

70% of the whole course. You will be informed of the time for the
examination.
Summary
This course intends to provide you with the necessary knowledge of the
art and science of adult medico-surgical nursing and the therapeutic
skills needed for effective management of systemic disorders in the
body.
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Course Code NSS 321

Course Title Medico-Surgical Nursing I
Course Team Dr. Clara Agbedia (Developer/Writer) - DELSU

Prof. O.C. Nwana (Programme Leader) - NOUN
Simeon K.Olubiyi (Coordinator) - NOUN
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Headquarters
14/16 Ahmadu Bello Way
Victoria Island
Lagos
Abuja Office
No. 5 Dar es Salaam Street
Off Aminu Kano Crescent
Wuse II, Abuja
Nigeria
e-mail: centralinfo@nou.edu.ng
URL: www.nou.edu.ng
Published By:
First Printed 2009
ISBN: 978-058-343-2
All Rights Reserved
x
I
CONTENTS PAGE
Module 1 General Introduction to the Course……….…….. 1
Unit 1 Framework of Nursing Practice…………….………. 1

Unit 2 Nursing Process …………………………….………. 21
Unit 3 Application of the Nursing Process.………………… 38
Module 2 Medical - Surgical Conditions………………….…. 56
Unit 1 Fluid and Electrolyte Distribution………………….. 56

Unit 2 Fluid and Electrolyte Imbalances……………….…… 74
Unit 3 Acid–Base Imbalance…………………………….…. 93
Unit 4 Inflammation…………………………………….…... 113
Unit 5 Shock…………………………………………….…... 132
Unit 6 Neoplasms…………………………………….……... 150
Unit 7 Pain…………………………………………………... 170
Module 3 Diagnostics and Investigations of Medical –

Surgical Conditions …………………….………… 188

Surgical Condition………………………………… 188
Unit 2 Clinical Observations……………………………… 207
Unit 3 Preoperative Intervention………………………….. 225
Unit 4 Post Operative Nursing Care……………………… 242
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MODULE 1 GENERAL INTRODUCTION TO THE

COURSE
Unit 1 Framework of Nursing Practice

Unit 2 Nursing Process
Unit 3 Application of the Nursing Process
UNIT 1 FRAMEWORK OF NURSING PRACTICE
CONTENTS
1.0 Introduction
2.0 Objectives
3.0 Main Content
3.1 Why Does Nursing Need Theory?
3.2 Components of Nursing Theories
3.2.1 Selected Nursing Theories
3.2.2 Henderson’s Complementary-Supplementary
Model
3.2.3 Orem’s Theory of Self-Care
3.2.4 King’s Theory of Goal Attainment
3.2.5 Johnson’s Behavioral System Model
3.2.6 Roy’s Adaptation Model
3.2.7 Leininger’s Theory of Tran cultural Nursing
3.2.8 Watson’s Science of Caring
3.2.9 Rogers’ Science of Unitary Human beings
3.2.10 Neuman’s Systems Model
4.0 Conclusion
5.0 Summary
6.0 Tutor-Marked Assignment
7.0 References/Further Reading
1.0 INTRODUCTION
Since the 1960s, there has been a growing interest in developing nursing
theories. This interest emerged from the desire to clarify the nature of
nursing. Margaret Newman described three general approaches that
nurses use to develop nursing theory. One approach is to borrow theory
from other disciplines and integrate it into the science of nursing. An
example of this approach is the use of systems theory as seen in
Johnson’s behavioral system model for nursing. A second approach is to
analyse nursing practice situations for the theoretical underpinnings.
Orem’s self-care nursing model is representative of this approach. The
third approach is to develop a conceptual model from which theories can
be derived. This is the aim of most nurse theorists. At present, nursing
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frameworks and models reflect a synthesis of the first two approaches.

They combine scientific theories with analyses from nursing practice.
They focus on the interactions between the client and nurse by
describing the nursing activities or the relationship between the client
and nurse.
Most nursing theorists prefer to call their work models, because they do
not meet the narrow criteria of theories as a way of collectively
describing nursing frameworks and models. This unit begins with an
overview of selected theories and frameworks for professional nursing
practice, followed by a discussion on the use of the nursing process as a
framework for nursing practice.
2.0 OBJECTIVES
At the end of this unit, you should be able to:
• differentiate between a concept, theory, conceptual framework,

and model
• identify and define the four central concepts of nursing theories
• compare and contrast selected theories of nursing.
3.0 MAIN CONTENT
A concept is a building block of theory. It is an idea or word that

describes objects, events, or properties, bring up a mental image of the
phenomenon.
A theory is a statement or group of statements that describes, explains,

or predicts the relationship between concepts (e.g. objects events or
properties). Theories may be broad or limited in scope, thus varying in
their ability to describe, explain or predict.
A conceptual framework provides the orienting scheme or world view

that helps focus our thinking. A conceptual framework can be visualised
as an umbrella under which many theories can exist. The major
distinction between a conceptual framework and a theory is the level of
abstraction, with a conceptual framework being more abstract than a
theory.
3.1 Why Does Nursing Need Theory?
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The purpose of a theory in nursing is to achieve desired outcomes for
nursing. To do this, a theory must arise from the systematic abstraction
of nursing reality. A systematically developed theory will produce a
well-founded basis for the continued use of these purposes in nursing
practice. This process challenges thinking, provides new analytic skills,
and helps all practitioners become more purposeful in their actions.
Thus, theory development depicts collective efforts of nurses to define
and direct the profession and provide the basis for continued theoretical
development. A theory is of value in guiding or channelling the function
of the profession, including the guiding of education, research, and
practice with potential or actual links between the three."
3.2 Components of Nursing Theories
These are:- (a) The Nature of Nursing (b) The Individual (c) Society and
Environment (d) Health.
Nature of Nursing
In nursing theory, the nature of nursing is generally represented as being

a helping discipline, with the primary focus on interpersonal interactions
occurring between nurse and client. This general idea does not clearly
distinguish nursing from other helping disciplines, but it does provide an
important focus for formulating propositions regarding nursing actions
and the knowledge needed to develop and improve nursing practice.
This description of the nature of nursing distinguishes nursing clearly
from medicine, in that medicine focuses on surgical and pharmacologic
interventions with interpersonal interactions as an adjunct to these
interventions. In contrast, interpersonal interactions are primary for
nursing, while technical and medical interventions are an adjunct to
primary interpersonal interactions.
While different authors generally present a conceptualisation of the
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nature of nursing that is consistent with the underlying commitment that

interpersonal interactions are a primary focus, there are important
differences in the various definitions and conceptualisations. For some
authors, the interpersonal process involved in nursing rests heavily upon
the traits and will of the individual receiving care. That is, the client
largely or totally, defines the direction of the interaction and the specific
actions that are taken in achieving the goals of the interaction. The
nurse’s role in the interaction is primarily one of facilitator.
Conversely, other theories present a view of the interpersonal process as

one that is either shared or initiated by the nurse. In this view, nursing
processes and actions rest heavily upon initiative, knowledge, and
approaches actively taken by the nurse to reach the goal or purposes of
the interaction.
It can be argued that both views are consistent with nursing reality in
that nurses encounter situation in which the client primarily directs the
interaction and those in which the nurse is primarily the initiator.
The Individual
All existing nursing theories and models deal with the recipient of
nursing, usually an individual, but sometimes groups of people such as
families or communities. The most consistent philosophic component of
the idea of the individual is the dimension of wholeness or a holistic
view of the person. Holism means that the whole is greater than the sum
of the parts and that the whole cannot be reduced to parts without losing
something in the process. Thus an individual cannot be viewed in
isolation ozone body part take precedence over another. Early nursing
theories and models made some attempts to deal with the individual as a
whole person, but these ideas have become increasingly developed with
more recent conceptualizations.
Society and Environment
The concept of society and environment are consistently viewed as

central to the discipline of nursing. Several nursing theories deal
primarily with society and view society as a critical interacting force
with the individual. The environment was central for Nightingale in her
concepts of nursing. Nightingale believed that the primary focus for
nursing actions was to alter the environment in order to place the human
body in the best possible condition for the reparative processes of nature
to occur.
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Health
The concept of health is usually identified as the purpose or goal of

nursing. Contemporary nursing theories are remarkably congruent with
this early conceptualisation. Most theories and models of the early
twentieth century were based on a conceptualization of a health-illness
continuum, and nursing purpose was to assist the ill client to achieve the
best level of health possible. More recently, nurse authors have begun to
seriously examine the concept of health and to represent health as more
than, or different from, the absence of disease. Health is viewed in
current nursing theories as a dynamic state or process that changes with
time and varies according to circumstances.
3.2.1 Selected Nursing Theories
The theoretical perspectives presented here include a brief overview,

basic assumptions about the individual and the environment, definitions
of health and illness, a description of nursing including the goal of
nursing, and definition of concepts and sub-concepts specific to each
theory. You are encouraged to consult other books to gain a full
appreciation of the depth, scope, and extent of the relationships put
forth.
Nightingale’s Environmental Theory
The environment is critical to health and the nurse’s role in caring for
the sick is to provide a clean, quiet, peaceful environment to promote
healing. Florence Nightingale conceptualized disease as a reparative
process and described the nurse’s role as manipulating the environment
to facilitate and encourage this process. Her directions regarding
ventilation, warmth, light, diet, cleanliness, variety, and noise are
discussed in her classic nursing textbook.
The Individual
Individuals are responsible, creative, in control of their lives and health,

and desire good health.
Environment
The environment is external to the person but affects the health of both
sick and well persons. The environment includes pure air, pure water,
efficient drainage, cleanliness, and light.
Health
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Health, in this context, is defined as a state of being well and using one’s
powers to the fullest. Illness or disease is the reaction of nature against
the conditions in which we have placed ourselves. Disease is a
reparative mechanism, an effort of nature to remedy a process of
poisoning or decay.
Nursing
Nursing’s role is to promote or provide the proper environment for the

patients. These include fresh air, light, pure water, cleanliness, warmth,
quiet, and appropriate diet. The goal of nursing is to promote the
reparative process by manipulating the environment.
This model identifies some relationships- environment, and the nurse’s

relationship with the patient. Nursing’s role is to manipulate the
environment to encourage healing. This includes the proper use of fresh
air, light, warmth, cleanliness, quiet, and the proper selection and
administration of diet. According to Florence Nightingale, the sine qua
non of all good nursing is never to allow a patient to be awakened,
intentionally or accidentally. “A good nurse will always make sure that
no blind or curtains should flap. If you wait till your patient tells you or
reminds you of these things, where is the use of their having a
nurse?” (p. 27).
3.2.2 Henderson’s Complementary-Supplementary Model
According to Henderson, a nurse’ role is that of a substitute for the

patient, a helper to the patient, and a partner with the patient. She later
identified fourteen basic patients’ needs that are essential components of
nursing care. In the book, The Nature of Nursing (1966), she indicated
that the “unique function of the nurse is to assist the individual, sick or
well in the performance of those activities contributing to the health or
its recovery (or a peaceful death) that he would perform unaided if he
had the necessary strength, will or knowledge” (p. 15).
The Individual
Since individuals will achieve or maintain health if they have the

necessary strength, will, or knowledge (1966: 15), it therefore follows
that assistance may be necessary to achieve health.
Environment
According to Henderson, this is an aggregate of all the external

conditions and influences affecting the life and development of an
organism.
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Health: Health, in this Henderson’s theory, is equated with

independence. Conversely, it can be inferred that illness is a lack of
independence.
Nursing
Nursing has a unique function of assisting sick or well individuals in a

supplementary or complementary role. The goal of nursing is to help the
individual gain independence as rapidly as possible.
Key Concepts
Henderson identifies fourteen basic needs as essential components of

nursing care. These are:
1. Breathe normally.
2. Eat and drink adequately.
3. Eliminate body wastes.
4. Move and maintain desirable position.
5. Sleep and rest.
6. Select suitable clothes.
7. Maintain body temperature within normal range by adjusting

clothing and modifying the environment.
8. Keep the body clean and well groomed to protect the integument.
9. Avoid dangers in the environment and avoid injuring others.
10. Communicate with others in expressing emotions, needs fears, or
opinions.
11. Worship according to one’s faith.
12. Work in such a way that there is a sense of accomplishment.
13. Play or participate in various forms of recreation.
14. Learn, discover, or satisfy the curiosity that leads to normal
development and health and use available health facilities.
3.2.3 Orem’s Theory of Self-Care
Orem (1950), focuses on nursing as a deliberate human action and notes

that all individuals can benefit from nursing when they have health-
derived or health-related limitations for engaging in self-care or care of
dependent others. To Orem, self-care practices are a set of learned
behaviors, to sustain life, to maintain or restore functioning, and to bring
about a condition of well-being. The role of the nurse is to assist clients
with self-care when there is a deficit in their ability to perform.
The Individual
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The individual is viewed as a unity whose functioning is linked with the

environment and who, with the environment, forms an integrated,
functional whole. “Human beings are capable of self-determined
actions” (1990, p. 76) and function biologically, symbolically, and
socially.
Environment
The environment is linked to the individual, forming an integrated and

interactive system. It implied that the environment is external to the
individual.
Health and Illness
Health, which has physical, psychological, interpersonal, and social

aspects, is a state in which human beings are structurally and
functionally whole. Illness occurs when an individual is incapable of
maintaining self-care as a result of health-related limitations.
Nursing
Nursing involves assisting the individual with his or her self-care

practices to sustain life and health, recover from disease or injury, and
cope with their effects. The goal of nursing is to move a patient toward
responsible self-care or meeting existing health care needs of those who
have health care deficits for purposes of maintaining, protecting, or
promoting their functioning as human beings.
Key Concepts
Self-care – This involves learned activities and sequences of actions that

individuals initiate and perform on their own behalf to maintain life,
health, and well-being.
Self-care requisites – These are actions “performed by or for

individuals in the interest of controlling human and environmental
factors” (1990: 121). There are three categories of self-care requisites:
Universal – This is common to all human beings. They are concerned

with the promotion and maintenance of structural and functional
integrity.
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Developmental – This is associated with conditions that promote

known developmental processes at each stage of the life cycle.
Health-deviation – This is associated with genetic and constitutional

defects and deviations that impair the individual’s ability to perform
self-care.
Therapeutic self-care demands – This is the totality of self-care

actions performed by the nurse and/or self in order to meet known self-
care deficit requisites.
Self-care deficits – These are gaps between known therapeutic self-care

demands and the ability to perform self-care or dependent care.
Nursing systems – This refers to actions of nurses and patients that

“regulate patient’s self-care capabilities and meet patient’s self-care
needs”. This can be (a) whole compensation (b) partial compensation.
In the context of wholly compensatory, the nurse compensates for the

individual’s total inability to perform self-care activities. When the
nurse compensates for the individual’s inability to perform some (but
not all) self-care activities, this is called partly compensatory. In
supportive–educative system, the patient performs or learns to perform
required measures of therapeutic self-care that they cannot do so without
assistance.
3.2.4 King’s Theory of Goal Attainment
The Theory of Goal Attainment is advanced by Imogere King in her

publication Toward a Theory for Nursing (1981). The Theory identified
the focus of nursing as being on interacting with their environments,
leading to a state of health, which is the ability to function in roles.
Individual
The individual is viewed as open systems that interacts with their

environment and are conceptualized as social, sentient, rational,
perceiving, controlling purposeful, action-oriented beings.
Environment
As an open system, it is implied that the individual and the environment

interact and that both the internal and external environments generate
stressors.
Health and illness
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Health is described as an individual’s ability to function in social roles,

which implies optimal use of one’s resources to achieve continuous
adjustment to internal and external environmental stressors. Illness is a
deviation from the norm, an imbalance in a person’s biological structure,
psychological makeup, or social relationships.
Nursing
In a process of action, reaction, and interaction, the nurse and client

communicate, set goals, and explore means to achieve those goals. “The
domain of nursing includes promoting, maintaining and restoring health,
caring for the sick and injured and caring for the dying” (1981: 4). The
goal of nursing is to assist individuals to maintain their health so they
can function in their roles.
Key Concepts
Two sets of concepts are subsumed in the theory, one relating to the
parties involved in the nurse-client relationship and the other pertaining
to goal attainment.
Personal System – This refers to an individual.
Interpersonal System – It refers to two or more interacting individuals.
Social System – This describes communities and societies that the

patient lives.
Concepts of Goal Attainment – This is an interaction of contextual

variable.
Interaction – This refers to a process of perception between the person

and environment or one or more persons, represented by verbal and
nonverbal behaviors that are goal-directed.
Perception – This is an individual’s representation of reality.
Communication – This is the process of giving information from one

person to another.
Transaction – It refers to observable behavior or individuals interacting

with their environment.
Role – It refers to a set of behaviors displayed by an individual who

occupies a given position in a social system.
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Stress – This is a dynamic state of interaction with the environment

needed to maintain balance for growth, development, and performance.
Growth and Development – This refers to “continuous changes in

individuals occurring at molecular, cellular and behavioral levels”.
Time – This is the duration between one event and another.
Space – It can be defined by “gestures, postures and visible boundaries

erected to mark off personal space” (1981. 148).
3.2.5 Johnson’s Behavioral System Model
Johnson views the individual as a behavioral system that is continually

striving for balance. The nurse serves as an external regulatory force to
preserve and maintain this system balance.
The Individual
As a behavioral subsystem, the individual strives to attain and maintain

behavioral system balance. This often will require adaptation and
modification.
Environment
The internal or external natural forces constitute the environment in

which the behavioral system exists.
Health
Health, within the theory occurs when there is an equilibrium, to the

extend that the behavioral system is self-maintaining and self-
perpetuating, and interrelationships between the subsystems are
harmonious. Illness is a state of disorganization and dysfunction of the
system.
Nursing
In this context, nursing is described as an external regulatory force,

imposes external controls to fulfill the functional requirements of the
subsystems. According to Johnson, the goal of nursing is to restore,
maintain, or attain behavioral system balance and stability at the highest
possible level for the individual
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Key Concepts
Behavioral System – This consists of seven behavioral subsystems that

are integrated in and characterise each person’s life.
Behavioral Subsystem – This is a formed set of behavioural responses

that seem to share a common drive but that are modified over time,
through maturation or learning. The seven subsystems are:
Affinitive
This suggests intimacy, and the formation and maintenance of a strong

social bond.
Dependency
Refers to succoring behavior that calls for the response of nurturing or

physical assistance.
Ingestive
Refers to appetite satisfaction determined by social and psychological

considerations.
Eliminative
Describes elimination of body wastes as a learned behaviour.
Sexual
Refers to gender role identity and the broad range of behaviours

dependent on one’s biologic sex.
Achievement
Refers to mastery or control over some aspect of the self or

environment. This may include intelligence, physical, creative,
mechanical, and social skills.
Aggressive
Refers to protection and preservation of self and society within the

limits approved by society.
3.2.6 Roy’s Adaptation Model
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Sister Calista Roy describes the individual as a biopsychosocial adaptive

system and nursing as a humanistic discipline that “places emphasis on
the person’s own coping abilities” (1984. 32). The individual and the
environment are thus sources of stimuli that require modification to
promote adaptation. Thus the role of the nurse promotes adaptation by
modifying external stimuli.
The Individual
The individual is in constant interaction with a changing environment

and must respond positively to environmental change, for proper
adaptation. However, the person’s adaptation level is determined by the
combined effect of three classes of stimuli – focal, contextual, and
residual. The individual uses both innate and acquired biologic,
psychological, or social adaptive mechanisms and has four modes of
adaptation.
Environment
This comprises of situation and circumstances surrounding or

influencing the development and behaviour of persons and groups. The
environment is constantly changing and consists of both internal and
external components.
Health
In this model, health is described as a process of being and becoming an

integrated and whole person. Conversely, illness is a lack of integration.
Nursing
As an external regulatory force, or the goal of nursing is to promote the

person’s adaptation in the four adaptive modes, thus contributing to
health, the quality of life, and dying with dignity.
Key Concepts
Adaptation – Refers to the individual’s ability to cope with the

constantly changing environment.
Adaptive system – This consists of two major internal control

processes:
(a) Receives Input from the external environment and from changes
in the person’s internal state.
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(b) Input from external and internal stimuli that involves

psychological, social, physical, and physiological factors, and
processes it through cognitive pathways.
Adaptive Modes
Refers to ways a person adapts. Adaptative Model includes:
Physiological
This is determined by need for physiological integrity derived from the

basic physiological needs.
Self-Concept
This is determined by need for interactions with others and psychic

integrity regarding perception of self.
Role Function
This is determined by the need for social integrity, it also refers to the
performance of duties based on given positions within society.
Interdependence
Refers to ways of seeking help, affection, and attention.
Adaptive Level
Refers to a combination of stimuli. These are focal stimuli (stimuli

which immediately confront the individual), contextual stimuli (other
stimuli present) and residual stimuli (beliefs, attitudes, or traits that have
effect on the present situation).
3.2.7 Leininger’s Theory of Transcultural Nursing
Madeleine Leininger’s Theory of Transcultural Nursing analyses

different cultures and subcultures in the world with respect to their
caring behavior, nursing care, health-illness values, and patterns of
behavior with the goal of developing a scientific and humanistic body of
knowledge needed for culture-specific and culture-universal nursing
care practices.
The Individual
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Clients from different cultures perceive health, illness, caring, curing,

dependence, and independence differently.
Environment
The environment is defined as a social structure, that includes the

following elements, the political (including legal) economic, social
(including kinship) educational, technical, religious and cultural systems
Health
Leininger asserts that worldviews, social structure, and cultural beliefs

influence perceptions of health and illness, therefore health cannot be
universally defined.
Nursing
The goal of nursing is directed toward promoting and maintaining health

behaviors or recovery from illness in a way that is culturally congruent.
Key Concepts
Among the core concepts of transcultural nursing theory are:
Care
This refers to assistive, supportive, or enabling behaviour on individual

with evident or anticipated needs. The main purpose is to ease or
improve a human condition.
Culture
This encompases values, beliefs, norms, and lifeway practices of a

particular group, that guide thinking, decisions, actions, and patterned
ways.
Cultural Care
Entails cognitively known values, beliefs, and patterned expressions that

assist, support, or enable another individual or group to maintain well-
being, improve a human condition, or to face death.
Cultural Care Diversity
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Refers to the variability of meaning, patterns, values, or symbols of care

that are culturally derived for health or to improve a human condition.
Cultural Care Universality
These are common, similar, or uniform meanings, patterns, values or

symbols of care that are culturally designed for health or to improve a
human condition.
3.2.8 Watson’s Science of Caring
According to Watson’s theory, though caring is central to nursing

practice, it is a moral ideal rather than a task-oriented behaviorur. Jean
Watson’s theoretical formulations focus on the philosophy and science
of caring, the core of nursing.
The Individual
Individuals (i.e., both the nurse and client) are nonreducible and are
interconnected with others and nature
Environment
The client’s environment contains both external and internal variables

and it is the responsibility of the nurse to promote a caring environment
to allow individuals to make choices relative to the best action for
himself at that point in time.
Health
Health is more than the absence of illness.
Nursing
The practice of nursing is different from curing and consists of 10

curative factors as described below. Thus the goal of nursing is to
promote and restore health and prevent illness by offering a relationship
that the client can use for personal growth and development.
Key concepts
Ten curative factors form the core of nursing and delineate the domain
of nursing practice. These are:
1. Formation of a humanistic-altruistic system of values.

2. Instillation of faith-hope to promote wellness.
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3. Cultivation of sensitivity to self and to others.

4. Development of a helping-trust relationship.
5. Promotion and acceptance of the expression of positive and
negative.
6. Systematic use of the scientific problem-solving method for
decision-making.
7. Promotion of interpersonal teaching-learning.
8. Provision for a supportive, protective, or corrective mental,
physical, socio-cultural, and spiritual environment.
9. Assistance with the gratification of human needs.
10. Allowance for existential-phenomenological forces.
3.2.9 Rogers’ Science of Unitary Human beings
The individual is viewed as an irreducible four-dimensional energy field

that is integral with the environment. Rogers views nursing as a science
and art that focuses on the nature and direction of human development
and human betterment. The role of the nurse is to promote symphonic
interactions between humans and their environments
The Individuals
The individual is a unified whole, manifesting characteristics that are

more than and different from the sum of his or her parts, and is
continuously evolving irreversibly and unidirectional along a space-time
continuum.
Environment
The individual and the environment are continually exchanging matter

and energy with each other, resulting in changing patterns in both the
individual and the environment.
Health
Health and illness are value-laden and culturally defined. They are not
dichotomous but are part of the same continuum. Health seems to occur
when patterns of living conflict with environmental change. While
illness occurs when patterns of living conflict with environmental
change and are deemed unacceptable.
Nursing
According to Rogers, nursing is a science and an art. The science of

nursing should be concerned with studying the nature and direction of
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unitary human development and the relationship. The art of nursing

refers to the use of scientific principles in the delivery of nursing care
for human betterment. The goal of nursing is the attainment of the best
possible state of health for the individual who is continually evolving by
promoting symphonic interactions between humans and environments.
Key Concepts
Energy Fields
They are dynamic fields having no real boundaries. Energy fields are of
two types, human energy field and environmental energy field.
Openness
As energy fields, the individual and environment are continuously open

and extending to infinity.
Pattern and Organisation
Refers to characterised human and environmental fields.
Principles of Nursing Science
Refers to the nature and direction of unitary human development and it

is also called Principles of Homeodynamics, which are as follows:
Helicy
It is “the continuous, innovative, probabilistic increasing diversity of

human and environmental field patterns characterized by repeating
helymicities”.
Resonancy
This is the continuous change from lower to higher frequency wave

patterns in human and environmental fields.
Integrality
Refers to the continuous mutual human and environmental field process.
3.2.1.0 Neuman’s Systems Model
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This theory offers a holistic view of the client system. It also includes
the concepts of open systems, environment, stressors, prevention, and
reconstitution. Nursing is concerned with the whole person. Neuman
believes that nursing encompasses a holistic client systems approach to
help individuals, families, communities, and society reach and maintain
wellness.
The Individual
The client is viewed as an open system in interaction with the

environment the client is a dynamic composite of interrelationships
between physiological, psychological, sociocultural, developmental, and
spiritual variables.
Environment
The environment includes all the factors affecting and affected by the
system. This may include interpersonal, intrapersonal, and extrapersonal
that might disturb the person’s normal line of defence.
Health
In this context, health is equated with optimal system stability.
Nursing
Nursing is concerned with all of the variables affecting the individual’s

response to stress. The major concern of nursing is in keeping the client
system stable through accuracy in both the assessment of effects and
possible effects of environmental stressors and in assisting client
adjustments required for an optimal wellness level.
Key Concepts
The nurse is concerned with all the variables affecting an individual’s

response to stressors:
Primary prevention reduces the possibility of encounter with stressors

and strengthens the flexible lines of defence.
Secondary prevention protects the basic structure by strengthening the

internal lines of resistance.
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Tertiary prevention focuses on readaptation and stability. A primary

goal is to strengthen resistance to stressors by reeducation to help
prevent recurrence of reaction or regression.
4.0 CONCLUSION
Nursing theories and frameworks can be accommodated within the

framework of the nursing process, but the focus differs according to the
specific theory that is guiding the care. For example, a nurse using
Orem’s theory would focus on the concept of self-care in all stages of
the nursing process, assessing for self-care deficits, and planning
interventions to compensate for or alleviate those deficits. Similarly, a
nurse using Roy’s adaptation model would assess biopsychosocial
aspects of the individual and design interventions to modify stimuli to
promote adaptation in the four adaptive modes.
5.0 SUMMARY
• Conceptual Models are similar to theories. However; they are more

abstract than theories.
• Four Component of Nursing Theories a) The nature nursing (b)

the individual (c) society and environment (d) health.
• A number of conceptual models have been developed in nursing.

Example, Roy’s model describes adaptation as the primary
phenomenon of interest to nursing, and it identifies the elements she
considers essential to adaptation. Orem considers self-care to be the
phenomenon central to nursing. Her model explains how nurses
facilitate the self-care of clients. Rogers sees human beings as the
central phenomenon of interest to nursing, and her model is designed
to explain the nature of human beings. The essence of Hildegard
Peplau Interpersonal Model is the relationship between an individual
who is sick or in need of health services and a nurse educated to
recognize and to respond to the need for help. Peplau views the
individual as an organism living in an unstable equilibrium.
6.0 TUTOR-MARKED ASSIGNMENT
Discuss any five theories of nursing.
7.0 REFERENCES/FURTHER READING
Johnson, D. E. (1980). ‘The Behavioral System Model for Nursing’, In

J.P. Reihl & C. Roy (Eds), Conceptual Models for Nursing
Practice. New York: Appleton-Century-Crofts.
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King, I. A (1981). Theory for Nursing: Systems, Concepts. Process.

New York: John Wiley.
Neuman, B. (1989).The Neuman Systems Model. (2nd ed.). Norwalk:

Appleton and Lange.
Nightingale, F. (1946).Notes On Nursing: What It Is And What It Is Not.

Philadelphia: Edward Stem. (Original work published 1958) .
Orem, D. (1980).Nursing: Concepts of Practice. (2nd ed.). New York:

McGraw-Hill.
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UNIT 2 THE NURSING PROCESS
CONTENTS
1.0 Introduction
2.0 Objectives
3.0 Main Content
3.1 The Scientific Method and the Nursing Process
3.1.1 Uses of the Nursing Process
3.2 Concept of Nursing Process
3.3 Component of the Nursing Process
3.3.1 Assessment
3.3.1.1 Problem Recognition
3.3.1.2 Collection of Data
3.3.2 Diagnosis
3.3.2.1Nursing Diagnosis Taxonomy
3.3.3 Planning
3.3.3.1 Setting Priorities
3.3.3.2 Establishing Goals of Care
3.3.3.3 Selecting Intervention Strategies
3.3.4 Implementation
3.3.5 Evaluation
4.0 Conclusion
5.0 Summary
1.0 INTRODUCTION
Overview of the Nursing Process
The nursing process has been described as the core and essence of
nursing. It is central to all nursing actions, applicable in any setting and
within any conceptual reference. It is flexible and adaptable, yet
sufficiently structured to provide a base from which all systematic
nursing actions can precede. It is organized, methodical, and deliberate
(Yura & Walsh, 1988). As illustrated in Fig. 1, the nursing process is
continuous and can accommodate changes in the client’s health status
and/or failure to achieve expected outcomes through a feedback
mechanism. This mechanism allows the nurse to reenter the nursing
process at the appropriate stage to collect additional data, restructure
nursing diagnoses, design a new plan, or change implementation
strategies.
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Assessment
Evaluation Nurse-client Diagnosis

Relationship
Implementation Planning
Table1
2.0 OBJECTIVES
• demonstrate that the nursing process, as a systematic approach to

nursing, establishes the scientific basis of nursing as a profession
• explain the relationship between the “scientific method,” and the
nursing process
• describe the four steps of the nursing process assessment, planning,
implementation, and evaluation
• identify the three major skills and their related sub skills in the
execution of the nursing process: intellectual, technical, and
interpersonal.
3.0 MAIN CONTENT
3.1 The Scientific Method and the Nursing Process
In using the nursing process, the nurse deliberately analyses the client’s
health problems and decides how she will act to meet these problems.
This progression is identical to the scientific method developed by
scientists such as Sir Francis Bacon and Sir Isaac Newton. The scientific
method can be stated as follows:
1. Recognise and define the problem.

2. Collect data.
3. Formulate and implement a solution.
4. Evaluate the solution.
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The scientific method and the nursing process are almost identical in
form, but they are different in purpose. While the scientist is looking for
new knowledge, the nurse is usually looking for answer to an immediate
problem in a particular setting. Also, while scientists deal with facts, a
nurse deals primarily with people. It is not necessary for every nursing
action to be backed up by carefully reasoned scientific principles. The
scientific method is also adapted to the nursing process in other ways.
Recognition and definition of the problem are dependent on assessment.
The scientist assesses data collected from observation and experiments
while the client’s physical status (appearance and function) and his
psychosocial and mental status are included in nursing assessment.
Therefore, data collection is an essential step in any scientific inquiry as
well as nursing.
3.1.1 Uses of the Nursing Process
1. The intelligent use of the nursing process helps one to avoid the
extremes. A nurse, who is only a technician, who works in an
automated “cookbook” fashion, does not benefit clients. In other
words, a nurse who thinks only in terms of a specific duty and
carries it out, oblivious of the total picture, does not benefit them.
2. When nursing care is given in a disorganized or instinctive

fashion (even though sincere and compassionate), the client is
likely to become puzzled and uncooperative. The nurse in turn
may become frustrated or resentful because the client seems
ungrateful.
3. The framework of a nursing plan is based on information about

why a person needs care and judgments made about what kind of
care he needs.
3.2 Concept of Nursing Process
The nursing process generally is described as a four or five steps

process. Some experts describe the four steps as: (1) Assessment, (2)
Plan, (3) Implementation, and (4) Evaluation (Reilly & Hermann, 1985;
Yura & Walsh, 1988). Others identify five steps: (1) Assessment, (2)
diagnosis, (3) Plan, (4) Implementation, and (5) Evaluation (Oermann,
1995). In conceptualizing nursing process as a four-step process,
diagnosis is considered to be the final component of assessment. As five
or more steps, nursing diagnosis becomes a separate phase of the
process, distinct from the other steps. Regardless of whether nursing
diagnosis is viewed as a separate step, it is an essential phase of the
nursing process from which the plan and interventions are generated.
The five phases of the nursing process are described in Table 2
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1.
ASSESSMENT
• Gathering date
– Taking a history
(interviewing)
– Conducting a physical
examination
• Making a nursing diagnosis
2. 3.
PLANNING IMPLEMENTATION
• Formulating a plan • Coordinating care
– Writing nursing orders – With other health care
• Revising the plan team members
• Collaborating with the client – With relatives and
4.
EVALUATION friends of the client
• Looking for client reactions
• Checking efficiency and
effectiveness of care
• Making necessary changes
(Modification)
The nursing process is primarily a cognitive or intellectual process that

requires skill in clinical judgment and the use of psychomotor skills in
the collection of data through physical assessment and in terms of
interventions to be carried out.
In addition to the necessary cognitive skills, three types of nursing

knowledge guide the use of the nursing process. These are (1) scientific
knowledge, which includes nursing models and theories, concepts and
theories from other disciplines that are applied to nursing, and research
findings; (2) ethics of practice nursing; and (3) knowledge based on
intuition, tradition, and experience (Benner, 1984). Such knowledge
provides guidelines for the nurse to determine what data to collect,
ascribe meaning to the data, make a judgment regarding the nursing
diagnosis, and formulate a plan. Theory and research also direct the
nurse in selecting nursing measures and evaluating care. The nurse’s
experience influence decision in the practice setting. Competency in
nursing practice improves as the nurse acquires experience with similar
clinical situations. This experience enables the nurse to approach a client
with an expectation of the typical problems and nursing approaches for
this particular patient, thereby providing a framework for decision-
making.
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3.1 Components of the Nursing Process
3.3.1 Assessment
Assessment is the first step of the nursing process, other steps rest on it.
Assessment is an interactive process in that the nurse, through
interaction with the client, family, and other, collects essential data to
identify health problems. The two steps in the assessment phase are (1)
problem recognition and (2) collection of data.
3.3.1.1 Problem Recognition
The first step within assessment begins with problem recognition, in

which the nurse identifies a possible health problem, that data gathering.
Initial problem recognition assists the nurse in collecting the most
relevant guides data needed for diagnosis and planning care. This
process saves time and makes data gathered more manageable. It may be
the nurse who initially recognizes actual and potential problems, or the
client, the family, or other health care professionals may communicate
those problems to the practitioner.
3.3.1.2 Collection of Data
The second step within assessment involves the actual collection of data.
Yura and Walsh (1988) identify the nursing history and physical
assessment as two major sources of data for determining the client’s
actual and potential health problems. Other sources are records and
reports. Both subjective (described by the patient, family, and other) and
objective (observable) data are gathered in the assessment process. The
data to be collected and the organization of the data vary with the
conceptual model of nursing used.
3.3.2 Diagnosis
The second step of the nursing process begins with an analysis of data
obtained in assessment and results in the statement of nursing diagnoses
about the client. The diagnoses provide the basis for planning care and
selecting interventions. Independent nursing actions involving the client
arise from these diagnoses. When the nurse has collected information
from the client that suggests an actual or potential health problem, the
process of clinical judgment is initiated. Clinical judgment is the
cognitive or thinking process used by the nurse for analyzing data,
deriving a nursing diagnosis from the information, and deciding on
appropriate interventions. Gordon (1987b) describes four components of
the diagnostic process: (1) collecting information (i.e., assessment); (2)
interpreting the information; (3) clustering the information; and (4)
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naming the cluster (p. 19). The actual nursing diagnosis, the statement of
the client’s health problem, is the end product of this thinking. Data
analysis is more than interpreting individual pieces of data; the nurse
must see relationships among the data to identify the health problems.
In interpreting the information, the nurse assigns meaning to the data;

the nurse interprets cues to the client’s health status. Cues include data
about the status, responses, and environment of the client. These data
suggest a possible nursing diagnosis. Once cues are recognised, the
nurse makes an inference or judgment about the meaning of the data.
For example, a cue might be 5’3’’, weight of 200 pounds, which will
lead the nurse to infer obesity. An inference of anxiety or fear might be
drawn from the following cues: increased pulse and respiratory rate,
elevated blood pressure, voice tremors rapid speech, and dry mouth. The
nurse clusters data cues with common properties into groups and then
decides how the data ‘fit’ a nursing diagnosis then the nurse applies the
diagnostic label to the cluster of cues and makes the nursing diagnosis.
Nursing diagnoses are actual or potential health problems of an

individual, family, or group for which nursing can intervene. An actual
problem is an existing health deficit. Whereas potential problems are
factor predisposing individuals, families, and even communities to
health problems. In addition to nursing diagnoses, in many health care
settings nurses also identify collaborative problems, which are actual or
potential problems resulting from complications of diseases, treatments,
or diagnostic studies in which nursing intervenes in collaboration with
physicians and other health professionals. Collaborative problems
cannot be resolved by nursing care alone. Whereas nursing diagnoses
represent health problems requiring independent nursing interventions,
collaborative problems necessitates interventions by nurses and other
health professionals.
PES Format, Gordon (1987b) identifies three essential components of a

nursing diagnoses and refers to these components as the PES format
P: health problem of the individual, family or community.
E: etiologic or related factors.
S: defining signs and symptoms
PES format provides a structure for writing nursing diagnoses for

clients, other uses include means of communicating to other
practitioners the type of health problem, the contributing factors, and a
cluster signs and symptom often found with that particular problem. The
problem (P) represents a description of the health status of the client:
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individual, family, or community. The health problem may be an actual

health deficit or a potential problem based on the presence of risk factors
identified by the nurse. The health problem should be stated clearly and
concisely, preferably in two or three words. For example, activity
intolerance, ineffective breathing pattern, and pain are concise
descriptions of the health problem. The North American Nursing
Diagnosis Association (NANDA), the national group responsible for
generating nursing diagnoses, provides a list of diagnoses for the nurse
(Table2). Each of the diagnoses on the list represents a health problem
of the client that is incorporated into a nursing diagnosis.
The etiology (E) or related factors are the probable factors that are
causing or contributing to the client’s health problems. They may be
situational, pathophysiologic, treatment-related, or maturational in
nature. The etiologic and contributing factors are connected to the
diagnostic label with a “related to.” For example, in
P = shock
E = related to heamorrage
The phrase “related to” implies a relationship between these two parts of
the diagnostic statement. When the etiologic factors are unknown, this
wording may be included in the nursing diagnosis; for example, “altered
family processes related to unknown etiology.” The defining
characteristics are a cluster of signs and symptoms (S) that are generally
observed with a particular nursing diagnosis. They represent the data
used for making a diagnosis. Not all the defining characteristics need to
be present to decide on a diagnosis. The nurse judges whether or not the
signs and symptoms present in the patient represent a particular health
problem. These characteristics, then, permit the nurse to discriminate
among diagnoses and determine a diagnostic label that represents the
cluster of signs and symptoms. In the previous example, the defining
characteristics include, for instance, sweating, cold clammy skins and
decreased pulse and respiration rate, and a fall in blood pressure.
The nursing diagnosis statement includes at least two parts: (1) the
client’s health problem (P) and (2) etiologic (E) or related factors. The
problem describes the client’s health state amenable to nursing
intervention. When specific characteristics are present, the nurse is able
to select a diagnostic category from an accepted list, such as NANDA,
or write his or her own diagnosis if a diagnostic that actually describes
the health problem is not on the list. The “related to” phrase links the
diagnostic label with the etiologic or contributing factors. Thus, the
diagnostic statement in the previous example, would be
P+ E
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or shock related to heamorrage. The defining characteristics were

present for the nurse to make this diagnosis.
Alfaro (1986) suggests that the defining characteristics (signs and

symptoms) be included with the diagnostic statement, thus resulting in a
three-part statement:
P = shock
E = related to heamorrage
S = as manifested (or evidenced) by sweeting, cold clammy skins

and decreased pulse and respiration rate, fall in blood pressure.
A three-part diagnostic statement is possible only with an actual nursing

diagnosis, because the signs and symptoms are present. When potential
nursing diagnoses are written, signs and symptoms are not present; thus,
only a two-part statement is possible.
3.3.2.1 Nursing Diagnosis Taxonomy
A taxonomy is a classification system, a system of labelled groups or

classes organized according to some criterion. In nursing, efforts are
now directed toward developing a system for classifying nursing
diagnoses. The NANDA Taxonomy I Revised is the first official
taxonomy of nursing diagnoses. This list is being refined, revised and
expanded. The revised taxonomy includes nine major categories that
present central human response patterns:
1. Exchange: mutual giving and receiving

2. Communicating: sending messages
3. Relating: establishing bounds
4. Valuing: assigning relative worth
5. Choosing: selection of alternatives
6. Moving: activity
7. Perceiving: reception of information
8. Knowing: meaning associated with information
9. Feeling: subjective awareness of information
Table 3 depicts Taxonomy I Revised and related diagnoses (NANDA,

1988).
NANDA APPROVED NURSING DIAGNOSIS
The nine human response patterns is the currently accepted

classification system for Nursing Diagnosis. They include:
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Pattern I: Exchange
A human response pattern involving mutual giving and receiving.
1.1.2.1. Altered Nutrition: More than body requirements

1.1.2.2. Altered Nutrition: Less than body requirements
1.1.2.3. Altered Nutrition: Potential for more than body
requirements.
1.2.1.1. Potential for Infection
1.2.2.1 Potential Altered Body Temperature
1.2.2.2 Hypothermia
1.2.2.3 Hyperthermia
1.2.2.4 Ineffective Thermoregulation
1.2.3.1. Dysreflexia
1.3.1.1. Constipation
1.3.1.1.1. Perceived Constipation
1.3.1.1.2. Colonic Constipation
1.3.1.2. Diarrhoea
1.3.1.3. Bowel Incontinence
1.3.2. Altered Urinary Elimination
1.3.2.1.1. Stress Incontinence
1.3.2.1.2. Reflex Incontinence
1.3.2.1.3. Urge Incontinence
1.3.2.1.4. Functional Incontinence
1.3.2.1.5. Total Incontinence
1.3.2.2. Urinary Retention
1.4.1.1. Altered Tissue Perfusion (Specify Type)
(Renal, Cerebral, Cardiopulmonary, Gastrointestinal,
Peripheral)
1.4.1.2.1. Fluid Volume Excess
1.4.1.2.2.1. Fluid Volume Deficit
1.4.1.2.2.2. Potential Fluid Volume Deficit
1.4.2.1. Decreased Cardiac Output
1.5.1.1. Impaired Gas Exchange
1.5.1.2. Ineffective Airway Clearance
1.5.1.3. Ineffective Breathing Pattern
1.6.1. Potential for Injury
1.6.1.1. Potential for Suffocation
1.6.1.2. Potential for Poisoning
1.6.1.3. Potential for Trauma
1.6.1.4. Potential for Aspiration
1.6.1.5. Potential for Disuse Syndrome
1.6.2. Altered Protection
1.6.2.1. Impaired Tissue Integrity
1.6.2.1.1. Altered Oral Mucous Membrane
1.6.2.1.2.1 Impaired Skin Integrity
1.6.2.1.2.2 Potential Impaired Skin Integrity
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Pattern 2: Communicating
A human response pattern involving sending messages
2.1.1.1. Impaired Verbal Communication
Pattern 3: Relating
A human response pattern involving establishing bonds.
3.1.1. Impaired Social Interaction

3.1.2. Social Isolation
3.2.1. Altered Role Performance
3.2.1.1.1. Altered Parenting
3.2.1.1.2. Potential Altered Parenting
3.2.1.2.1. Sexual Dysfunction
3.2.2. Altered Family Processes
3.2.3.1. Parental Role Conflict
3.3. Altered Sexuality Patterns.
Pattern 4: Valuing
A human response pattern involving the assigning of relative worth.
4.1.1 Spiritual Distress (distress of the human spirit)
Pattern 5: Choosing
A human response pattern involving the selection of alternatives
5.1.1.1 Ineffective Individual Coping

Impaired Adjustment
Defensive Coping
Ineffective Denial
Ineffective Family Coping: Disabling
Ineffective Family Coping: Compromised
Family Coping: Potential for Growth
Non Compliance (Specify)
5.3.1.1. Decisional Conflict (Specify)
5.4.1.1 Health Seeking Behaviours (Specify)
Pattern 6: Moving
A human response pattern involving activity
Impaired Physical Mobility
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Activity Intolerance
Fatigue
Potential Activity Intolerance
Sleep Pattern Disturbance
Diversional Activity Deficit
6.4.1.1. Impaired Home Maintenance Management
6.4.2. Altered Health Maintenance
6.5.1.9. Feeding Self Care Deficit
6.5.1.1. Impaired Swallowing
6.5.1.2. Ineffective Breast-feeding
6.5.1.3. Effective Breast-feeding
6.5.2. Bathing / Hygiene Self Care Deficit
6.5.3. Dressing / Grooming Self Care Deficit
6.5.4. Toileting Self Care Deficit
6.6. Altered Growth and Development
Pattern 7: Perceiving
A human response pattern involving the reception information
Body Image Disturbance

Self Esteem Disturbance
Chronic Low Self Esteem
Situational Low Self Esteem
Personal Identify Disturbance
Sensory/Perceptual Alterations (Specify) (Visual,
Auditory, Kinesthetic, Gustatory, Tactile, Olfactory)
Unilateral Neglect
Hopelessness
Powerlessness
Pattern 8: Knowing
A human response pattern involving the meaning associated with

information
8.1.1. Knowledge Deficit (Specify)

8.2. Altered Thought Processes
Pattern 9: Feeling
A human response pattern involving the subjecting awareness of

information
Pain
Chronic Pain
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9.2.1.1. Dysfunctional Grieving

9.2.1.2. Anticipatory Grieving
9.2.1.3. Potential for Violence: Self-directed or directed at others
9.2.1.4. Post-Trauma Response
9.2.1.5. Rape-Trauma Syndrome
9.2.1.5.1. Rape-Trauma Syndrome: Compound Reaction
9.2.1.5.2. Rape-Trauma Syndrome: Silent Reaction
9.3.1.1. Anxiety
9.3.1.2. Fear.
3.3.3 Planning
The basis for the next phase of the nursing process is nursing diagnosis.
Planning care to address the client’s health problems. Planning includes
setting priorities, establishing goals, and selecting interventions.
3.3.3.1 Setting Priorities
In most cases, multiple nursing diagnoses are identified for a client, and
priorities need to be set because not all diagnoses and goals can be or
should be addressed at the same time. The first step in prioritizing
problems is to identify the most important ones for the client. Some
problems are life-threatening and may have deleterious effects on the
client; these must be taken care of immediately. Other factors that may
influence the priorities set by the nurse are, the nature of the health
problems, their immediate and potential effects on the client, and the
client’s overall health status. Treatments received may have high
priority if they adversely affect the patient. In setting priorities, the client
should be closely involved. These processes will result in a preferential
order of goals that provides direction in planning care.
3.3.3.2 Establishing Goals of Care
Developing goals is an important step in the planning process because it

identifies the desired outcomes of care. Yura and Walsh (1988) define
goals as the expected behavioural outcomes specified in relation to each
nursing diagnosis (p. 139). Goals represent the desired level of wellness
for the client. Goals set by nursing must be congruent with goals of
other health professionals to ensure a coordinated approach to care. The
two types of goals are (1) short-term goals, which are achieved quickly
or as interim steps to meeting a goal that requires more time; and (2)
long-term goals, which are met over a longer period. In some instances,
long-term goals describe an overall goal of the plan of care, often
referred to as discharge goal for the client.
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Below are some characteristics of goal:
(1) Goals are stated in terms of client outcomes or what the client
will be able to accomplish rather than what the nurse plans to do.
(2) Goals should be specific to the client.
(3) Should be both realistic and attainable.
(4) Goals are derived from the problem statement (P). For example,
with the nursing diagnosis of ineffective airway clearance related
to postoperative immobility, a goal might be stated as follows:
“The client will maintain a clear airway.”
(5) Goals represent the expected behaviors of the client and are
derived from the nursing diagnoses.
(6) Goals need to be stated in measurable terms because they provide

criteria for determining the effectiveness of nursing interventions.
Measurable verbs describe the exact behaviour of the patient,
family, or group. These behaviours may be cognitive
(knowledge); psychomotor (skill); or affective (value). Below is a
list of verbs in each of these three domains, all of which are
measurable and, therefore, appropriate for use in stating client
goals
Verbs Appropriate for Writing

Objectives in the Cognitive,
Affective, and Psychomotor
Domains
1. Cognitive 2. Affective
Define Acknowledge
Identify Show awareness of
Name Discuss willingly
Recognize Express satisfaction
Give examples of In
State in own Seek opportunities
Words Accept
Choose Agree
Demonstrate use Cooperate with
Of Participate in
Describe Respect
Explain Support
Differentiate Assume
Discriminate Responsibility
Interpret Declare
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Select Defend
Conclude Act consistently
Predict Is accountable
Apply
Use 3. Psychomotor
Relate Follow example of
Compare Imitate
Contract Follow procedure
Detect Practice
Distinguish Demonstrate skill
Evaluate Perform
Classify Carry out
Design
Develop
Modify
Organize
Synthesize
Assess
Judge
3.3.3.3 Selecting Intervention Strategies
The planning process involves the selection of nursing interventions,

nursing activities, and action directed toward the achievement of the
goals. Nursing interventions are the treatments for specific nursing
diagnoses. Interventions are directed toward the etiology component of
the nursing diagnostic statement and are planned to eliminate or at least
reduce the effects of these contributing factors. For example, with the
nursing diagnosis of ineffective airway clearance related to
postoperative immobility, interventions would be planned to reduce the
effect of the immobility following surgery. With potential nursing
diagnoses, interventions frequently focus on assessing client status to
monitor the problem and avoid its becoming a reality.
Nursing practice requires multiple intervention strategies to meet client

needs. Some patient problems are accompanied by prescribed nursing
measures, actions typically performed for clients with a particular
problem, such as interventions to reduce the effect of being
immobilized, including positioning, turning, coughing, and deep
breathing. In other situations, however, the nurse needs to decide
creatively on the best interventions for a particular patient and plan care
because prescribed activities have not yet been established. In these
situations, the nurse considers alternatives and consequences of different
approaches to care if selected and determines the best action to take in
terms of its benefits. Such decision-making is important in choosing
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interventions that meet the client’s needs and have an underlying

scientific basis for their use.
The final step in the planning process is to document or write the plan of
care. Documentation is essential for continuity of care and evaluation.
The nursing care plan includes important data about the client; the data
are organized so that they communicate clearly the nursing diagnoses,
goals, and intervention strategies.
3.3.4 Implementation
Implementation is the action phase of the nursing process in which the

nurse carries out the plan of care. Critical thinking, problem solving, and
the decision-making skills are essential for implementing the nursing
plan as well as ability to perform psychomotor skills. Also important are
the attitudes and values of the nurse because they influence the way in
which the nurse interacts with the patient and family and carries out
care. Respect for the dignity and worth of others is of particular
importance in the implementation of care.
During implementation, the nurse continually assesses client responses

and movement toward goals and obtains data for use in evaluating the
effectiveness of nursing interventions and the need for alternative
actions. Implementation also includes keeping a chart on or
documenting nursing care. “Charting” provides a means of
communicating data about the patient and status and assists others in
assessment of client responses.
3.3.5 Evaluation
Evaluation, the final phase of the nursing process, it measures the

effectiveness of nursing care in promoting achievement of client goals.
The two types of evaluation are (1) Formative and (2) Summative.
Formative evaluation occurs throughout the nursing process, particularly
in the implementation phase as the nurse is providing care. It is ongoing
in nature and provides feedback to the nurse on the client’s health status
and progress toward meeting goals. Summative evaluation occurs after
care has been provided, enabling the nurse to judge whether or not the
goals have been achieved. Donabedian (1969) identifies three
components in the evaluation of the quality of health care: (1) Outcomes
of care, (2) Process of care, and (3) Structure in which the care is
provided. This framework for evaluation has been adopted widely for
evaluating the quality of nursing care.
Outcome evaluation focuses on changes in the client as a result of

nursing interventions. In this context, the nurse determines the degree to
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which client goals were achieved. The goals thus become the criteria for
evaluation. Process evaluation is another type of evaluation of the
nursing process, but the focus is on the nurse rather than the client.
Evaluation addresses the process of care for the client from assessment
through implementation in terms of quality of nursing actions. The ANA
(1973) standards of nursing practice provide a framework for process
evaluation because they specify characteristics of quality for each step
of the nursing process. The nursing audit is a means of evaluating the
process of care. Structure evaluation focuses on the health care setting in
which care is provided. This type of evaluation provides data on
environmental variables, such as the agency’s policies and procedures,
quantity and characteristics of nursing and other staff, availability of
resources needed for care, and financial resources of the institution and
their effect on the delivery of care.
4.0 CONCLUSION
The nursing process is central to all nursing actions and, applicable in

any setting. It is continuous and can accommodate changes in the
client’s health status and/or failure to achieve expected outcomes
through a feedback mechanism. This mechanism allows the nurse to re-
enter the nursing process at the appropriate stage to collect additional
data, restructure nursing diagnoses, design a new plan, or change
implementation strategies.
5.0SUMMARY
• The nursing process as a systematic approach to nursing, establishes

the scientific basis of nursing as a profession.
• The four steps of the nursing process are assessment, planning,

implementation, and evaluation.
• The scientific method and the nursing process are almost identical in
form, but they are different in purpose. While the scientist is
looking for new knowledge, the nurse is usually looking for answer
to an immediate problem in a particular setting.
• Critical thinking, problem solving, and the decision-making skills are
essential for implementing the nursing plan as well as ability to
perform psychomotor skills.

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What do you understand by the nursing process? What are its

importance?
The North America Nursing Diagnosis (NANDA) Taxonomy. 1 Revised

1990.
Barbara Kozier, Glenora Erb.[no date]. Fundamentals of Nursing.

Concepts and Procedures. (2nd ed.).
Brunner & Suddarth. (2004). Medical Surgical Nursing. (10th ed)

Lippincott Wilkins.
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UNIT 3 APPLICATION OF THE NURSING PROCESS

CONTENTS
1.0 Introduction
2.0 Objectives
3.0 Main Content
3.1 Why/Who Develops a Nursing Care Plan?
3.2 Component of a Nursing Care Plan
3.3 Guideline for Writing a Nursing Care Plan
3.4 Assessment Tools for Planning Care
3.4.1 Tools for Data Collection
3.4.2 Interaction
3.4.3 Observation
3.4.4 Measurement
3.5 Documentation a Nursing Care Plan
3.6 Implementation of a Nursing Care Plan
3.7 Scientific Principle use in a Nursing Care Plan
3.8 Evaluation of a Nursing Care Plan
3.8.1 Forms of Evaluation
3.8.2 Criteria and Standards
3.8.3 Guidelines for Evaluation
3.9 An Hypothetical Nursing Care Plan
3.10 Nurse-Patient Relationship
3.11 Skills Required in the Nursing Process
3.11.1 Intellectual Skill
3.11.2 Interpersonal Skills
3.11.3 Technical Skills
4.0 Conclusion
5.0 Summary
1.0 INTRODUCTION
This unit is the continuation of the previous one. You will learn how to
write hypothetical nursing care plan using the information learnt from
the previous unit.
2.0 OBJECTIVES
• learn how to write a nursing care plan

• explain how to evaluate nursing care
• understand the skill necessary for the use of the nursing process
• explain the concept of nurse-patient relationship.
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3.0MAIN CONTENT
Nursing Care Plan
This is the plan of care that a nurse draws out for the individual
patient, after carefully assessing the patient’s need and arranging
them in order of priority.
What is a Plan?
The nursing plan begins with the nursing diagnostic statement and
progresses to the goal and objectives. Once these are identified, unique
nursing actions–nursing orders–are selected to help the client achieve
the goals and objectives. This is the core of nursing management, the
independent prescriptive role of writing nursing orders. The term
“nursing order” is used synonymously with nursing plan in this text.
Nursing orders are different from “standard care” orders, such as routine
procedures or common orders for all clients. Nursing orders are
individually tailored to meet the specific needs of the client; the standard
care plans are useful as a point of reference. Nursing care plans are not
delegated medical orders or functions. Although nurses are still involved
in implementing these functions and orders, the nursing order is separate
and is explicitly a nursing action. The nursing order complements the
medical order with related activities such as teaching, discussion,
demonstration, or methods of illness prevention and health maintenance
or promotion.
3.1 Why and Who Develops a Nursing Care Plan?
A well-written plan gives direction, guidance, and meaning to nursing

care. It is a central source of information to all who are involved in the
care of a given client. It is the primary means of communicating,
synchronising, and organising the actions of all nursing staff. The
nursing care plan provides for continuity of care through primary nurses,
constantly changing nursing staff, shift reports, and nursing rounds.
Current updating of nursing actions with new assessment data assures

continuous quality of care. Adequate communication of this
information, in both written and verbal forms, is a mark of the
professional nurse.
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The nurse and client work together to form the plan of care. The client,
the family, and significant others bring their uniqueness to the situation.
The nurse brings knowledge and expertise of nursing care to the client.
Together, sharing this information, the client and nurse optimize the
writing of the plan.
The principal facilitators in developing the plan are the primary nurse,
the client; the client’s family, other nurses involved in direct care, and
selected resource people. Complex client concerns require additional
assistance. Resource people include the clinical nurse specialist,
dietician, physical therapist, occupational therapist, social worker,
chaplain, and physician.
3.1 Components of a Nursing Care Plan
The care plan is divided into five parts listed below:
1. Nursing Diagnosis
This is a brief statement of the patient’s response to his actual or

potential unhealthful situation that nursing can help change. The
statement should be a standardised nursing diagnostic category. An
actual diagnosis is written in 3 parts: (1) Category (2) Related to
contributing factors (3) As manifested by signs and symptoms. While a
potential diagnoses can be continually identified depending on the
patient’s condition, these should be prioritized.
2. Objectives
Objective is a statement of what the nursing action to achieve for the

patient. It is patient oriented, measurable, attainable, brief and
timebound.
3. Nursing Actions
This is the actual nursing care that a nurse carries out to meet the
objectives of a particular need. It is written as briefly as possible. It
should be written in order from. It is a continuous process based on
evaluation and reassessment of patient’s condition. The action can
include independent, dependent, and interdependent roles of the nurse.
4. Rationale/Scientific Principles
This is the statement of the reasons or scientific basis for the nursing
care that the nurse carries out. It should relate to the objective as well as
the actions.
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5. Evaluation
This is the final assessment of the objectives the nurse set out to achieve,
stating either negative or positive outcomes. If negative, reassess the
problem to cause outcome, you can write as the anticipated outcome.
3.2 Guidelines for Writing Plans for Implementation
The following guidelines are suggested for writing plans for

implementation.
1. The plan is dated and contains the signature of the responsible

nurse. The date is important, since the nursing orders are
reviewed and updated periodically. The date the plan is written is
used as a point of reference for evaluation and future planning.
2. Implementation strategies and nursing orders are appropriate to

their respective objectives. A nursing strategy is defined as an
overall plan or tactic that serves as a guide for individual nursing
orders. Clearly defined objectives provide a sound basis for
selecting nursing strategies.
3. Plans are written in terms of client and nursing behaviours

sufficient to achieve goals and objectives. Nursing plans define
the types of nurse and client actions. In some plans, such as
crutch-walking, the client takes over the action completely; in
other plans, the nurse assumes the dominant role.
4. The nursing plans are stated in specific terms, giving direction to

the behaviour of the nurse and client. The nursing orders need to
be specific. What does the client need to do to achieve the
objectives and goal?
5. The plan includes preventive, promotional, and rehabilitative

aspects of care. All three aspects of care–prevention, promotion,
and rehabilitation–are included in the plans for each client. The
client’s general state of health, identified health concerns and
strengths, and the situation, dictate which aspect is the focus.
6. The nursing plan includes collaborating and coordinating

activities. Collaboration and coordination are essential
components of nursing leadership that are intrinsic to the nursing
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care plan. With whom do you need to collaborate to assist the

client in achieving the objective: the physical therapist,
nutritionist, community health nurse, or agency that can supply
information, materials, finances, consultation, equipment, or
appliances to the client?
7. The plans are placed in an appropriate sequential order based on

priority. The nurse needs to establish the sequence of events in
order to achieve the objective. What is the most important action
to take first? When the objectives have been arranged in order of
priority, the nursing orders should follow accordingly.
8. The plan incorporates the autonomy and individuality of the

client. The plan is individually tailored to the unique
characteristics of the client. Autonomy and individuality can be
encouraged by giving the client the choice in setting the times for
care as well as in selecting the methods to be used.
9. Plans are kept current and revised and include alternate plans
when indicated. For a plan to remain current, it must be flexible.
The nurse must modify goals and approaches as situations
change.
10. Plans for the client’s future are included. The two major concepts
in the area of future planning are the termination of the nurse-
client relationship and discharge. The nurse-client relationship
terminates when the client no longer needs professional nursing
care.
3.3 Assessment Tools for Planning Care
Assessment is essential before making a plan and is made through:
1. Observation
By observing the patient and his immediate environment, some of his

needs can be identified: e.g., dyspnoea, dehydration.
2. Interview
By discussing with the patient or his relatives, other needs can be

identified: insomnia, pain, cough, fear, knowledge deficit.
3. Records
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The patient’s records provide useful data as to what care has been given
and the effect of such care, as well as recorded observations on progress
or condition of patient as noted by other health care personnel. It also
gives the nurse information about the dependent functions of care, e.g.,
pyrexia, bleeding, condition of drainage and wounds, vomiting,
diarrhoea, level of consciousness, orders such as bed rest.
3.4 Tools for Data Collection
Data collection occurs through the use of three tools: interaction,

observation, and measurement. Interaction data are considered as any
spoken word from the client, health care personnel, or significant others.
Observations made through the senses, including written documents, are
observation data. Measurement data are those obtained through the use
of instruments that quantify information. Definitions and examples of
these tools are given in the following discussion.
All these tools have strengths and limitations. They should not be used
in isolation, since accurate assessments cannot be made through the use
of one tool alone. In some situations the use of two tools will dominate,
depending on the age and health status of the client and the given
situation. Generally, the nurse should always use at least two of the three
tools for data collection.
3.4.1 Interaction
Interaction is defined as a continuous exchange between the nurse and

the client. The purpose is to obtain information or develop rapport, or
both. Nursing, today is often based on a series of transient interactions
with clients rather than sustained relationships.
Interviews, or transitory relationships between two persons for the

purpose of gaining information or developing rapport, can be classified
as directive-interrogative, rapport-building, or open-ended. Directive-
interrogative interviewing involves asking for specific information; the
purpose is primarily to get data. The nurse maintains control of the
direction of the interview, and the client becomes a passive participant.
This type of interview is advantageous when a specific amount of data is
needed in a short period of time, but disadvantageous in that the client is
passive and may not be able to discuss concerns.
History taking is an example of a directive-interrogative interview.

Rapport-building interviews focus on building a relationship, not on
getting information. Open, empathic responses are used by the
interviewer to facilitate the client’s control of the interview. Data
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emerge and a relationship develops, but rapport building takes time and
specific data may not be obtained. The open-ended interview is a
combination of the first two types; the goals are to get information from
the client and to build rapport. The client’s concerns emerge through the
use of a variety of communication techniques.
The interviewer starts with the least amount of authority (open-ended
statements and questions) to allow client directiveness and proceeds to
increasing authority (more specific focus). All three types of interviews
have a place in nurse-client interactions. In general, the nurse should use
the least amount of authority necessary to obtain the information needed
within the time allotted.
The outcome of interactions is data that reflect what the client said and
what the nurse observed. Observations include the client’s nonverbal
behavior, appearance, and function, and the environment. Statements by
the client should be noted as direct quotations. Paraphrasing what
someone says tends to increase the probability of interpreting or placing
one’s own meaning to the data. Table 3-3 provides examples of
objective statements of interaction data versus their personal
interpretations.
3.4.2 Observation
Observation is a process of noting pieces of information or cues through

the use of the senses (sight, touch, hearing, smell, and taste). These
senses are used in a variety of ways to observe the client’s (1) general
characteristics of appearance and physical function, (2) content and
process of interactions and relationships, and (3) environment. Each
sense is discussed in relation to these three categories.
The sense of sight is used to identify visual cues that clients and data
sources project. Examples of data collected through the use of sight are
as follows:
1. General characteristics of appearance and physical function:

colour, shape, amount, approximate size, gait, balance, and dress;
data from written records about general characteristics (such as
nurses’ notes).
2. Content and process of interactions: nonverbal communication

such as body movements, gestures, eye contact, personal space,
use of touch.
3. Environment: neighborhood characteristics such as number of

houses and cleanliness; characteristics of client’s home such as
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rooms available, cleanliness, and furniture; data from written

sources about client’s environment.
The sense of touch is used to determine qualities of an object or person.

Through simple touch or the use of palpation* and percussion* the
following data can be obtained.
1. General characteristics: texture, moisture, temperature, density,
and muscle and skin tone.
2. Content and process of interactions: not applicable.
3. Environment: temperature of air, moisture (humidity), and

furniture.
Hearing is primarily used to actively listen to clients’ verbal messages or

to note interaction data. Other important uses of hearing are:
1. General characteristics: auscultation* of lung, heart, and bowel

sounds, and percussion (along with touch) of tissue.
2. Content and process of interactions: amount of interacting with

others, tone of voice(s), interruptions in conversations, and
specific content of what is said.
3. Environment: house/neighborhood noise levels; usual sounds in

home or community.
The senses of smell and taste are used less frequently. The odours of
client, home, and environment are detected through smell. The taste of
local foods and, in some environments, chemical in the air can be
detected through taste.
Maintaining objectivity in observing clients is an important element of

data collection. Examples of observation data that are objective versus
notations of personal interpretations are given in Table 3-4. Recording
specifically what one sees, feels, smells, or tastes is more accurate than
recording one’s interpretation of it.
3.4.3 Measurement
Measurement is actually a form of observation. The tool is separated to

indicate that certain data are conductive to more precise observation.
Measurement is used to ascertain extent, dimensions, rate, rhythm,
quantity, or size, frequently through the use of additional instruments
along with the senses. Some forms of measurement data include
laboratory values, vital signs, height, and weight for the individual
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client; number of family members, ages, and number of rooms in

dwelling for the family client; and population, number of blocks in
district, and epidemiological data for the community client. General
observation data that can be quantified are also considered measurement
data (for example, observation datum: smoked cigarettes during
interview; measurement datum: smoked five cigarettes during 30-minute
interview). Table 3-5 gives examples of objective, nonjudgmental
measurement data in contrast with personal interpretations from
measurement data.
3.5 Documenting Interactions, Observations, and

Measurements
The recording of interaction, observation, and measurement data is

facilitated by the use of a columnar approach. This format allows the
nurse to note the sequence and tools needed to collect data. Depending
on the client situation, two of the three tools are used more prominently.
The size of the data collection columns can vary accordingly. For
example, an infant client will provide minimum, if any, verbal data.
Some interaction data may be obtained from the parent or staff, so the
interaction column would be the smallest.
3.6 Implementation of the Nursing Plan
Implementation is the execution of the nursing plan. The nurse considers

three major phases when implementing the nursing order: preparation,
implementation itself, and post-implementation.
Preparation consists of the nurse’s being aware of the nursing orders;

having the knowledge to implement them; being cognisant of the legal
and ethical aspects; and knowing the possible side effects and
complications, as well as what technical skills and resources are needed.
Preparation also includes arranging a suitable environment in which the
client and nurse may implement the plan. A quiet environment free of
distractions enhances learning.
3.7 Scientific Rationale
Knowledge is the basis for prescribing and implementing nursing orders.

A scientific rationale describes and explains the basis for nursing orders.
For example, consider the scientific rationale relevant to the following
questions: Why do we restrict fluids at certain times for clients who
have problems of the circulatory or excretory system? Why should the
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nurse assess learning needs before teaching? Why must clients learn to
take their pulses before leaving the hospital for home if they will be
taking digoxin at home? Why do we encourage clients to cough to
loosen bronchial secretions if we know that deep breathing will produce
coughing? Why do we avoid arguing with a delusional client?
The rationale in each case is based on theories, models, frameworks, and

scientific principles from nursing, the natural and behavioural sciences,
and the humanities. The principle, concept, or theory that supports each
step of the plan is stated.
The rationale for the steps of the plan is usually not written into the
nursing orders, but it must be known by the nurse. In some instances, the
rationale is written into the plan to ensure effective communication. For
example, if a client is asked to change a complicated dressing alone, it
may be necessary to include a written rationale. Otherwise, another care
provider may do it for the client, not realizing that the client needs to
learn how to change the dressing alone.
The following guidelines are suggested for writing a scientific rationale:
1. The scientific rationale addresses the identified topic and strategy

and the individuality of the client and family.
2. The scientific rationale cites appropriate research findings and

current literature. Other sources to be used include interviews
with experts, textbooks, journal articles, and reference books.
Any reliable writings or persons may be considered appropriate.
The resource is cited for each supporting scientific rationale.
3.8 Evaluating Care Plan
Evaluation examines such questions as: Was the health care effective?
Were the goals and objectives met to the degree specified? Were the
changes in the client’s behavior in the direction expected? If so, which
nursing strategies were effective? If not, what was lacking in the nursing
care? By measuring the client’s progress toward meeting the objectives,
the nurse judges the effectiveness of nursing actions; thus nurses are
able to judge the quality of their car and determine ways to improve it.
This demonstrates accountability for their actions. Accountability
implies responsibility for one’s behaviour; it requires the ability to
define, explain, and measure the results of nursing actions. Evaluation
identifies those effective nursing strategies and may promote nursing
research.
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3.8.1 Forms of Evaluation
Evaluation may be conceptualized in three forms: structure, process, and

outcome. Process and outcome evaluation can both be subdivided into
two categories, concurrent (present) and retrospective (past), as shown
in Table 11-1. Each form will be discussed separately.
Structure The focus of structure evaluation is on the physical facilities,

equipment, and organizational pattern of the agency. Examples of
structure evaluation are the nursing audit.
Process evaluation focuses on the activities of the nurse. The nurse’s

activities are judged by observing her performance, asking clients what
the nurse did, or reviewing the nurse’s notes in the chart. This forms the
evaluation, concentrating on whether procedures are properly
performed, asks such questions as:
Concurrent process evaluation examines nursing performance when it

takes place. Examples include judging the nurse’s ability to teach insulin
administration and noting if neurological checks are performed
accurately and on time. The Slater Nurse Competencies Rating Scale
and the Quality Patient Care Scale are examples of tools for concurrent
process evaluation. Also, the chart may be reviewed for evidence of
appropriate nursing actions while the client is receiving the nurse’s care.
Outcome Evaluation focuses on changes in the client’s behavior

and health status. The nurse looks for evidence of improved
health status resulting from nursing intervention; for example, that
the client is free from signs of infection, or that the client
accurately states the correct dose of and time to take medication.
Concurrent Outcome Evaluation judges the client’s ability to

demonstrate behavioural and measurable progress in health status,
knowledge, or abilities.
Retrospective outcome evaluation examines the chart after the client has
been discharged. The chart is reviewed for evidence of the client’s
progress resulting from nursing intervention. Examples include
documentation that the client performed activities of daily living,
demonstrated positive attitudinal change, or planned a daily diabetic
menu.
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3.8.2 Criteria and Standards
The concepts of criteria and standards are often used interchangeably in

evaluation, but they are different. Criteria are measurable qualities,
attributes, or characteristics that specify skills, knowledge, or health
status. They describe acceptable levels of performance by stating the
expected behaviours of the nurse or client.
Standards represent acceptable, expected levels of performance by the

nursing staff or other health team members. They are established by
authority, custom, or general consent. Professions develop standards to
improve the levels of practice.
3.8.3 Guidelines for Evaluation
The guideline describes the steps in evaluation. They presuppose the

achievement of the preceding components in the nursing process.
1. Evaluation criteria are given if the objectives lack specificity.

Evaluation criteria are indicators of the expected client behaviors.
They are written like objectives but clarify the behaviours more
specifically.
2. The formative evaluation describes whether and to what extent

the client and nurse achieved the stated plans and objectives.
During each interaction, the nurse have observes and compares
the client’s behaviour with the criteria for the objectives. The
effectiveness of the plan is determined by changes in the client’s
behaviour.
3. The summative evaluation describes the client’s progress or lack

of progress in achieving the goals. The nurse evaluates the
client’s response in meeting the objectives and judges whether
the client’s behaviour shows progress toward goal achievement.
Is the client’s response in the expected direction and safe,
desirable, and reasonable, considering the time and situation?
4. The nursing care plan indicates revisions if the goals and

objectives have not been adequately met. Modification of the
plans, criteria, objectives, or goals is the last step in the
evaluation process. During ongoing evaluation, the nurse may
judge that the plans or objectives are ineffective in achieving the
goal.
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NSS 321 MEDICO-SURGICAL NURSING I
3.9 Hypothetical Nursing Care Plan

A Client with Pelvic Inflammatory Disease
DATE NURSING NURSING NURSING RATIONAL/SCIENTIFIC PRINCIPLE EVALUATION

DIAGNOSIS OBJECTIVE ACTION
Oct 29 1. Pain related to Patient will 1. Investigate pain 1. Changes in intensity may reflect Patient
irritation of the verbalize reports noting developing complications and pain acknowledge
pelvic region by satisfactory level duration and tends to become constant, more satisfactory level
inflammatory of pain control intensity. intense and diffuse over the entire of pain control
exudates evidenced within 48 hours. 2. Nurse in semi abdomen as inflammatory process
by reports of lower fowler’s accelerates.
abdominal pain x position. 2. Facilitates fluid drainage by gravity
4/7 3. Administer reducing irritation and abnormal
analgesics as tension and thereby reducing pain
ordered e.g. 3. Heat improves blood flow this
fortwin 30mg in promotes delivery of nutrients,
bed splinting removal of waste and muscle
painful area and relaxation.
restrict 4. Fortwin inhibits ascending pain
movement. pathways in CNS, increase pain
threshold and alters pain perception .
5. Reduces muscle tension which may

help minimize pain of movement
(Doenges Moorhouse and Geissler,
P. 371)
48
1. Temperature of 38.9 – 41.10c

suggests acute infection disease
process fever is observed to know
when and what type of medical
2. Hyperthermia intervention is needed. The temperature
related to increased Patient will 1. Monitor patient 2. Fan helps to reduce fever through did not reduce
metabolic rate demonstrate q 4 hours and convention, the movement of air, well with nursing
evidence by temp temperature within more often removes heat from the body to air. measures and
of 380c. normal range in during 3. Tepid sponging help body to lose antipyretic drug
24- 48 hours. measures to heat through conduction and but dropped to
reduce fever. evaporation of water from surface of 370c after 2 days
2. Place under the the body Panadol is used to reduce of antibiotic
3. Do tepid fever by its central action on the therapy.
sponging if hypothalamic heat regulating centre
temp remains at 4. Penicillin is bactericidal against
380c. microorganisms by inhibiting all wall
4. Give antipyretic synthesis during active
drug as ordered multiplication, thus combating the
e.g. Panadol II infectious disease process causing
PRN. fever.
5. Give Amplicllin 5. Aminiglycosides (Genticin) act
500mg IVq 6 directly on ribosomes of susceptible
hours as organisms by inhibiting protein
ordered synthesis
6. Give Genticin 6. Metronidazole is used in treating
80 mg IV q gram- negative anaerobic infection.
8hrs.
49
7. Give Flagyl 1) People need someone to whom to

500mg IV 8 talk and share their feelings
hours 2) The thick pus of gonorrhoea can
completely clog both fallopian tubes,
bind them with strictures & render a
woman sterile
Oct 30 3. Fear related to Patient will report
outcome of disease that fear is reduced
on reproductive to manageable
status evidenced by level within 48 1. Allow her to
frequent hours talk about the
questioning about problem and
outcome. express her
fears.
2. Confirm that
sterility can be
a problem of
gonorrhea but
we do not know
yet if this will
be true in her,
suggest that she
should try to
avoid future
VD by
abstaining from
sex until she is
50
married
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Students Activity
You are required to write care plans on patients on the wards to which
you are assigned the care plan should last minimum of 3 days or the
number of days on admission but not more than 7 days. You are not to
use a patient with PID (this example) as a care plan. The care plan
should be turned in not later than 1 week after completion of the week of
care. The grading system for care plans shall be a total of 50 marks
divided as follows: Nursing diagnosis, 5mks; Objective, 5 mks; Nursing
action, 15mks; rationale/ scientific principal, 15mks; evaluation, 10ks.
After completion, the grades will be averaged and one grade per
semester put on your final record. They should also be included in the
experience book
3.10 Nurse-Client Relationship
The nurse-client relationship is the means for applying the nursing

process. This relationship is the vehicle by which the nurse works with
the client. Carl Rogers identifies three aspects that facilitate personal
growth in a relationship: (1) genuineness, the ability to be aware of
one’s own feelings, or being real; (2) respecting the separateness of
another, accepting the other unconditionally; and (3) a continuing desire
to understand or empathize with the other. These aspects are applicable
to all human relationships, especially the nurse-client relationship.
Trust, empathy, caring, autonomy, and mutuality are five concepts basic
to the development of a nurse-client relationship. These concepts need
to be reciprocal during nurse-client interactions, but the nurse is
responsible for setting the tone. Therefore, the nurse needs to identify
specific actions that communicate trust (consistency, honesty), empathy
(touch, sincerity), caring (genuineness, eye contact), autonomy
(nonjudgmental, nonthreatening), and mutuality (inclusion of client in
decision-making).
Numerous communication techniques that foster the nurse-client

relationship have evolved from psychological theory and practice
disciplines. These techniques are useful during any nurse-client
interaction to facilitate obtaining information and establishing rapport.
The communication techniques are enabling devices that should be
incorporated naturally into nurse-client interactions. The techniques
chosen are based on the nurse’s comfort with them. Examples of
facilitative verbal and nonverbal communication techniques are found in
Table 3-1. In many situations, nonverbal communication reveals the
true, often unacceptable message. Nonverbal messages can be
unintentional as well as intentional. The nurse’s goal in communication
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is to exhibit congruent verbal and nonverbal messages; in other words,

the verbal and nonverbal messages should be saying the same thing.
Definitions of the techniques shown in Table 3-1 are in the glossary.
The use of these techniques does not guarantee a meaningful
relationship. All aspects of the situation must be taken into account,
such as the client’s health state, environmental influences, and the
nurse’s knowledge and use of self.
Effective nurse-client relationships can be attained when nurses are

willing to look at their own values, prejudices, strengths, and limitations.
Nurses discover how this “self” affects interactions with others. This
cannot be done through intellectual development alone; nurses must be
open to the discovery of their own motivations and feelings through
experience and relationships with others.
3.11 Skills Required in the Nursing Process
In the use of the nursing process the following skills are needed;
3.11.1 Intellectual Skill
Critical Thinking: Once the nurse has assembled a body of facts, she
uses critical thinking to sift through the information and start generating
ideas about what it means.
Definition of critical thinking by the National Council for Excellence in

Critical Instruction (Paul, 1993) parallels the steps of the nursing
process. The National Council for Excellence in Critical Instruction
defines critical thinking as:
“The intellectually disciplined process of activity and skill

fully conceptualizing, applying, analyzing synthesizing
and evaluating information gathered from or generated by
observation, experience, reflection, reasoning as a guide to
belief and action” (Paul 1993 p. 56).
Evident in this definition are the assessment, planning, implementation

and evaluation component of the nursing process.
Critical thinking is important largely because without it, the quality of
care the client is receiving may be inappropriate.
Problem Solving: After extracting a series of possible meanings from a

collection of facts, the nurse is ready for problem solving. This is the
thought process used to define problems based on interpretations made
in the critical thinking phase. Both levels of thinking are essential when
a nurse is faced with an unstructured situation. Problem-solving
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technique gives organization and direction to the various elements of

nursing practice. Problem-solving also allows for better assessment and
planning because it focuses the nurse’s thinking on the individual rather
than on the tasks involved in his care. It also helps in the planning and
use of written nursing care plans.
Decision-Making
This is the third major type of though process, and is used for deciding a
particular course of action. The thought process of decision-making is
similar to the steps of the nursing process. These are:
1. Recognize and define the problem.

2. Collect data from observation and experimentation.
3. Formulate and implement the solution.
4. Evaluate the solution.
During the assessment phase, the nurse searches for conditions that call
for action. What is the most important situation for which a decision is
demanded? What alternative actions can be explored? What are the
probable consequences of a particular alternative? During the planning
and implementation phase, the nurse analyzes each alternative and its
consequences. She must decide which course of action is the most
effective and efficient for the client.
The evaluation phase of decision-making is an interrelated cycle of

activities that allows the nurse to assess the care given. If the care given
is inadequate, she can go back to the assessment phase looking for clues.
3.11.2 Interpersonal Skills
It is these skills that distinguish the knowledgeable technician from a

professional.
Self-knowledge and Self-image
In order to be capable of reaching others, we must first be in touch with

ourselves. Self-knowledge is therefore first on the list of interpersonal
skills. The better a nurse understands herself and her own needs, the
more insight she will bring to the problems of clients. The term self-
image refers to the way we see ourselves or believe ourselves to be.
Those who are unable to perceive their own defects are often incapable
of giving to others except in a very limited way.
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Communication
No matter how self-aware a nurse is and how deep her ability to

empathize with others, her resources will be useless unless she is
capable of communicating. Basically, a nurse is concerned with
establishing a rapport that makes her more aware of the client’s needs. .
Through the use of therapeutic communication, the nurse helps the
client to make his own decisions and to come to his own conclusions.
Clients often feel that the nurse’s time is limited. They therefore hesitate
to push a conversation beyond an exchange of pleasantries. For this
reason, the nurse must use a variety of techniques to encourage
therapeutic communication.
The ability to listen is basic to communication. The nurse must be able

to pick up on faint signals. The ability to listen is based on an attitude of
acceptance. A client senses acceptance from a nurse who spends time
with him and tries to find out how he really feels about his illness.
Another set of interpersonal skills that the nurse is asked to develop is
the ability to convey interest, compassion, knowledge, and information.
This is especially important in the care of patients suffering from
terminal illness. She does so by being kind, gentle, gracious, humane,
and thoughtful.
In addition to being able to convey an empathetic attitude toward the

client, the nurse must also know how to transmit knowledge and
information about his condition.
3.11.3 Technical Skills
In giving care, a wide range of technical skill is used. The skill used
depends on the patient illness and the knowledge of the nurse. For
example, in the case of a client with chronic obstructive pulmonary
disease, the nursing plan might include simple measures such as
providing two pillows and avoiding tight bed linens across the chest,
limiting conversation and helping him get to the bathroom, describing
and recording sputum amount, colour, and consistency; and recording
fatigue, pulse, and respiratory response.
4.0 CONCLUSION
A well-written nursing care plan gives direction, guidance, and meaning

to nursing care. It is the primary means of communicating,
synchronising, and organizing the actions of all nursing staff. The
nursing care plan provides for continuity of care.
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5.0 SUMMARY
• The nursing care plan is the plan of care that a nurse draws
out for the individual patient after carefully assessing the
patient’s need and arranging them in order of priority.
• Assessment tools for planning care are made through observation,

interview and records. The patient’s records provide useful data as to
what care has been given.
• The nurse-client relationship is the means for applying the nursing

process. This relationship is the vehicle by which the nurse works
with the client. Trust, empathy, caring, autonomy, and mutuality are
five concepts basic to the development of a nurse-client relationship.
• In giving care a wide range of technical skill is used. The skill used
depend’s on the patient illness and the knowledge of the nurse.
Discuss the importance of the nursing care plan.
Barbara Kozier and Glenora, Erb. [no date]. Fundamentals of Nursing.

Concepts and Procedures. (2nd ed.)
MODULE 2 MEDICAL-SURGICAL CONDITIONS
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Unit 1 Fluid and Electrolyte Distribution

Unit 2 Fluid and Electrolyte Imbalances
Unit 3 Acid–Base Imbalance
Unit 4 Inflammation
Unit 5 Shock
Unit 6 Neoplasms
Unit 7 Pain
UNIT 1 FLUID AND ELECTROLYTE DISTRIBUTION
CONTENTS
1.0 Introduction
2.0 Objectives
3.0 Main Content
3.1 Fluids
3.1.1 Body Fluid Compartments
3.1.1.1 The Intracellular Fluid
3.1.1.2 The Extracellular Fluid
3.2 Distribution and Concentration of Electrolytes in Body
Fluid
3.2.1 Osmosis
3.2.2 Diffusion
3.2.3 Active Transport
3.2.4 Filtration
3.2.5 Pinocytosis and Phagocytosis
3.3 Common Sources of Fluid and Electrolyte Imbalance
3.4 Factors Influencing Fluid and Electrolyte Balance
3.5 Electrolytes
3.6 Mechanisms Regulating Fluid and Electrocyte Balance
3.7 Factors Affecting Fluid and Electrolyte Balance
3.8 Mechanism in which H2O and Electrolyte Enters and
Leaves the Body
3.9 Problems Related to Fluid Balance: Edema
3.9.1 Physiology of Dedema
3.9.2 Types of Edema
3.9.3 Signs and Symptoms
3.9.4 Nursing Care
3.10 Dehydration
3.10.1 Definition
3.10.2 Causes
3.10.4 Nursing Care
3.11 Anorexia, Nausea and Vomiting
3.11.1 Definitions
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3.11.2 Physiology of Vomiting

3.11.3 Physical Changes Accompanying Anorexia
3.11.4 Clinical Manifestation of Nausea
3.11.5 Factors causing Anorexia, Nausea and Vomiting
3.11.6 Observation of Anorexia, Nausea and Vomiting
3.11.7 Nursing Intervention for Anorexia, Nausea and
Vomiting
4.0 Conclusion
5.0 Summary
1.0 INTRODUCTION
All bodily functions rely on the proper distribution of fluids and

electrolytes between the intracellular and extracellular compartments.
Fluid and electrolyte balance is maintained by the interaction of renal,
hormonal, and metabolic mechanisms. Imbalances can occur secondary
to other disorders or as complications of therapy. The major objective of
fluid and electrolyte distribution is the replacement for prior deficits and
continuing losses, and nutrition.
2.0 OBJECTIVES
• identify body fluid compartment

• describe the mechanism regulatory fluid and electrolyte balance
• identify he factors affecting fluid and electrolyte balances
• explain route by which water and Electrolyte leave and enter the
body
• describe the types of electrolytes in the body
• distinguish between electrolyte balance and imbalance.
3.0 MAIN CONTENT
3.1 Fluids
The fluids system plays an important role in the body. The principal
functions of body fluids are:
1. maintains blood volume
2. aids digestion
3. transports material to and from body cells,
4. acts as a medium for cellular metabolism and
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5. excretes of waste, and

6. regulation body temperature.
Water is the largest single constituent of the human body and forms
about 50-70% of the total body weight (TBW) of the average young to
middle age adult. 75-80% of total body weight of an infant is made up
of water. By the age of two, the percentage of total body weight that is
fluid is the same as that of a young to middle aged adult (60%). The
total body fluid drops about 45-60% in the elderly because of changes
on the body tissue. In the adult, 60% of body weight consists of water,
of which 45% is intracellular fluid (ICF). The remaining 15% is
distributed between the intravascular and interstitial compartments and
is considered extracellular fluid (ECF).
3.1.1 Body Fluid Compartments
Body fluids are found in years major compartments of the body. These
are
a. Intracellular fluid
b. Extracellular fluid
3.1.1.1 The Intracellular Fluid
Compartment is found within the cells of the body. It accounts for

approximately 40-50% of the total body weight. The main electrolyte is
potassium (K) and this provides the cells with aqueous medium for its
chemical functions
3.1.1.2 The Extracellular Fluid
This is found outside the cells. The main electrolyte is sodium (Na).
The extracellular fluid is made up of two compartments:
a. Interstitial Fluid
This is found in the spaces between the cells and accounts for
approximately 15% of total body weight of an adult.
b. Intravascular Fluid
This is found in the blood and lymph vessels and makes up about 5% of
the total body weight.
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3.2 Distribution and Concentration of Electrolytes in

Body Fluid
Distribution and concentration of electrolytes in the body fluids are

regulated by osmosis, diffusion, active transport, filtration, and
pinocytosis and phagocytes.
3.2.1 Osmosis
Osmosis is the process by which water passes through a semi-permeable

membrane from a high concentration of water to a lower concentration
of water. This continues until equilibrium is achieved on both sides of
the membrane. Simply stated, in osmosis, water passes from a more
dilute solution to a more concentrated one. Water goes where the
electrolytes go. If blood cells are suspended in an isotonic solution (a
solution having the same osmotic pressure as the cells), the osmotic
pressure will remain the same inside and outside the cell. In this case, no
movement occurs. If the blood cells are placed in a hypotonic solution
(much less concentrated than the cellular contents), water will flow into
the cells until they swell and burst. In a hypertonic solution (more
concentrated than the cellular contents), water flows out of the cells and
they shrink
A M B
Water
3.2.2 Diffusion
Diffusion is a process whereby molecules move from higher

concentrations of solution to lower concentrations. Oxygen and carbon
dioxide exchange in the lungs occurs through diffusion.
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A M B
Solute
3.2.3 Active Transport
Active transport is a mechanism, still not fully understood, whereby ions

move from areas of lesser concentration to areas of greater
concentration. It involves the release of energy by the action of
adenosine triphosphate (ATP), which supplies the necessary “uphill
movement,” enabling certain substances to pass through the cell
membrane. Sodium, potassium, and amino acids are probably carried
through all cell membranes by active transport.
3.2.4 Filtration
Filtration is related to hydrostatic pressure produced by the pumping

action of the heart. (Hydrostatic pressure is the pressure of water or
other liquids.) It involves the transfer of both solute and solvent through
a permeable membrane from a region of higher hydrostatic pressure to a
region of lower pressure. An example is the passage of water and
electrolytes from the capillary beds to the interstitial fluid.
3.2.5 Pinocytosis and Phagocytosis
Pinocytosis is the process by which substances of higher molecular

weight, such as protein, enter the body. In this process, the cell
membrane folds inward to incorporate the substances. In phagocytosis,
foreign particles are engulfed or digested by specialized cells called
phagocytes.
3.3 Common Sources of Fluid and Electrolyte

Imbalance
1. Vomiting and Gastric Suction
When the quantity of acidic gastric juices is reduced through vomiting

or by gastric suction, a number of vital electrolytes is lost. These usually
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include hydrogen, chloride, potassium, and sodium. The total amount of

fluid in the body is decreased, and the client may develop metabolic
alkalosis from the resulting excess of base bicarbonate. The symptoms
of metabolic alkalosis include slow, shallow respiration, muscle
hypertonicity and tetany, and personality changes. The client may
become disoriented, irritable, or uncooperative.
2. Diarrhoea, and Other Sources of Gastrointestinal Fluid Loss
In a 24-hour period, 17,000 ml of fluid can be lost through diarrhoea.

With intestinal suction, 3,000 ml of fluid per day can be lost. Prolonged
use of laxatives and enemas can result in serious water and electrolyte
disturbances. Gastrointestinal fluids can also be lost through fistulas or
drainage tubes. Gastrointestinal obstruction also produces fluid loss
because the fluids are trapped within the intestine and cannot be used by
the body. In addition to fluid volume loss, gastrointestinal disturbances
can result in metabolic acidosis (because the intestinal secretions are
primarily alkaline). Symptoms of metabolic acidosis include shortness
of breath, deep, rapid breathing, weakness, malaise, and stupor
progressing to coma.
3. Wound Exudates
This can result in losses of protein and sodium and in a deficit in the
extracellular fluid volume.
4. Excessive Perspiration
This can lead to abnormal losses of water, sodium, and chloride. If fluid
intake of both water and electrolytes is not continued, the fluid volume
and proportion of electrolytes decrease. The client with this condition
may even develop sodium excess if insufficient water is ingested during
a period of heavy perspiration.
5. “Insensible”
Water loss occurs through the lungs and skin. It totals approximately
600 to 1,000 ml per day in the average adult. If respiratory activity is
increased, more water vapour is lost, and if there is damage to the skin,
still more loss occurs. Because only water, and not electrolytes, is lost
through the skin, water deficit and sodium excess will develop.
6. Hyperventilation
Results in respiratory alkalosis due to excessive elimination of carbon

dioxide.
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7. Hypoventilation
Which is more dangerous than hyperventilation, causes retention of

excessive amounts of carbon dioxide. This condition results in
respiration acidosis.
3.4 Factors Influencing Fluid and Electrolyte Balance
Age. The infant requires a large intake of fluid; his body contains 20
per cent more water than that of the adult, and this water acts as a
protective mechanism. Thus, imbalance is a major point of vulnerability.
This is also true with the elderly client, whose essential physiological
systems may not be completely adequate. The infant needs fluid in large
amounts to meet his needs for more dilute urine and to satisfy his higher
metabolic demands. In the infant, the balance of intra- and extracellular
fluids is also different. The infant’s balance is 50 per cent intracellular
and 50 per cent extracellular, while in the adult, the balance is 75 per
cent intracellular and 25 per cent extracellular.
With the elderly client, fluid imbalance can result from the breakdown
of one or more of the following systems: respiratory, renal, cardiac, and
gastrointestinal. Because the elderly are more subject to these
breakdowns, they are more vulnerable to fluid and electrolyte
imbalance. While the physiological processes of aging cannot be
reversed, dangerous fluid imbalances can be avoided.
3.5 Electrolytes
Electrolytes are chemicals that, when dissolved, dissociate into

positively and negatively charged ions (cations and anions). Total cation
always equals total anions. They are important constituents of
intracellular and extracellular fluids, serving vital functions in
maintaining fluid and acid – base balance, neuromuscular excitability,
blood clotting, and protein and cellular metabolism. The composition
and concentration of electrolytes in each fluid compartment vary.
Measurement of electrolytes is usually expressed in mill equivalents per
liter (mEq/L).
The electrolytes in the body fluid are involved in chemical reaction such
as:
i. Regulating the permeability of cell membranes thus, controlling

the transfer of various materials across the membrane.
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ii. Maintenance of the bodies acid-base balance.
iii. Promotion of neuron muscular irritability by transmission of

electrical energy within the body e.g. without calcium muscle
contraction cannot occur.
iv. Maintenance of fluids osmolarity (the osmotic pull of all particles

per kg of H2O).
3.6 Mechanisms Regulating Fluid and Electrolyte Balance
Proteins and electrolytes are the main forces holding H2O within the
various compartments of the fluid system in the body. In the
intravascular compartments the force is by the serum album where as in
the interstitial fluid by (Na+) ions and in the intracellular by potassium.
These substances exact an osmotic pressure which holds the H2O in their
respective compartments. For example a patient who has lost a great
deal of serum albumin through malnutrition tends to become odematus,
since fluid is drawn from the blood plasma into the intracellular space
because the main force holding the H2O in the blood vessels has been
lost.
1. Kidneys
This is the most important regulatory mechanism. This function is

regulated by the action of two hormones – Anti Diuretic Hormone
(ADH) which controls H2O reabsorption and Aldesterone which
promotes the retention of Na and the excretion of K. Under the influence
of these hormones the kidney assists in regulation of.
a. Total value of extra cellular fluid.

b. Electrolyte concentrate.
c. Acid-base balance.
d. Blood pressure is erythropoesis.
2. Gastrointestinal Tract
This is done through the selective reabsorption of H2Oand solute taking

place principally in the small intestine. The gastrointestinal tract absorbs
about 7-9 liters of glandular and gastrointestinal secretions per day.
About 100mls of H2O are excreted from the bowel daily, the rest are
reabsorbed. Both fluids and electrolytes may be lost in considerable
quantities in conditions as vomiting and diarrhoea.
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3. Thirst
This is stimulated by a decrease in extracellular fluid volume. Thirst

indicates a basic physiological need for H2O. The thirst mechanism is
stimulated by:
a. Increase osmotic pressure.

b. Decrease ECF.
c. Dry mucous membrane in the mouth.
4. Lungs
H2O is lost during expiration and inspiration, although amount of H2O

lost is small. Whenever respiration increases in rate and depth, the
amount of H2O lost via this routed is increased. This is seen in strenuous
muscular exercise, fever or any condition in which respiration is
increased or when the air that is breathed is very dry.
5. Skin
H2O is lost through perspiration
6. Hormonal Control
Three hormones play a particularly vital role in maintaining fluid and

electrolyte balances:
1. Antidiureretic hormone (ADH)
a. Is produced in the hypothalamus and stored and released from the

posterior pituitary gland.
b. Acts on the renal tubules to retain water and to decrease urinary
output.
2. Aldosterone
a. Is secreted by the adrenal cortex.

b. Acts on the renal tubules to reabsorb sodium and to excrete
potassium.
c. Increase circulatory volume by reabsorbing water along with
sodium.
3. Parathormone
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a. Produced by the parathyroid glands

b. Promotes absorption of calcium from the intestine
c. Promotes release of calcium from bone
d. Increases the excretion of phosphate ions by kidneys.
3.7 Factors Affecting Fluid and Electrolyte Balance
1. Insufficient intake of fluid.

2. Disturbance of the gastrointestinal tract such as diarrhoea and
vomiting, gastric suction and wash out.
3. Disturbances of kidney function e.g. cardio vascular dysfunction
or imbalance in antidiurectic hormone.
4. Excessive perspiration and evaporation.
5. Lost of body fluid as occurs will Hemorrhage, burns and body
trauma including surgical trauma.
3.8 Mechanism in Which H2O and Electrolyte Enter and

Leaves the Body
Water enters the body through
a. Oral liquids = 1,500ml
b. Water in fluids = 700ml
c. Water from oxidation = 200ml

2,400ml
Water leaves the body by several routes
a. Skin diffusion 350ml
b. Skin by perspiration 100ml
c. Lungs 350ml
d. Feaces 200ml
e. Kidneys 1400ml
= 2,400ml
As long as all organs are functioning normally, the body is able to

maintain balance in its fluid contents. i.e. the intake of fluid must
balance the output.
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Calculation of Maintenance Fluid in Children
Child’s Age/Weight KG Body Weight Formular Over 24hrs

Period.
0 – 72hrs old 60 – 100mls
0 – 10kg 100ml / kg (may ↑ up to 150ml / kg if renal and
cardiac function is adequate.
11 – 20kg 100ml for the 1st 10kg + 50ml for each kg over
10kg.
21 – 30kg 1500ml for the 1st 20kg + 25ml / kg for each kg
over 20kg
6 months 130ml / kg
3.9 Problems Related to Fluid Balance: Oedema
Definition: A condition in which excessive fluid is retained in the tissue

(interstitial space) this may be localized or generalized. It may result
from disturbances in the kidney or heart or increased permeability of cell
membrane. The source of the edematus fluid is from the blood plasma.
Normally, the interstitial compartment is dry, compact and expandable
with very little fluid present except that needed to fill the spaces
between the tissue substances. The dry state is significant in bringing
about movement of nutrient from the plasma to the intracellular fluid
and removing waste in the same way.
Any ↑ in the distance between the blood capillaries and the cells (such
as edema) interferes with the cells nutrition. In edema the low encotic
pressure in the intravascular space cannot pull fluid back into the
capillaries.
3.9.1 Physiology of Oedema
Accumulation of excess tissue fluid is known as oedema or dropsy. This

may result from excess tissue fluid formation or a failure of absorption.
There are a variety of causes of oedema, but basically it is caused by an
increase in the blood pressure in the capillaries which increases fluid
production, and or a decrease in effective osmotic pressure of plasma
proteins which decreases fluid reabsorption.
When there is wide arteriolar dilatation, there is a reduction in pressure

drop across the arterioles and a rise in capillary pressure. Similarly an
obstruction to the veins produces increased pressure in the veins distal to
the obstruction and eventual rise in the pressure at the venous end of the
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capillaries. These pressure gradients enhance extravasations of fluid into

the tissues causing oedema. This type of oedema is seen in the legs of
pregnant women due to pressure by the baby on veins in the pelvis,
when a plaster cast or bandage on a limb is too tight and obstructs the
venous return, and in patients with heart failure.
Reduction in the effective osmotic pressure of the blood is associated

with deficiency of plasma proteins seen in insufficient intake of protein
(malnutrition) excessive protein loss in the urine (kidney disease) and
increased permeability of the capillaries to protein as in burns injuries.
The loss of protein into the tissue space causes a reduction in the
osmotic effect which draws fluid back into the blood. Generally hypoxia
damages capillaries with resultant increased passage of protein into the
tissue spaces. This phenomenon is an additional cause of oedema in
heart failure.
Disorders of sodium chloride excretion may result in sodium retention

and subsequently water retention causing generalized oedema.
Capillary damage due to insect bite or injury may lead to a localized

oedema. Trauma to the capillary and the release of histamine and related
substances are responsible for the damage of the capillary.
3.9.2 The Causes of Oedema can thus be Summarised as

Follows
1. Increased arteriolar dilatation

2. Obstruction to venous drainage
3. Protein malnutrition
4. Kidney disease e.g. nephritis
5. Burns
6. Generalized hypoxia
7. Sodium retention
8. Local trauma
3.9.3 Types of Edema
a. Pitting Edema
Edema that after firm finger pressure on the stun leaves a small
depression called the pit. This is caused by movement of the edematous
fluid in the adjacent tissue.
b. Dependent Edema
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Refers to edema that collects in lower patient or most dependent regions

of the body–fat, ankles, sacral regions.
Additional site of Edema includes:
c. Cerebral Edema
Excessive accumulation of fluid in brain tissues.
d. Pulmonary Edema
Fluid in interstitial spaces of the lungs.
e. Ascites
Accumulation of fluid in the abdominal cavity but specifically in the

peritoneal cavity.
a. Weight gain
b. Tissue swelling
c. Puffy eyelids
d. Decreased fluid output compared to intake
e. Amber-dark coloured urine
f. Decreased Hct, heamoglobin and RBC count
g. Weakness and anorexia
h. Mental confusion
i. Slow/absent responses
j. Apathy
3.9.5 Nursing Care
a. Good skin care – pressure area care, use of comfort devices to

prevent pressure source.
b. Restriction of fluid intake
c. Accurate measure of intake and output
d. Daily weight
e. If edema of the feet, elevate foot of bed
f. If pulmonary edema, nurse in cardiac position
g. If sacral-edema, turn patient q2
h. Low soft diet.
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3.10 Dehydration
3.10.1 Definition
This is a condition in which the body or tissue are deprived of H2O. In

dehydration, there is loss of 10% or more of the body H2O. The effect of
dehydration depends upon the rate and volume of fluid deficit. If patient
are young, elderly or if their general condition is poor, the effect will be
more acute. Wide variation occurs in electrolyte changes depending on
volume and composition of the fluid lost, rate of renal function,
underlined disease process and amount of intake, the proportion of
electrolyte as compared to water loss.
3.10.2 Causes
a. Insufficient intake of fluid.

b. Excessive loss of fluid as in sweating.
c. Vomiting and diarrhea.
1. Sunken eyes, Weight loss

2. Poor skin tugor
3. Excessive thirst
4. Decrease in urine output
5. Decreased sweating
6. Increased Hematocrit (Hct)
7. Conc. Urine
8. Weakness and malaise
3.10.4 Nursing Care
1. Increased fluid intake about three liters per day

2. Good skin care and mouth care
3. Proper record of intake and output
4. Adequate rest
5. Monitor temperature
3.11 Anorexia, Nausea and Vomiting
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These indicate varying degree of distress of the upper gastrointerstinal

tract. Anorexia may precede nausea; nausea in return, may reproceed
vomiting.
3.11.1 Definitions
Anorexia: This is the loss of appetite, lack of desire for food.
Nausea: This is a feeling of the urge to vomit in which each

thought of food is with an uncomfortable sensation in the
stomach.
Vomiting: This is forceful ejection of stomach contents.
3.11.2 Physiology of Vomiting
The primary vomiting centre is located in the medullar oblongata. The

physiology involves a sequence of actions
Initially, there is relaxation of the upper portion of the stomach,

including the cardiac sphincter. This is followed by strong contractile
waves in the lower portion of the stomach which closes the pyloric
sphincter. Subsequently, the diaphragm and abdominal muscles contract,
leading to increase in intra-abdominal pressure and the stomach is
squeezed between two sets of muscles. The content in the relaxed upper
portion of the stomach are then forced upward through the oesophagus
out through the mouth. Normally, the glottis is closed, respiratory ceases
during vomiting to prevent vomitus from being aspirated.
3.11.3 Physical Changes Accompaning Anorexia
1. Hypo functioning of the stomach.

2. Lessened gastric tone.
3. Decrease hydrochloric secretion.
4. Stomach is pale in colour.
3.11.4 Clinical Manifestation of Nausea
They are similar to in anorexia expect they are more pronounced:
a. There is other signs relaxation of the walls of the stomach.

b. Gastric secretions and muscular contractions ceases in nausea.
c. Uncomfortable sensation in the gastric region.
d. Frequent perspiration and increased salivation.
e. There may be hypotension and tachycardia.
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f. Some people feel faint, dizzy or complain of headache.

g. Wrenching – unproductive attempt at vomiting which may occur
several times before vomiting takes place.
3.11.5 Factors Causing Anorexia, Nausea and Vomiting
Drugs
Many drugs have anorexia, nausea and vomiting as side affects e.g.
Digitalis, anesthetics, antibiotics etc. Bacteria toxins that are circulating
in the blood may sometimes stimulate deformity centre resolution in
vomiting.
Motion Sickness
A disturbance in the motion or any rapid change in the direction of the

body stimulates receptors in the labyrinth (ear). Impulses are then
transmitted to the vomiting centre in the medulla.
Strong Emotions
Unpleasant, stressful, situation may give rise to nausea. In this case, a

stimuli originating from the cerebral cortex activates the vomiting centre
directly.
Internal Factors
Parts of the body like the stomach, uterus, kidneys, semi lunar canals,
duodenum, pharynx and heart contain vomiting receptors. These body
parts can be stimulated in many different ways like irritation, stretching,
pressure, thus vomiting centre is stimulated.
3.11.6 Observation of Anorexia, Nausea and Vomiting:
a. Subjective Observation
– Listen to patient’s complaint

– Note reaction to food
– Observe for listlessness (apathy)
b. Objective Observation
– Observe for outward signs like palour

– Excessive perspiration
– Assess the vomiting in terms of the nature of vomiting:
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(i) Projectile or regurgitated

(ii) Preceded by feeling of nausea
(iii) Its frequency
(iv) Its occurrence in relation to food intake

(v) Assess vomiting in terms of the characteristics of the vomitus i.e.
colour, consistency (watery, liquid or solid), the presence of
undigested food, blood or other foreign substance, odour etc.
3.11.7 Nursing Intervention for Anorexia, Nausea and

Vomiting
Nursing action is directed toward three goals
1. Prevention of symptoms
2. Maintenance of comfort and hygiene
3. Maintenance of hydration and nutritional status.
Prevention of Symptoms
a. Clean and maintain a pleasant environment.

b. Keep emesis basin out of sight but if patient feels more secured
with it thereby it can be kept within easy reach.
c. Minimize unpleasant odours.
Room should be ventilated: Use of deodorant may be necessary

symptoms.
d. Oral hygiene may be due before meals.

e. Provide for patients emotional and physical comfort:
– Prevent / eliminate of pain

– Appropriate positioning
– Good oral hygiene
– Reduction of fever
f. Psychological support to help patient deal with anxiety.
g. Use of anti-emetic drugs to prevent vomiting.
Maintenance of Comfort and Hygiene
a. Holding emesis basin over patients chin to catch vomits.

b. Position for vomiting.
c. Support patient in a sitting or sideline position.
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d. In post-operative vomiting, the patient will find it less painful if

the nurse supports its incision with her hands when vomiting.
e. Nurse should stay with patient.
f. While patient is vomiting, nurse should provide him with tissue

and help him to wipe its mouth.
g. After vomiting, wash hands and face and give mouth care.
Maintenance of Hydration and Nutritional Status
a. Encourage regular fluid intake.

b. If having difficulty retaining food, give small amount of food at
frequent intervals.
c. Clear liquids are permitted after vomiting has subsided.
d. For anorexic or nauseated patient, small portion of meal
attractively served are usually more appealing.
e. Determine food preference by asking patient what he likes to eat.
f. If unable to tolerate foods or fluid / oral, parenteral fluid may be
prescribed or patient may be fed via tube which is inserted into
the stomach Fluid And Electrolyte Disturbances
4.0 CONCLUSION
A large percentage of body weight is composed of water containing

dissolved particles of organic and inorganic substance and filtration.
5.0 SUMMARY
• Water is contained in two compartments: intracellar and

extracellular.
• The mechanism by which water and solute move in the body are
osmosis.
• Three hormones (antidiuretic aldesterone and parathormb play vital
role in maintaining fluid and electrolyte balance.
Discuss the importance and functions of water to the body.
Brunner & Suddarth (2004). Medical Surgical Nursing. Lippincott

Wilkins.
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Barbara C, Long and Wilma J. Phipps (1985). Essentials of Medical-

Surgical Nursing. A Nursing Process Approach. St. Loius: The
C. V. Mosby Company.
UNIT 2 FLUID AND ELECTROLYTE IMBALANCES
CONTENTS
1.0 Introduction
2.0 Objectives
3.0 Main Content
3.1 Extracellular Volume Deficit: Hypervolemia

3.1.1 Causes
3.1.2 Clinical Manifestations
3.1.3 Medical Management
3.1.4 Nursing Diagnoses
3.2 Extracellular Volume Deficit-Hypovolemia
3.2.1 Causes
3.2.2 Clinical Manifestation
3.2.4 Nursing Care
3.3 Electrolyte (Osmolality) Disturbances
3.3.1 Hypernatremia: Increased Serum Osmolality
3.3.2 Causes
3.3.5 Nursing Care
3.4 Hyponatremia
3.4.3 Nursing Care
3.5 Potassium
3.5.1 Hyperkalemia
3.5.2 Causes
3.5.5 Nursing Care
3.6 Hypokalemia
3.7 Calcium
3.7.1 Hypercalcemia
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3.8 Hypocalcemia
3.8.1 Causes
4.0 Conclusion
5.0 Summary
1.0 INTRODUCTION
Almost all medical-surgical conditions threaten fluid and electrolyte

balance. There may be deficits or excesses of water or of any electrolyte.
The assessment and maintenance of a patient’s fluid and electrolyte
balance is a major nursing responsibility. This unit describes some basic
information about water and electrolytes in the body and the causes and
effects of common fluid and electrolyte imbalances. Nursing process
approach is used in discussing the condition.
2.0 OBJECTIVES
• distinguish between electrolyte balance and imbalance

• explain all the clinical manifestation of Fluid electrolyte imbalance
• apply nursing process in the assessment and management of
conditions due to Fluid electrolyte imbalance.
3.0 MAIN CONTENT
3.1 Extracelullar Volume Deficit: Hypervolemia
Hypervolemia is a condition in which the ECF compartment becomes

expanded, and there is a surplus of circulating fluid with normal or near
normal proportions of electrolytes.
3.1.1 Causes
1. Inability of the kidneys to excrete excess water and electrolytes

as seen in chronic renal disease, chronic liver disease congestive
heart failure, or administration of oral or parenteral fluids at a rate
beyond renal capacity for excretion.
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2 Administration of intravenous fluids at a rate beyond renal

capacity for excretion especially in patients with impaired kidney
function, in infants or elderly people.
3 Fluid retention following administration of large doses of

corticosteroids resulting from the increased level of aldosterone.
3.1.2 Clinical Manifestations
This is due to expanded extracellular volume
1. If excess fluids are in the vascular space there will be elevated BP,
bounding pulse, distended neck veins, weight gain, dyspnea, crackles
(rales), and pretibial and sacral edema. If overload becomes
sufficiently severe to exceed the pumping capacity of the left
ventricle, pulmonary edema will result.
2. Laboratory findings are variable. Serum osmolality usually remains

unchanged. Serum sodium values are not often affected, although
they may be low. Hematocrit may be decreased.
The treatment is according to severity but the goal is to obtain a

definitive diagnosis of the underlying cause to determine appropriate
treatment.
1. Restrict fluids and sodium intake.

2. Administer diuretics e.g. Lasix to eliminate excess fluids.
3. Replace potassium losses secondary to diuretic therapy.
4. Administer dialysis for patients with renal failure or life-threatening
hypervolemia.
Fluid volume excess, edema related to surplus of circulating fluid.
Nursing Objective
Patient’s vital sign, physical findings, and laboratory values are within
acceptable limits.
Interventions
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1. Assess vital sign and monitor input and output; measure weight
daily. Watch out for an irregular pulse, which can be indicative of
dangerous hypokalemia.
2. Observe for and report edema, which may not be clinically evident
until 5 – 10 pounds of fluid have been retained. Check sacral areas in
patients on bed rest. Look for edema in the ankles and pretibial areas
of ambulatory patients.
3. Maintain fluid and sodium restrictions as prescribed.
4. Administer diuretics as prescribed.
5. Monitor lab values; be especially alert to decreased potassium in

patients on diuretics.
6. Monitor for clinical indicators of potassium depletion during

diuretic therapy. These include muscle weakness, cramping,
nausea, anorexia, and cardiac dysrhythmias.
7. Replace potassium losses by administering potassium

supplements as prescribed.
8. Teach patient about foods high in potassium, including oranges,

tomatoes, and bananas.
Nursing Diagnoses
Impaired Gas Exchange related to tissue hypoxia secondary to

pulmonary edema.
Nursing Objective
Patient does not exhibit signs of respiratory dysfunction.
Interventions
1. Monitor character, rate, and depth of respirations; auscultate lung

fields for adventitious breath sounds.
2. Keep patient in semi-Fowler’s position to facilitate respirations.
3. Teach patient deep-breathing exercises to enhance gas exchange.
3.2 Extracellular Volume Deficit-Hypovolemia
Hypovolemia is a condition in which depletion of ECF occurs as a result

of water and sodium loss in varying proportions from the body,
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depending on underlying pathology there .One third of the lost is from

vascular space and two thirds from the interstitial space. There is no
water shift between intra and extracellular fluid compartment because
there is no change in osmolarity.
3.2.1 Causes
1. GI losses such as vomiting, diarrhoea, fistulous drainage, ileostomy,

gastric suction.
2. Urinary losses from diuretic administration, renal or adrenal disease,
diabetes insipidus.
3. Sequestration of fluid that is (plasma-to-interstitial fluid shift). This
is with burns, peritonitis, ileums, ascites, and acute pancreatitis.
4. Profuse diaphoresis, hyperventilation, fever.
5. Decreased intake of water and electrolytes.
6. Blood loss
1. Postural hypotension, weak pulse with tachycardia, flattened neck

veins, increased respirations, poor skin turgor, longitudinal furrows
in the tongue, absence of moisture in the groin and maxillae,
decreased tearing and salivation, anorexia, nausea, vomiting,
weakness, apathy, weight loss, subnormal temperature, and
decreased urine output. Shock and coma can ensue if volume
depletion is severe.
2. Laboratory Findings: BUN is elevated to serum creatinine, and an

elevated hematocrit and protein count, all reflective of
hemoconcentration. Urinary sodium is decreased, and urine specific
gravity is elevated.
3.2.3 Medical management
The goal is to restore ECF volume and correct the underlying cause.
1. Administer oral or intravenous fluids to replace water and electrolyte

losses while definitive diagnosis is being made. Isotonic fluid such
as Lactate Ringer solution and 0.9% saline are given. Blood
transfusion may be given in severe shock.
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3.2.4 Nursing care
Nursing Diagnosis
Fluid Volume Deficit related to abnormal loss and/or decreased intake.
Nursing Objective
Patient’s vital sign, physical findings, and lab values are within
acceptable limits.
Interventions
1. Monitor vital sign, laboratory values, and input and output for
evidence of dehydration; measure weight daily. Check specific
gravity of urine.
2. As appropriate, encourage oral intake or administer prescribed

replacement solutions. Observe for indications of fluid overload
during rapid IV replacement.
3. Provide oral hygiene at frequent intervals.
4. Obtain accurate measurements of “third space” (interstitial) fluid

accumulation areas such as the abdomen and limbs. Measure
abdomen or limb(s) at the same place with each assessment. To
ensure accuracy, mark the measurement site with indelible ink, and
use the same tape measure for all assessments.
5. Position patient in supine with foot slightly elevated to allow blood

flow to the brain and the heart.
6. Teach patients on diuretic therapy, leg exercises and to rise up

slowly from bed.
3.3 Electrolyte (Osmolality) Disturbances
This disturbance affects both intracellular and extracellular

compartments. When osmolality in one compartment is altered water
shifts to balance the osmolality. Therefore both compartments become
equally increased or decreased.
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Sodium
Sodium is the major action of extracellular fluid and is primarily

responsible for osmotic pressure in that compartment. Normal serum
sodium concentration is approximately 137 – 14 me/L. Body water and
electrolyte regulation by the kidneys is based in part on sodium
concentration in the ECF. When ECF sodium concentration rises, the
kidneys attempt to maintain normal sodium concentration by retaining
water. When ECF water increases, sodium is retained. An elevated
serum sodium level (hypernatremia) usually reflects a relative ECF
water deficit rather than an increase in total body sodium. Hyponatremia
exists when the serum sodium concentration in a given amount of
plasma water falls below normal. Symptoms might not occur until the
serum sodium level is <120–125 mEq/L. Sodium is also important in
cellular functioning normal acid–base balance. Aldosterone, which is
secreted by the adrenal cortex, is essential in sodium regulation through
its effect on renal tubular reabsorption of sodium.
3.3.1 Hypernatremia: Increased Serum Osmolality
3.3.2 Causes
1. Decreased intake of water due to inability to respond to thirst,

such as in an unconscious state; less efficient functioning of the
thirst centre in the base of the brain, as is commonly seen with
the elderly.
2. Increased output of water from severe hypotonic fluid losses

through the GI and respiratory tracts.
3. Increased urinary water loss through osmotic diuresis, and

diabetes insipidus.
4. Increased intake of sodium from excessive administration of

concentrated electrolyte mixtures.
(1) Intense thirst

(2) flushed skin; dry
(3) Sticky mucous membranes
(4) Rough, reddened, dry tongue
(5) Elevated temperature
(6) Lost of skin tugor
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(7) Agitative behaviour such as restlessness, excitement,

convulsions; decreased reflexes;
oliguria or anuria.
Laboratory findings: Serum sodium >147 mEq/L, increased serum

osmolality, urine specific gravity >1.030 (except in diabetes insipidus).
The goal is to restore normal sodium concentration.
1. Replace water: Plain water given by mouth may be sufficient in the

early stages of sodium excess or if serum sodium <160 mEq/L; IV
infusion of hypotonic solution of water and electrolytes (5%Dextrose
water intravenously) in advanced stages or if serum sodium is >160
mEq/L. Note: Rapid reduction of serum sodium (serum osmolality)
may lead to cerebral edema, seizures, or death.
2. Administer diuretics by mouth with plain water.
3. Draw serum sodium levels q6h.
3.3.3 Nursing Care
Nursing Diagnosis
Fluid Volume Deficit related to abnormal (hypotonic) loss or decreased

intake.
Nursing Objective
acceptable limits.
Interventions
1. Monitor vital sign and input and output, and assess skin turgor and
mucous membranes for evidence of dehydration. Check urine
specific gravity and monitor serum sodium levels.
2. As appropriate, encourage oral fluids or administer prescribed fluid

replacement.
3. Administer diuretics, if prescribed.
4. Assess patient’s sensorium; institute seizure precautions and notify

doctor if significant findings are noted.
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3.4 Hyponatremia
1. Loss of sodium-containing fluids from vomiting, diarrhoea, profuse

diaphoresis, salt-losing nephropathy, adrenal insufficiency.
2. Excessive diuretic use together with reduced sodium intake.
3. Plasma-to-interstitial fluid shift in massive burns and trauma.
4. Impaired renal excretion of water as seen in renal failure, nephrotic

syndrome, CHF, and hepatic cirrhosis.
5. Increased intake of water, which dilutes serum sodium.
6. Excessive administration of electrolyte-free IV solutions, fresh-water

drowning, or compulsive polydipsia.
7. Secretion of inappropriate antidiuretic hormone (SIADH).
8. Loss from skin such as diaphoresis, large open lesion and burns
1. Include:
(1) Anorexia, nausea, vomiting

(2) Cold and clammy skin
(3) Postural hypotension
(4) Apprehension
(5) Seizures
(6) Headache
(7) Abdominal cramps.
2. Laboratory findings:
(1) Serum sodium below normal

(2) Urine specific gravity <1.010.
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The goal is to restore normal serum sodium levels as quickly as possible

without volume overload and to establish a definitive diagnosis to
determine appropriate therapy.
1. Replace salt and water orally in cases of mild deficit.

2. Provide parenteral replacement with 3–5% sodium chloride in water
if the deficit is severe.
3. Restrict water if the hyponatremia is dilutional.
3.4.3 Nursing Care
Nursing Diagnosis
Fluid volume deficit or excess related to abnormal fluid loss, increased

intake, or interstitial spacing of fluids.
Nursing Objective
Patient’s physical findings and lab values are within acceptable limits.
Interventions
1. Monitor input and output and weigh patient daily.

2. Monitor serial sodium levels.
3. Maintain fluid restrictions, or administer oral or parenteral fluids as
prescribed.
4. Provide safety measures as indicated for patients with altered LOC.
3.5 Potassium
Potassium is the major cation of intracellular fluid, and it plays a leading

role in cellular metabolic activities. It is essential for neuromuscular
function and is instrumental in maintaining normal cellular water
content. Potassium is not stored in the body, nor do the kidneys conserve
it. Most of the daily potassium intake is excreted in the urine, with only
small amounts lost through perspiration and faeces. Potassium excess
does not usually develop in the presence of normal renal function.
Although only 2% of body potassium is extracellular, serum potassium
concentration generally reflects total body potassium and is affected by
the pH of ECF. In acidosis, extracellular hydrogen is exchanged for
intracellular potassium. An opposite reaction occurs in alkalotic states.
The body is intolerant of fluctuations from normal serum potassium
concentration, which is 3.5–5.5 mEq/L; excess or deficit can cause a
medical crisis.
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3.5.1 Hyperkalemia (Potassium is >5.0mEq)
Causes
1. Decreased potassium excretion as seen in renal failure; adrenal

insufficiency (Addison’s disease).
2. Increased tissue breakdown, as in crush injuries, burns, major

surgery, rhabdomyolysis, severe hemolysis, or GI bleeding;
3. Excessive administration of potassium-containing IV solutions or

potassium supplements; potassium-sparing diuretics or
4. High doses of penicillin in patients with renal failure;
5. Massive transfusions of stored blood.
6. Redistribution of intracellular potassium resulting from metabolic

acidosis.
8. Neuromuscular: Irritability, weakness, paresthesia, muscular or

respiratory paralysis.
9. Nausea, diarrhoea, intestinal.
10. Weak heart muscle: Bradycardia, ventricular fibrillation.
11. Laboratory findings: Repeated serum potassium values >5.6 mEq/L.
12. EKG: Tall, peaked T-waves, development of wide, bizarre QRS

complexes culminating in ventricular fibrillation or asystole.
The goal is the rapid restoration of normal serum potassium levels.
1. Administer IV calcium gluconate or calcium chloride, 5–10 mL of a

10% solution, to quickly antagonize the toxic neuromuscular and
cardiac effects of hyperkalemia, particularly if hypocalcaemia is
present.
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2. Redistribute ECF potassium: IV injection of one ampule of sodium

bicarbonate, which causes rapid movement of potassium into the
cells; IV administration of hypertonic solutions of glucose and
regular insulin, which causes intracellular potassium shift. These are
temporary measures for the immediate reduction of serum potassium
until potassium removal can be effected by other means.
3. Perform dialysis to remove potassium from the blood.
4. Treat the underlying disease.
3.5.4 Nursing Care

Nursing Diagnosis
Ineffective breathing patterns related to restricted chest movement

secondary to impairment/paralysis of respiratory muscles.
Nursing Objective
Patient’s respiratory rate and depth are within acceptable limits
Interventions
1. Assess character, rate, and depth of respirations.
2. Reposition patient q2h to enhance aeration. Elevate head of bed to

facilitate respirations; ensure that patient deep breathes and coughs at
frequent intervals.
3. Suction airway if patient is unable to expectorate secretions.
Risk to Alterations in Cardiac Output
Decreased: Risk of dysrhythmias and cardiac arrest secondary to

hyperkalemia.
Desired Outcome
Patient’s VS and lab and physical findings are within acceptable limits.
1. Monitor EKG, cardiac rate and rhythm, and serial serum potassium
values. Notify MD if potassium levels exceed 6.0 – 6.6 mEq/L.
2. Administer IV calcium gluconate or calcium chloride as prescribed.
3. Administer prescribed IV or oral fluids and/or ion-exchange resins.
Knowledge Deficit
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Foods relatively high in potassium and diuretics that is potassium-

sparing.
Desired Outcome
Patient can verbalize knowledge of foods that are relatively high in

potassium and diuretics that are potassium-sparing.
1. Teach patient the importance of limiting dietary potassium intake.

2. As appropriate, teach patient about diuretics that spare potassium.
3.6 Hypokalemia
Causes
1. GI losses: Diarrhoea, vomiting, NG suctioning, intestinal or biliary

fistulas.
2. Urinary losses as occurs in renal tubular disorders, osmotic diuresis,

administration of potent diuretics, corticosteroid therapy.
3. Inadequate intake as seen in starvation, inadequate replacement

during diuretic therapy, prolonged administration of potassium-free
parenteral fluids.
1i. Fatigue
ii. Muscle weakness,
iii. Anorexia
iv. Nausea
v. Vomiting
vi. Decreased bowel sounds, paralytic ileus.
2. Heart arrythimas.
3. Laboratory findings: Repeated serum potassium <3.5 mEq/L.
4. On EKG: There is prolonged P–R interval, flattened or inverted
T waves, S–T segment depression, and prominent U wave.
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The goal is to replenish potassium without inducing hyperkalemia.
1. Administer oral potassium through dietary intake of potassium-rich

foods or give oral potassium supplements in liquid, tablet, or powder
form.
2. Administer IV potassium chloride if hypokalemia is severe.
Knowledge Deficit
Foods high in potassium and diuretics that spare potassium.
Nursing Objective
Patient can verbalize knowledge of foods that are high in potassium and
diuretics that spare potassium.
Interventions
1. Teach patient the importance of eating foods in potassium.

2. Give diuretics that spare potassium.
Risk for Alterations in Cardiac Output
Decreased: Risk of dysrhythmias secondary to hypokalemia.
Desired Outcome
Patient’s vital sign and laboratory and physical findings are within
acceptable limits.
1. Monitor vital sign. Assess cardiac rate and rhythm, noting character
and intensity of pulse and heart tones.
2. Monitor serum potassium levels. Especially if below, notify MD if K

+ is below 3.5 mEq/L.
3. Administer oral potassium supplements with a lot of 4 ounces of

water or fruit juice to minimize gastric irritation.
4. Where necessary, administer prescribed parenteral potassium

supplements.
3.7 Calcium
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Calcium serum level is controlled by hormonal activity of the

parathyroid glands and is inversely related to phosphate levels. Calcium
is necessary for the formation of bones and teeth, blood clotting,
maintenance of the normal transmission of nerve impulses, and muscle
contraction. Sufficient vitamin D and protein are required for normal
calcium utilization. Approximately half the circulating calcium is bound
to albumin; the rest is ionized (free).
Hypercalcemia refers to excess calcium. Hypocalceamia refers to

calcium deficiency.
3.7.1 Hypercalcemia
Causes
1. Excessive administration of vitamin D

2. Prolonged immobility
3. Multiple fractures
4. Osteoporosis
5. Osteomalacia
6. Ingestion of excessive amounts of dietary calcium and/or
calcium-containing antacids.
1. Anorexia
2. Nausea
3. Vomiting
4. Pathologic fractures
5. Deep bone pain
6. Flank pain (related to kidney stone formation).
7. Relaxed skeletal muscles
8. Personality changes
9. Lethargy
10. Stupor
11. Coma
12. Laboratory findings: Repeated serum calcium levels >5.8 mEq/L
13. EKG: Shortening of Q–T interval
14. Radiographic findings: Generalized osteoporosis, urinary calculi,
bone cavitation
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The goal is to restore normal serum calcium levels.
1. Promote renal calcium excretion: Rapidly infuse saline solution to

induce calcium diuresis (sodium inhibits tubular reabsorption of
calcium) and diuretics to prevent volume excess; replace urinary
water, sodium, and potassium losses.
2. Restrict calcium intake.
3. Administer steroids to inhibit intestinal absorption of calcium and

reduce inflammation and associated calcium-mobilizing stress
response.
4. Administer calcitonin subcutaneously or intramuscularly to reduce

serum calcium levels temporarily when hypocalcaemia is caused by
increased parathyroid hormone (PTH).
5. Monitor serial serum calcium values.
Alteration in Pattern of Urinary Elimination
Dysuria, urgency, or frequency related to presence of renal calculi.
Nursing Objective
Patient relates the return of a normal voiding pattern.
Interventions
1. Encourage early mobility to prevent further mobilization of

calcium from the bones.
2. If patient is on bed rest, assist with ROM exercises.
3. Turn patient q2h, and encourage gastrocnemius, gluteal, and

quadriceps muscle-setting exercises.
4. Administer prescribed fluids and medications, and encourage oral

fluid intake to dilute urinary calcium, which can result in kidney
stones.
5. Monitor I&O and serum calcium levels.
6. Strain all urine to check for renal stones.
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7. Teach patient to avoid foods and medications high in calcium

(e.g., cheese, milk, spinach, eggs, peanuts, oysters, and calcium-
containing antacids).
3.8 Hypocalcemia
Causes
Loss of calcium-rich secretions through diarrhoea or wound exudates.
3.8.1 Clinical manifestation
1. Muscle cramps, paresthesia, numbness and tingling of the fingers,

tetany.
2. Cardiovascular: Hypotension, bleeding if hypocalcemia is

severe.
3. Laboratory findings: Repeated serum calcium values <4.5 mEq/

L or 8.5 mg/dL (provided that albumin level is within normal
range).
4. EKG: Prolonged Q–T interval.
The goal is to restore serum calcium level to normal with minimal

hypercalciuria.
1. Administer IV calcium: 100–200 mg calcium (10–20 mL 10%

calcium gluconate) over 10–15 minutes in acute symptomatic
hypocalcemia, followed by IV administration of 600–800 mg
calcium gluconate in 1000 mL D5W (5% dextrose in water), which is
titrated until the need can be met orally.
2. Administer oral calcium supplements in less acute conditions.
3. Administer Vitamin D to enhance calcium absorption from the GI

tract.
4. Monitor serial serum calcium.
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Potential for injury related to increased risk of seizure activity

secondary to hypocalcemia.
Nursing Objective
Patient’s physical findings are within acceptable limits.
Interventions
1. Administer prescribed calcium, Vitamin D, and magnesium

supplements. Teach patient about foods containing calcium.
2. Observe patient for (1) numbness and tingling around the mouth, an
early indicator or hypocalcemia, (2) signs and symptoms of tetany:
muscle twitching, facial spasms, and painful tonic muscles spasms.
3. Monitor serum calcium values.
4. Assess for carpopedal spasm when blood supply to hand is

decreased.
5. Assess spasm of lip and cheek when the facial nerve is tapped.
6. If significant findings are noted notify doctor.
4.0 CONCLUSION
Almost all medico surgical condition threatened fluid and electrolyte

balance. There may be deficit or excesses of water or any electrolyte.
5.0 SUMMARY
• Sodium, pottasium, calcium and magnesium are major electrolyte in

the body.
• The Buffer systems in the body are haemoglobin, protein carbonic

acid con and bicarbonate con.
• The normal PH of the body is slightly alkaline – 7.30 – 7.45.
Discuss the functions of fluids and electrolytes to the body system.

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Brunner & Suddarth (2004). Medical Surgical Nursing. (10th ed)

Lippincott Wilkins.
Barbara C, Long and Wilma J. Phipps 1985). Essentials of Medical-

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UNIT 3 ACID BASE IMBALANCE
CONTENTS
1.0 Introduction
2.0 Objectives
3.0 Main Content
3.1 Acids
3.1.1 Bases
3.2 Maintenance of Acid–Base Balance
3.3 Acid –Base Imbalance
3.4 Components of Arterial Blood Gases
3.5 Respiratory Acidosis
3.5.1 Causes
3.5.4 Nursing Diagnoses and Interventions
3.6 Metabolic Acidosis
3.6.1 Causes
3.7 Respiratory Alkalosis
3.7.1 Causes
3.8 Metabolic Alkalosis
3.8.1 Causes
3.8.3 Medical management
3.8.4 Nursing diagnoses
3.9 Parental Fluid Therapy
3.9.1 Purpose
3.9.2 Types of IV Solutions
3.9.3 Other IV Substances
3.9.4 Nursing Management
3.9.5 Venipuncture Devices
3.9.6 Factors Affecting Flow
3.9.7 Guidelines for Starting an Intravenous
3.9.9 Complications
4.0 Conclusion
5.0 Summary
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1.0 INTRODUCTION
The human body maintains a relatively constant internal environment, of

which the balance between acids and bases is one vital aspect.
Optimally, cellular processes occur within a narrow range of pH values
(concentration of free hydrogen ions). When an imbalance occurs,
compensatory mechanisms engage to bring the pH into normal range.
Arterial blood gas (ABG) analysis is a clinical tool that can reveal a
variety of acid–base disturbances. Arterial blood is slightly alkaline
solution with a normal pH range of 7.35 – 7.45. A decrease in the pH
below approximate 6.8 or above 7.8 is incompatible with life. A variety
of homeostatic mechanism interact to maintain the pH with normal limit
2.0 OBJECTIVES
• explain the role of the kidney lungs and chemical buffers in

maintaining acid-base balance
• compare metabolic acidosis and alkalosis with regard to causes,
clinical manifestations, diagnosis, and management
• compare respiratory acidosis and alkalosis with regard to causes,
clinical manifestations, diagnosis, and management
• interpret arterial blood gas measurements
• demonstrate a safe and effective procedure of venipuncture
• describe the measures used for preventing complications of
intravenous therapy.
3.0 MAIN CONTENT
3.1 Acids
There are two categories of acid found in the body: nonfixed (volatile)
and fixed (nonvolatile).
1. Nonfixed Acids
These are acids that can change easily between a liquid and gas state.
Carbonic acid (carbon dioxide dissolved in water) is the most prevalent
nonfixed acid and is primarily controlled and excreted by the respiratory
system.
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2. Fixed Acids
These are produced by metabolic processes within the body and

buffered and excreted by the kidneys. The three predominant categories
include the following:
i. Sulfuric, phosphoric, and other acids that are produced from dietary
intake.
ii. Lactic acid, produced by RBCs, WBCs, skeletal muscles, and the
brain, and during periods of anaerobic metabolism (e.g., vigorous
exercise, cardiac/respiratory arrest).
iii. Ketoacids, produced as byproducts of fatty acid oxidation. Fatty

acids are an alternate energy source for cell metabolism in glucose-
deficient states such as starvation and insulin-deficient states such
as diabetes mellitus.
3.1.1 Bases
These are substances that are capable of accepting free hydrogen ions.
Bicarbonate is the body’s predominate base.
3.2 Maintenance of Acid–Base Balance
There are three ways the body maintains acid–base balance: the buffer
system response, respiratory response, and renal response:
Buffer System Response
A buffer is a combination of two or more compounds that can combine

either with acids or bases to maintain pH. One common combination is
carbonic acid and sodium bicarbonate. Others are the plasma proteins,
hemoglobin, phosphate, and ammonium complexes. A buffer may be
regarded as a chemical sponge.
Respiratory System Response
This involves the change in rate and depth of ventilation. Increased

respirations will cause CO2 levels to decrease, and decreased
respirations will increase CO2 levels.
Renal Response
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Kidney excretes varying amounts of acid or base thus controlling the

body’s PH. Controlling base bicarbonate does this. Excess hydrogen is
excreted in urine. The kidney also excretes more or less bicarbonate to
achieve balance. This occurs over a 2–3-day period and is the slowest of
the three responses.
3.3 Acid –Base Imbalance
Body fluids are maintained within a PH range of 7.35 to 7.45. Imbalance

in the PH of the body leads to acidosis or alkalosis. There are two
categories of acid–base imbalance. These are respiratory and metabolic
acidosis.
a. Respiratory acidosis: This is caused by clinical situations that

interfere with pulmonary gas exchange, causing retention of CO2
and increase in the blood carbonic acid. Two major conditions
that can cause respiratory acidosis are central nervous system
depression and obstructive pulmonary disease.
b. Respiratory alkalosis: This is the result of lack of carbonic acid

due to hyperventilation as in fever and anxiety.
c. Metabolic acidosis: This occurs because of high acid content in

extracellular fluid and low base bicarbonate. This is characterized
by deep and rapid breathing as the lungs exhale more CO2 and the
kidneys excrete hydrogen and urine becomes acidic. This is seen
in diarrhoea, vomiting, diabetes mellitus etc.
d. Metabolic alkalosis: It occurs when the level of base bicarbonate

is high. This may be caused by ingestion of large amounts of
sodium bicarbonate or by the loss of chloride through vomiting or
gastric suction.
3.4 Components of Arterial Blood Gases
Normal Values for Arterial Blood Gases
pH––7.40 range 7.38–7.42

Paco2––40 mm Hg range 36–44
HCO3––24 mEq/L range 22–26
Pao2––90 mm Hg range 80–100 (room air)
1. pH: The concentration of hydrogen and hydroxyl ions in

equivalents per liter, or in the commonly known scale of pH. An
increase in hydrogen ions will cause a more acidic environment,
and a decrease will cause a more alkaline environment. pH is
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inversely proportional to the number of hydrogen ions. As they

increase in number, the pH decreases (acidosis occurs); as they
decrease in number, pH increases (alkalosis occurs).
2. Paco2: The partial pressure of dissolved CO2 in arterial blood.

Along with water, CO2 is an end-product of cell metabolism;
therefore, Paco2 can be considered an index of the effectiveness
of ventilation in relation to the metabolic rate. Carbon dioxide is
highly soluble and can rapidly diffuse into plasma to form
carbonic acid, which breaks down to form hydrogen and
bicarbonate ions. The formation of hydrogen and bicarbonate
ions plays an important role in diffusing O2 and CO2 in the lungs
and in maintaining electrical neutrality within the RBCs.
3. HCO3: The measurement of bicarbonate ion concentration in the

blood. The bicarbonate system is the major and most immediate
buffer response. Bicarbonate is a base, and is capable of
accepting hydrogen ions. Increased amounts of bicarbonate or
other bases can cause an alkaline environment. The kidneys
regulate bicarbonate excretion and reabsorption.
4. Pao2: The partial pressure of dissolved oxygen in arterial blood.

Oxygen is dissolved and carried in the plasma and combined with
hemoglobin in the RBCs. Hemoglobin plays a key role in the
transport of CO2 and O2 from the lungs and tissue. Generally,
hemoglobin has a strong affinity for oxygen, but this affinity can
be altered by hydrogen ion concentration, CO2 concentration, and
body temperature.
3.5 Respiratory Acidosis
3.5.1 Causes
Reduced ventilation states found with respiratory arrest, head/brain

trauma, pneumonia, hypoventilation caused by sedation or anesthesia,
atelectasis, Guillain-Barre syndrome, chronic obstructive pulmonary
disease (COPD).
Early signs include weakness, headache, fatigue, anxiety, and tremors.

Progressive signs include dehydration and confusion, leading ultimately
to coma if untreated.
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a. Find the cause to determine appropriate treatment.

b. Administer bicarbonate.
c. Begin antibiotic therapy for patients with pneumonia.
d. Administer naloxone hydrochloride for patients who are oversedated.
e. Replace potassium chloride (because acidosis causes potassium ions
to leave and hydrogen ions to enter the cells).
3.5.4 Nursing Diagnoses and Interventions
Potential alteration in respiratory function related to prolonged

inactivity and/or omission of deep breathing,
Ineffective Breathing Pattern related to decreased respiratory depth

secondary to anesthesia, immobility, and guarding with painful surgical
incision.
(These are only a few examples of related nursing diagnoses.)
3.6 Metabolic Acidosis
3.6.1 Causes
Build up of fixed acids, as in cardiac arrest, renal failure, keto-acidosis,

or ingestion of acidic substances; loss of base, as in diarrhoea.
Kussmaul’s respirations, dehydration, lethargy, malaise, fatigue, nausea/

vomiting, headache, SOB, vasodilatation, tremors, coma.
i. Find the cause to determine appropriate treatment.

ii. If ketoacidosis is the cause, administer glucose, insulin, or IV
potassium chloride.
iii. Replace fluid losses.
iv. Administer bicarbonate.
v. If renal failure is the cause, prescribe diet low in protein and high
in carbohydrates.
vi. Replace phosphates.
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Fluid Volume Deficit related to abnormal losses.
Nursing Objective
acceptable limits.
Nursing Intervention
1. Monitor input and output and vital sign; evaluate laboratory results
for abnormal values of glucose and potassium; monitor EKG for
evidence of cardiac dysrhythmias.
2. Assess for signs of dehydration and decreased sensorium.
3. Test urine pH and specific gravity.
4. Encourage intake of fluids and/or administer fluids such as IV lactate

and NaHCO3 as prescribed.
5. Institute seizure precautions if patient exhibits signs of decreased

sensorium.
3.7 Respiratory Alkalosis
3.7.1 Causes
Hyperventilation states, as in mechanical overventilation, pain, anxiety,

brain injury, fever, pulmonary edema, acute asthma.
Dizziness, lethargy, weakness, tingling, spasms, tetany, anxiety.
b. Decrease ventilations, for example, with sedation or rebreathing

apparatus.
c. Replace sodium and/or chloride.

d. Replace potassium chloride.
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Ineffective-breathing patterns related to hyperventilation.
Nursing objective
Patient’s respiratory rate and depth are within acceptable limits.
Nursing intervention
1. Monitor vital signs...

2. Place patient in semi-fowler’s position to enhance ventilation.
3. Allay patient’s anxieties.
4. Sedate patient as prescribed.
3.8 Metabolic Alkalosis
3.8.1 Causes
This is caused by the build up of bicarbonate or base by ingestion of

bicarbonate in the form of antacids; loss of chloride or hydrogen ions as
with long-term NG suctioning, diuretic therapy, and/or vomiting; and
corticosteroid treatment.
Dizziness, lethargy, weakness, dyshythmias, tetany, hypoventilation,

convulsions, irritability, disorientation.

b. Replace fluids; administer intravenous fluids.
c. Replace potassium, sodium, and/or chloride, if needed.
d. Administer acetazolamide to increase excretion of HCO3.
Fluid volume deficit related to abnormal losses.
Nursing Objective
acceptable limits.
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1. Monitor input and output; monitor for indicators of hypokalemia,

such as dysrhyhmias and tetany.
2. Ensure minimal bicarbonate administration or ingestion.
3. Administer potassium chloride, sodium chloride, and fluids as

prescribed.
4. Use saline rather than water to irrigate NG tube.
5. Institute seizure precautions if indicated.
3.9 Parental Fluid Therapy
Intravenous fluid administration is performed in the hospital, out patient

diagnostic and surgical settings, clinics, and home to replace fluids,
administer medications, and provide nutrients when no other route is
available.
3.9.1 Purpose
Generally, intravenous fluids are administered to achieve one or more of

the following goals.
• To provide water, electrolytes, and nutrients to meet daily

requirements.
• To replace water and correct electrolyte deficits.
• To administer medications and blood products.
3.9.2 Types of IV Solutions
Solutions are often categorized as isotonic, hypotonic, or hypertonic,

according to whether their total osmolality is the same as, less than, or
greater than that of blood.
Isotonic Fluids
Fluids that are classified as isotonic have a total osmolality close to that
of the ECF and do not cause red blood cells to shrink or swell. The
composition of these fluids may or may not approximate that of the
ECF.
D5 W
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A solution of D5W has a serum osmolality of 252 mOsm/L. Once

administered, the glucose is rapidly metabolized, and this initially
isotonic solution then disperses as a hypotonic fluid, one-third
extracellular and two-thirds intracellular. During fluid resuscitation, this
solution should not be used because it can cause hyperglycemia.
Therefore, D5W is used mainly to supply water and to correct an
increase serum osmolality.
Normal Saline Solution
Normal saline (0.9% sodium chloride) solution has a total osmolality of

308 mOsm/L. Because the osmolality is entirely contributed by
electrolytes, the solution is often used to correct an excellular volume
deficit. Although referred to as “normal,” it contains only sodium and
chloride and does not actually simulate the ECF. It is used with
administration of blood transfusions and to replace large sodium losses,
as in burn injuries. It is not used for heart failure, pulmonary edema,
renal impairment, or sodium retention. Normal saline does not supply
calories.
Several other solutions contain ions in addition to sodium and chloride

and are somewhat similar to the ECF in composition. Lacnated Ringer’s
solution contains potassium and calcium in addition to sodium chloride.
It is used to correct dehydration and sodium depletion and replace GI
losses. Lactated Ringer’s solution contains bicarbonate precursors as
well.
Hypotonic Fluids
One purpose of hypotonic solutions is to replace cellular fluid, because

it is hypotonic as compared with plasma. Another is to provide free
water for excretion of body wastes. At times, hypotonic sodium
solutions are used to treat hypernatremia and other hyper-osmolar
conditions. Excessive infusions of hypotonic solutions can lead to
intravascular fluid depletion, decreased blood pressure, cellular edema,
and cell damage. These solutions exert less osmotic pressure than the
ECF.
Hypertonic Fluids
Higher concentrations of dextrose, such as 50% dextrose in water, are

administered to help meet caloric requirements. These solutions are
strongly hypertonic and must be administered into central veins so that
they can be diluted by rapid blood flow.
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3.9.3 Other IV Substances
When the patient’s GI tract is unable to tolerate food, nutritional

requirements are often met using the IV route. Parental solutions may
include high concentrations of glucose, protein, or fat to meet nutritional
requirements. The parenteral route may also be used to administer
colloids, plasma expanders, and blood products. Examples of blood
products include whole blood, packed red blood cells, albumin, and
cryoprecipitate. The IV route also delivers many medications, either by
infusion or directly into the vein. Because IV medications enter the
circulation rapidly, administration by this route is potentially very
hazardous. All medications can produce adverse reactions; however,
medications given by the IV route can cause these reactions within 15
minutes after administration because the medications are delivered
directly into the bloodstream. Administration rates and recommended
dilutions for individual medications are available in specialized texts
pertaining to IV medications and in manufacturers’ package inserts;
these should be consulted to ensure safe IV administration of
medications.
3.9.4 Nursing Management
Choosing an IV Site
Many sites can be used for IV therapy. Because they are relatively safe
and easy to enter, arm veins are most commonly used (Fig. 1). The
metacarpal, cephalic, basilic, and median veins as well as their branches
are recommended sites because of their size and ease of assess. Ideally,
both arms and hands are carefully inspected before choosing a specific
venipuncture site that does not interfere with mobility. For this reason,
the antecubital fossa is avoided, except as a last resort. The following
are factors to consider when selecting a site for venipuncture:
1. Condition of the vein

2. Type of fluid or medication to be infused
3. Duration of therapy
4. Patient’s age and size
5. Whether the patient is right- or left-handed
6. Patient’s medical history and current health status
7. Skill of the person performing the venipuncture.
After applying a tourniquet, the nurse palpates and inspects the vein.
The vein should feel firm, elastic, engorged, and round not hard, flat, or
bumpy. Because arteries lie close to veins in the antecubital fossa, the
vessel should be palpated for arterial pulsation (even with a tourniquet
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on), and cannulation of pulsating vessels should be avoided. General

guidelines for selecting a cannula include:
1. Length: ¾ to 1.25 inches long
2. Diameter: narrow diameter of the cannula to occupy minimal

space within the vein
3. Gauge: 20 to 22 gauge for most Intravenous fluids; a larger

gauge caustic or viscous solutions; 14 to 18 gauge for blood
administration and for trauma patients and those undergoing
surgery
Hand veins are easiest to cannulate. The tips should not rest in a flexion
area (e.g., the antecubital fossa) as this could inhibit the IV flow.
3.9.5 Venipuncture Devices
Equipment used to gain access to the vasculatute includes cannulas,

needleless IV delivery systems, and peripherally inserted central catheter
or midline catheter access lines.
Cannulas. Most peripheral access devices are cannulas. They have an

obturator inside a tube that is later removed. “Catherer” and “Cannula”
are terms that are used interchangeably. The main types of cannula
devices available are those referred to as winged infusion sets (butterfly)
with a steel needle or as an over-the-needle catheter with wings
indwelling plastic cannulas inserted through a steel needle. Scalp vein or
butterfly needles are short steel needles with plastic wing handles. These
are easy to insert, but they are small and nonpliable.
Preparing the IV Site
Before preparing the skin, the nurse should ask the patient if he or she is
allergic to latex or iodine, products commonly used in preparing for IV
therapy. Excessive hair at the selected site may be removed by clipping
to increase the visibility of the veins and to facilitate insertion of the
cannula and adherence of dressings to the IV insertion site. Because
infection can be a major complication of IV therapy, the IV device, the
fluid, the container, and the tubing must be sterile. The insertion site is
scrubbed with a sterile pad soaked in 10% povidone-iodine (Betadine)
or chlorhexidine gluconate solution for 2 to 3 minutes, working from the
center of the area to the periphery and allowing the area to air day. The
site should not be wiped with 70% alcohol because the alcohol negates
the effect of the disinfecting solution. (Alcohol pledgets are used for 30
seconds instead, only if the patient is allergic to iodine.) The nurse must
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perform hand hygiene and put on gloves. Nonsterile disposable gloves

must be worn during the venipuncture procedure because of the
likelihood of coming into contact with the patient’s blood.
3.9.6 Factors Affecting Flow
The flow of an IV infusion is governed by the same principles that

govern fluid move in general.
1. Flow is directly proportional to the height of the liquid column.

Raising the height of the infusion container may improve a
sluggish flow.
2. Flow is directly proportional to the diameter of the tubing. The

clamp on Ivtubing regulates the flow by changing the tubing
diameter. In addition, the flow is faster through large-gauge
rather than small-gauge cannulas.
3. Flow is inversely proportional to the length of the tubing. Adding

extension tubing to an IV line will decrease the flow.
4. Flow is inversely proportional to the viscosity of a fluid. Viscous

IV solutions, such as blood, require a larger cannula than do
water or saline solutions.
3.9.7 Guidelines for Starting an Intravenous
Nursing Rationale
Preparation
1. Verify prescription for IV therapy, 1. Serious errors can be avoided by
check solution label, and identify careful checking.
patient.
2. Explain procedure to patient. 2. Knowledge increases patient

comfort and cooperation.
3. Carry out hand hygiene and put on 3. Asepsis is essential to prevent
disposable nonlates gloves. infection. It Prevents exposure of
nurse to patient’s blood and of
patient and nurse to latex.
4. Apply a tourniquet 4–6 inches above 4. This will distend the veins and
the site and identify a suitable vein. allow them to be visualized.
5. Careful site selection will
5. Choose site. Use distal veins of hands increase likelihood of successful
and arms first. venipuncture and preservation of
vein. Using distal sites first
preserves sites proximal to the
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previously cannulated site for

subsequent venipunctures. Veins
of feet and lower extremity
should be avoided due to risk of
thrombophiebitis. (In
consultation with the physician,
the suphenous vein of the ankle
or dorsum of the foot may
6. Choose IV cannula or catheter. occasionally be used.)
6. Length and gauge of cannula
should be appropriate for both
site and purpose of infusion. The
shortest gauge and length needed
7. Connect infusion bag and tubing and to deliver prescribed therapy
run solution through tubing to displace should be used.
air; cover end of tubing. 7. Prevent delay; equipment must be
ready to connect immediately
after successful venipuncture to
8. Raise bed to comfortable working prevent clotting.
height and position for patient; adjust 8. Proper positioning will increase
lighting. Position patient’s arm below likelihood of success and provide
heart level to encourage capillary comfort for patient.
filling. Place protective pad on bed
under patient’s arm.
Procedure
1. Depending on agency policy and 1. Reduces pain locally from
procedure, lidocaine 1% (without procedure and decreases anxiety
epinephrine) 0.1–0.2 ml may be about pain.
injected locally to the IV site or a
transdermal analgesic cream (EMLA)
may be applied to the site 60 minutes
before IV placement or blood
withdrawal. Intradermal injection of
bacteriostatic 0.9% sodium chloride
may have local anesthetic effect.
2. Question the patient carefully about 2. Reduces risk of allergic reaction.

sensitivity to latex; use blood-pressure
cuff rather than latex tourniquet if
there is possibility of sensitivity.
3. The tourniquet distends the vein
3. Apply a new tourniquet for each and makes it easier to enter; it
patient or a blood pressure cuff 15 to should never be tight enough to
20 cm (6–8 in) above injection site. occlude arterial flow. If a radial
Palpate for a pulse distal to the pulse cannot be palpated distal to
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tourniquet. Ask patient to open and the tourniquet, it is too tight. A

close fist several times or position new tourniquet should be used for
patient’s arm in a dependent position each patient to prevent the
to distend a vein. transmission of microorganisms.
A blood pressure cuff may be
used for elderly patients to avoid
rupture of the veins. A clenched
fist encourages the vein to
become round and turgid.
Positioning the arm below the
level of the patient’s heart
promotes capillary filling. Warm
4. Ascertain if the patient is allergic to packs can promote vasodilatation
iodine. Prepare site by scrubbing with as well.
chlorhexidine gluconate or povidone- 4. Strict asepsis and careful site
iodine swabs for 2 – 3 min in circular preparation are essential to
motion, moving outward for injection prevent infection.
site. Allow to dry.
a. If the site selected is
excessively hairy, clip hair.
(Check agency’s policy and
procedure about this practice.)
b. 70% isoprophyl alcohol is an
alternative solution that may be
used.
5. With hand not holding the venous
access device, steady patient’s arm and 5. Applying traction to the vein
use finger or thumb to pull skin taut helps to stabilize it.
over vessel.
6. Holding needle bevel up and at 5°–25°
angle, depending on the depth of the 6. Bevel-up position usually
vein, pierce skin to reach but not produces fewer traumas to skin
penetrate vein. and vein. A superficial vein
needs a smaller cannula angle
7. Decrease angle of needle further until and a vein deeper in
nearly paralled with skin, then enter subcutaneous tissue requires a
vein either directly above or from the greater cannula angle.
side in one quick motion. 7. Two-stage procedure decreases
chance of thrusting needle
through posterior wall of vein as
skin is entered. No attempt
should be made to reinsert the
8. It backflow of blood is visible, stylet because of risk of severing
straighten angle and advance needle. or puncturing the catheter.
Additional steps for catheter inserted 8. Backflow may not occur if vein
over needle: is small; this position decreases
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e. Advance needle 0.6 cm (¼ – ½ chance of puncturing posterior

in) after successful wall of vein.
venipuncture. a. Advancing the needle slightly
f. Hold needle hub, and slide makes certain the plastic
catheter over the needle into the catheter has entered the vein.
vein. Never reinsert needle into b. Reinsertion of the needle or
a plastic catheter or pull the pulling the catheter back can
catheter back into the needle. sever the catheter, causing
g. Remove needle while pressing catheter embolism.
lightly on the skin over the c. Slight pressure prevents
catheter tip; hold catheter hub in bleeding before tubing is
place. attached.
9. Infusion must be attached

9. Release tourniquet attaches infusion promptly to prevent clotting of
tubing; open clamp enough to allow blood in cannula. After two
drip. unsuccessful attempts at
venipuncture, assistance by a
more experienced health care
provider is recommended to
avoid unnecessary trauma to the
patient and the possibility of
limiting future sites for vascular
access.
10. The gauze acts as a sterile field.
10. Slip a sterile 2-in x 2-in gauze pad
under the catheter hub. 11. A stable needle is less likely to
11. Anchor needle firmly in place with become dislodged or to irritate
tape. the vein.
12. Tape encircling extremity can act
12. Cover the insertion site with a as a tourniquet.
transparent dressing, bandage, or
sterile gauze; tape in place with
nonallergenic tape but do not encircle 13. The loop decreases the chance of
extremity. inadvertent cannula removal if
13. Tape a small loop of IV tubing onto the tubing is pulled.
dressing. 14. Transparent dressings allow
assessment of the insertion site
14. Cover the insertion site with a dressing for phlebitis, infiltration, and
according to hospital policy and infection without removing the
procedure. A gauze or transparent dressing.
dressing may be used. 15. Labelling facilitates assessment
15. Label dressing with type and length of and safe discontinuation.
cannula, date, time, and initials. 16. Secures cannula placement and
16. A padded, appropriate-length arm allows correct flow rate
board may be applied to an area of (neurovascular checks assess
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flexion (neurovascular checks should nerve, muscle, and vascular

be performed frequently). function to be sure function is
not affected by immobilization).
17. Circulate infusion rate and regulate 17. Infusion must be regulated
flow of infusion. For hourly IV rate carefully to prevent over infusion
use the following formular: gtt/mL of or under infusion. Calculation of
infusion set/60 (min in hr) total hourly the IV rate is essential for the
vol=gtt/min. safe delivery of fluids. Safe
administration requires
knowledge of the volume of
fluid to be infused, total infusion
time, and the calibration of the
18. Document site, cannula size and type, administration set (found on the
the number of attempts at insertion, IV tubing package; 10, 12, 15, or
time, solution, IV rates, and patient 60 drops to deliver 1 mL of
response to procedure. fluid).
18. Documentation is essential to
promote continuity of care.
3.9.8 Complications
IV therapy predisposes the patient to numerous hazards, including both

local and systemic complications. Systemic complications occur less
frequently but are usually more serious than local complications. They
include circulatory overload, are embolism, febrile reaction, and
infection.
Fluid Overload
Overloading the circulatory system with excessive intravenous fluids

causes increased blood pressure and central venous pressure. Signs and
symptoms of fluid overload include moist crackles on auscultation of the
lungs, edema, weight gain, dyspnea, and respirations that are shallow
and have an increased rate. Possible causes include rapid infusion of an
IV solution or hepatic, cardiac, or renal disease. The risk for fluid
overload and subsequent pulmonary edema is especially increased in
elderly patients with cardiac disease; this is referred to as circulatory
overload. The treatment for circulatory overload is decreasing the IV
rate, monitoring vital signs frequently, assessing breath sounds, and
placing the patient in a high Fowler’s position. The physician is
contacted immediately. This complication can be avoided by using an
infusion pump for infusions and by carefully monitoring all infusions.
Complications of circulatory overload include heart failure and
pulmonary edema.
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Air Embolism
The risk of air embolism is rare but ever-present. It is most often

associated with cannulation of central veins. Manifestations of air
embolism include dyspnea andcyanosis; hypotension; weak, rapid pulse;
loss of consciousness; and chest, shoulder, and low back pain.
Treatment calls for immediately clamping the cannula, placing the
patient on the left side in the Trendelenburg position, assessing vital
signs and breath sounds, and administering oxygen. Air embolism can
be prevented by using a Luer-Lok adapter on all lines, filling all tubing
completely with solution, and using an air detection alarm on an IV
pump. Complications of air embolism include shock and death. The
amount of air necessary to induce death in humans is not known;
however, the rate of entry is probably as important as the actual volume
of air.
Septicemia and Other Infection
Pyrogenic substances in either the infusion solution or the IV

administration set can induce a febrile reaction and septicemia. Signs
and symptoms include an abrupt temperature elevation shortly after the
infusion is started, backache, headache, increased pulse and respiratory
rate, nausea and vomiting, diarrhoea, chills and shaking, and general
malaise. In severe septicemia, vascular collapse and septic shock may
occur. Cause of septicemia includes contamination of the IV product or
a break in aseptic technique, especially in immunocompromised
patients. Treatment is symptomatic and includes culturing of the IV
cannula, tubing, or solution if suspect and establishing a new IV site for
medication or fluid administration.
Infiltration and Extravasation
Infiltration is the unintentional administration of a nonvesicant solution

or medication into surrounding tissue. This can occur when the IV
cannula dislodges or perforates the wall of the vein. Infiltration is
characterized edema around the insertion site, leakage of Intravenous
fluid from insertion site, discomfort and coolness in the area of
infiltration, and a significant decrease in the flow rate. When the
solution is particularly irritating, sloughing of tissue may result. Closely
monitoring of the insertion site is necessary to detect infiltration before
it becomes severe.
Phlebitis
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Phlebitis is defined as inflammation of a vein related to a chemical or

mechanical irritation, or both. It is characterized by a reddened, warm
area around the insertion site or along the vein, and swelling.
Treatment consists of discontinuing the IV and restarting it in another
site, and applying a warm, moist compress to the affected site. Phlebitis
can be prevented by using aseptic technique during insertion, using the
appropriate-size cannula or needle for the vein, considering the
composition of fluids and medications when selecting a site, observing
the site hourly for any complications, anchoring the cannula or needle
well, and changing the IV site according to agency policy and
procedures.
Hematoma
Hematoma results when blood leaks into tissues surrounding the IV

insertion site. Leakage can result from perforation of the opposite vein
wall during venipuncture, the needle slipping out of the vein, and
insufficient pressure applied to the site after removing the needle or
cannula. The signs of a hematoma include ecchymosis, immediate
swelling at the site, and leakage of blood at the site.
Treatment includes removing the needle or cannula and applying

pressure with a sterile dressing; applying ice for 24 hours to the site to
avoid extension of the hematoma and then a warm compress to increase
absorption of blood; assessing the sites; and restarting the line in the
other extremity if indicated. A hematoma can be prevented by carefully
inserting the needle and using diligent care when a patient has a
bleeding disorder, takes anticoagulant medication, or has advanced liver
disease.
4.0 CONCLUSION
The balance between acids and bases is one vital mechanism that the
body uses to maintain internal homeostasis. When an imbalance occurs,
compensatory mechanisms engage to bring the pH into normal range.
Arterial blood gas (ABG) analysis is a clinical tool that can reveal a
variety of acid–base disturbances.
5.0 SUMMARY
• Intravenous fluids are administered to provide water, electrolytes,

and nutrients to meet daily requirements and to administer
medications and blood products.
• IV Solutions are often categorized as isotonic, hypotonic, or
hypertonic, according to whether their total amorality is the same as,
less than, or greater than that of blood.
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• There are three ways the body maintains acid–base balance: the
buffer system response, respiratory response, and renal response
Barbara C, Long and Wilma J. Phipps (1985). Essentials of Medical-

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UNIT 4 INFLAMMATION
CONTENTS
1.0 Introduction
2.0 Objectives
3.0 Main Content
3.1 Causes of Inflammation
3.3 Inflammatory Response
3.4 Pathophysiology
3.5 Clinical Manifestations
3.6 Characteristics of the Exudates
3.7 Termination of Inflammatory Response
3.8 Management
3.9 Nursing Care of Patient with Inflammation
3.10 The Process of Healing
3.11 Allergy
3.11.1 Common Causes
3.11.2 Types of Allergic Reactions
3.11.3 Pathophysiology
3.11.4 Diagnosis
3.11.5 Treatment
3.12 Human Immunodeficiency Virus (HIV) Infection
3.12.2 Transmission
3.12.3 High-Risk Behaviours
3.12.3 Progression of HIV Infection
4.0 Conclusion
5.0 Summary
1.0 INTRODUCTION
Natural protection of the body against invasion by organisms and

damage by injury is ensured by the process of inflammation and the
immune system. Inflammation can therefore be protective in certain
circumstances and harmful in others. This unit exposes you to
inflammation processes in the body
2.0 OBJECTIVES
• explain the concept of inflammation

• describe inflammation response.
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3.0 MAIN CONTENT
Definitions
Inflammation has been defined in several ways. But the basic underlying
principle of these definitions is that inflammation occurs following the
presence of any foreign irritating matter in the body in an attempt to
remove or resist this foreign material.
According to Jones D. A. et al, inflammation is a protective mechanism

exhibited by the tissues in response to an insult that may be of various
origins. Inflammation is a tissue reaction to injury or irritants.
3.1 Causes of inflammation
Various agents are responsible for inflammation.
These include
1. Chemical: - Strong acids and alkalis, irritating gases, poisons,

drugs.
2. Biological: - Micro organisms.
3. Immunological: - Antigen – antibody and auto – immune

reactions.
4. Mechanical: - Trauma, pressure.
5. Thermal: - Extreme heat or cold.
3.2 Inflammatory Response
This is an active and aggressive response to tissue injury and infection.

It is a process or reaction to relieve the area of injury and to prepare it
for repair. And it is one of the most common responses of the body to
injury. Injury can be caused by bacteria invasion, mechanical, chemical.
Body structures that defend the body against injury are:
1) Intact skin and mucous membranes.
2. Bone structures such as skulls, ribs and pelvis.
3. Secretions of some glands help to remove irritants e.g.

hydrochloride acid removes any ingested germs.
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4. Reflexes such as blinking, sneezing, coughing, vomiting, prevent

contact with injurious agents or remove then after they have
gained entrance to body structures.
Certain cells in the blood destroy harmful elements by digestion or by

altering their chemical structure for example the lymphatic system.
When the body is subjected to adverse conditions, it may respond in

several ways. These include:
a. Hyperplasia
This is extra growth of normal tissue resulting in hypertrophy. The

physiology is unknown. It usually occurs in time of need. For example if
one kidney is removed and the other enlarges. At other times
hyperplasia may result where there is no apparent need and this often
results in illness or toxicity to the body. Example of these include
hypertrophy of the thyroid gland, prostate gland, tumor formation
b. Activities of the Autonomic Nervous System
This system provides body protection because of the adjustments it

makes automatically in response to ever-changing environment.
Sweating regulated – speed and slowing of heartbeat etc.
c. Fever
Fever is one of the body’s responses to a microorganism. It is a reliable

indication of a path physiological process in the body, usually
inflammation or infection. Although it can have ill effects such as
cellular damage or fluid or electrolytes imbalance, it also has a useful
purpose in some infections. It can destroy a large numbers of organisms
or make some less virulent. It can also help to identify hidden infections.
The increase of metabolism may support an increase of antibody
formation.
d. Pain
Although pain is a disagreeable sensation, its purpose is mainly

protective. The destruction that can occur in the absence of pain
demonstrates its value.
3.3 Pathophysiology
Injury to the tissue involves local and systemic responses. Local

response consists of vascular response and cellular response. Shortly
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after the injury, there is brief constriction of blood vessels which may
last for five minutes. This is replaced by dilatation of the vessels
occurring within thirty minutes of the injury. The dilatation of the blood
vessels accounts for increased blood supply – (hyperemia) and increased
permeability of the venules and capillaries.
Exudation (escape) of some cells and fluid (plasma) into the tissues
occurs. Hypereamia causes redness and heat as seen and felt on the
affected part. Swelling and firmness are brought about by the
accumulation of fluid and cells in the interstitial spaces. Pain occurs due
to the pressure of the exudate on nerve endings. Pain and swelling
account for the loss of function of the area. This vascular response is
basically mediated by the presence of histamine released by injured or
irritated cells.
There is decrease in the intravascular volume, following the escape of

plasma and some blood cells into the tissue. Consequently, blood flow,
through the dilated vessels, decreases. Leucocytes marginate (adhere to
the walls of the blood vessels) and move through the capillary walls to
the inflammatory site (diapedesis). Chemical products within the tissue
(products of inflammation, bacterial toxins) attract these leucocytes
(chemotaxis) to the site where they engulf and destroy or inactivate the
foreign substances through a process called phagocytosis.
Inflammation of bacterial origin often results in abscess formation due

to the walling of the inflammed area. An abscess is a cavity formed as
phagocytosis takes place and damaged tissue is consumed. Pus
formation (suppuration) occurs after phagocytes have engulfed and
digested bacteria and necrotic tissue. The phagocytic cells eventually
die. Pus consists of dead phagocytic cells, partially digested and
undigested bacteria and necrotic tissue. Enzymes liberated by the dead
cells digest the dead debris and accounts for the liquid consistency of
pus. The presence of undigested bacteria makes the exudates highly
infectious. The pus may be absorbed to the surrounding tissues if the
abscesses remain encapsulated and content autolyzed. It may persist in
an encapsulated abscess.
The systemic responses occur, especially in inflammatory conditions

caused by invasive micro organisms. Leucocytosis and an increase in
erythrocyte sedimentation rate are main features. When soluble products
of tissue reaction diffuse into the blood stream (toxaemia) general body
irritation and non-specific responses are manifested. These responses
include general malaise, loss of appetite, headache, lethargy, weakness,
and fever. These symptoms are also referred to as constitutional
symptoms.
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A. Local
1. Redness seen on the affected area

2. Heat felt on the affected area
3. Swelling
4. Pain
5. Loss of function in the affected area
6. Pus formation
B. Systemic
1. Leucocytosis
2. Increased erythrocyte sedimentation rate (ESR)
3. General Malaise
4. Loss of appetite
5. Headache
6. Fever
7. Lethargy
8. Weakness
3.5 Characteristics of the Exudates
The fluid that forms:
1. Serous Exudates
On a mild inflammation, serum is similar to the normal insterstial fluid

e.g. burns, it is a clear fluid.
2. Fibrinous or serosanguinous
Found on a more severe form inflammation contains large amount of

fibrin and can be found with patient in burns.
3. Purulent Exudates
This is the exudates that contains a lot of pus, found in an infection that
is caused by pyogenic bacteria (pus forming bacteria) can be whitish, the
serous sanguinous is pinkish in colour; purulent can be whitish,
yellowish, pinkish, greenish, depending on the kind of organism.
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3.6 Termination of Inflammatory Response
1. Resolution
Products of inflammation are digested and absorbed into the circulation.
2. Spontaneous Rupture and Drainage
E.g. boils – it nurtures on its own, when the exudates gathers at one
point, it ruptures on is own. Drain surface through a sinus or tract.
3. Surgical Drainage (1 + D) Incision and Drainage
Cut and drain surgically / Done Surgically under aseptic technique,

facilitates healing by aiding in removal of materials that can be
etherioise absorbed and digested before healing can take place.
4. Ulcers or Erosion
Sometimes you can have ulcers extend through covering members,

erosion involves only the covering membrane, erosion is more
superficial where as ulcers are deeper.
5. Organism Causing Infection
Staphylococcus onus and staphylococcus algus Alpha and beta

nemolytic streptococcal, clostridium tetani, Escherichia coli (E. coli),
Acrobacter organism.
3.7 Management
Usually, resolution follows inflammation and repair of the damaged

tissue takes place. This process may be achieved naturally if the
individual’s body defence system is adequate to bring about resolution
without any assistance. In case of a more severe injury when resolution
is not easily accomplished death of some cells occurs. The area is healed
by replacement of the destroyed tissue with living cells. This process
requires a considerable strengthening of the body defence mechanisms
and weakening the attack.
Nursing Intervention
1. Strengthening the Defences
Rest is essential in overcoming the inflammatory reactions. It assists the

body to mobilize adequate defence mechanisms and decreases the
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energy being expended by the patient. Local rest can be achieved with
the use of splints, slings, and sand bags. Further trauma is prevented and
pain lessened.
Affected parts should be elevated as it encourages venous and lymphatic

drainage, reduces swelling, increases fresh blood flow to the area. Fresh
blood carries more elements to combat the offending agent and
facilitates repair.
Application of heat or cold could be carried out. Heat causes relaxation

of muscles, facilitates increased blood flow. Cold constricts blood
vessels; reduces volume of exudates and the degree of swelling. It
lessens pain by reducing nerve endings sensitivity and also prevents the
growth of bacteria when they are the cause agents.
Nutritional status of the patient should be promoted and maintained by

the nurse. There is need for increased calorie intake to meet the
increased energy demand and tissue catabolism. Vitamin C is essential
for the formation of collagen fibers that support the development of
fibrous tissue. Increased protein intake is needed to provide essential
amino acids important for new tissue growth.
Prescribed medications, which may include analgesics, antibiotics,

antitoxin or anti-inflammatory agents, should be administered.
In the presence of an open lesion surgical wound dressing should be

carried out to promote healing. Aseptic measures should be considered.
Assessment of the patient should be carried out by the nurse.
2. Weakening the Attack
The use of antibiotics is the most desirable method of weakening the

attack of the micro-organisms. This, however, should not be used in
trivial infections when the defences of the body are likely to prove
adequate on their own. Ideally, antibiotics are only employed after
sensitivity tests have been carried out and results indicate the type of
antibiotics to be used. The antibiotics are used either systemically or
locally introducing them into wounds in the form of powders.
When pus has formed, antibiotics will only sterilize it (the pus) and
healing will not occur until removal of the pus has been done. Incision
of the abscess is therefore indicated. This (the incision line) must be
sufficient to permit free drainage.
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3. Replacement of fluids
- Increase metabolic rate and the loss of fluid need replacement.

- Give nourishing fluids: fruit juice, pepper soup, bournvita,
pineapple, lucozade e.t.c.
- Provision of nourishment (bland diet – diet that is not containing
roughages).
- Make sure the food is balanced.
- If the patient is draining profusely from the inflammation side,
lost protein has to be replaced.
- Nutrients to increase caloric intake.
- Emotional support should be provided.
- Provision of comfort measure.
- Reassure the patient
3.8 Nursing Care of Patient with Inflammation
1. Goal is to prevent further injury.
2. Understand the nature of the warning of the inflammation.
3. Premature or improper opening of an abscess will interfere with

mechanism of the body for limiting the spread of micro-organism
and lead to their wide spread determination.
4. Ambulation of boils and tissues should be avoided until they have

a well defined area of pus in the centre, and then they should be
opened under surgical conditions.
5. Medical and surgical asepsis should be maintained.
6. Pus should not come in contact with surrounding skin or person

caring for abscess.
7. Pus contains living bacteria as well as enzymes which can digest

both dead and living tissues therefore, when changing dressings,
you should protect self by using instruments or glares.
8. Good hand washing technique.
9. Careful disposal of dressing.
10. Protection of one part of the body by use of cradle and support
e.t.c.
11. Conservation of energy through rest.
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12. Production of leukocytes, increase blood flow, removal of debris

and tissue repair all require energy expense.
13. Promotion of adequate circulation to the affected area to be able

to covert invasion of the pathogenic organism and promote
healing.
14. Heat is the form of dry or most heat so that blood flow to that
area will be increased.
15. Medical wet heat fermentation, siting bath, use of hot H2O bottle
– to apply heat and increase blood supply to affected area.
16. Elevation of the extremity involved to promote venous returns,

and help to reduce pain, improve circulation.
17. Use of bandage to promote comfort, promote venous return, and

support the area to relieve pain.
18. Assistance in overcoming causative agent – removal of foreign

body.
19. Give specific antibiotics before giving antibiotics; be sure of the

causative organism.
20. Removal of debris through incision and drainage Debridment

(removal of dead tissue.) Debridment done for osteomylibis
(inflammation of the bones) is:
3.9 Allergy
Definitions
Allergy is an abnormality or disease condition in which the

immunological defence system responds by forming antibodies to
agents, which are not usually antigenic. It differs from beneficial
immunological reactions in that there is harm to body tissue. It can
occur at any age and often differs in the same individual over the years.
3.9.1 Common Causes
a) Inhalants – dust, feathers, animal danders, pollen
b) Ingestants – egg, seafood, nuts, chocolate
c) Contactants - wool, dye, nylon, cosmetics
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d) Drugs – penicillin, ASA, quinine, chloroquine, dragents such as

Telepoques
3.9.2 Types of Allergic Reactions
a) Immediate
(1) Occurs within seconds or minutes

(2) Antibodies are found in the blood stream
(3) Localized lesion or systemic reaction (anaphylactic shock)
b) Delayed
(1) Takes several hours or days to develop

(2) No antibodies in plasma but probably in lymphatic system
Most of the pathological effects of mild and severe allergic reactions can
be traced to the effects of suddenly released histamine on the blood
vessels, bronchial muscles, and exocrine gland cells.
a) On the Vascular System
Initial skin flush with wheal or edema at the site. Itching at these
urticarial sites caused by action of histamine on sensory nerve endings
in the skin. Histamine acts as vasodilator, this account for the flushing
and for vascular headache. Histamine increases capillary permeability
which causes the swelling. It also causes laryngeal edema and nasal
congestion. Because blood trapped in dilated terminal arterioles, protein
containing fluid is forced into the extravascular spaces. This loss of
plasma proteins together with the reduced resistance of the arterioles
results in fall in blood pressure, decreased cardiac output which can
result in loss blood flow to brain and loss of consciousness and loss of
respiratory control.
b) On smooth Muscle
Smooth muscles, other than those of small arterioles, are contracted.

This is pronounced in bronchioles which reduces vital capacity.
Breathing becomes difficult as in asthma.
c) Exocrine Glands
G.I. tract, respiratory system, lacrimals etc. are stimulated by histamine.

Increased HCL causes epigastric distress, nausea, vomiting, and
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diarrhoea. This will result in increase in bronchial secretions in asthma,

and increased lacrimation in hay fever.
3.9.4 Diagnosis
a. Establishing a cause and effect relationship may not be clear cut if

patient is allergic to several things.
b. Careful and detailed history is very important.
c. Skin tests.
(1) Begin by scratch on skin.

(1) If scratch is negative, small amount of antigen is injected
intradermally.
(2) Wait for 20 minutes and observe for any reaction.
(3) Positive test is indicated by a wheal surrounded by erythema.
(5) Observing for reactions after skin tests (within 20 minutes).
(6) Careful observations in effort to determine causes.
(7) Epinephrine 1:1000 is kept ready in case of severe reaction.
3.9.5 Treatment
a. Since there is no real cure, the best that can be done is avoidance of
allergen or minimizing contact with allergen.
b. Desensitization
With this, a very small dosage of allergen is injected into skin in

gradually increasing dosages until patient develops tolerance. Histamine
is prevented from being released with this method. However,
precautions must be taken as with skin tests.
c. Drug therapy
Antihistamines provide symptomatic relief by inhibiting action of

histamine especially to relieve symptoms of short duration such as drug
sensitivity or hay fever. An adrenergic agent such as Epinephrine is used
primarily to relax bronchiolar smooth muscle spasm by counteracting
effects of histamine. Corticosteroids can be given for brief periods if
symptoms are very severe.
3.10 Human Immunodeficiency Virus (HIV) Infection
The human immunodeficiency virus (HIV) causes damage to the

immune system. It is associated with a spectrum of disease, ultimately
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presenting as required immune deficiency syndrome (AIDS). HIV is

primarily a sexually transmitted disease and carries with it connotations
of ‘sin’ and ‘evil’. The myths and misconceptions about HIV and AIDS
are widespread amongst the general public and healthcare professionals.
The genetic information of most organisms is composed of DNA, and

complementary molecules of RNA are made as templates for protein
production. HIV is a retrovirus: its genetic information is RNA but it has
an enzyme called reverse transcriptase, which can synthesize DNA by
using RNA as the pattern. The virus can infect cells that carry a protein
called CD4 on their surface. Their primary target is the T4 or T helper
cells of the immune system. Once HIV has invaded a cell, the reverse
transcriptase converts its RNA to DNA, which is then integrated into the
DNA of the host cell. HIV particles then assemble in the cytoplasm of
the cell and escape by budding through the cell membrane, killing the
cell in the process. As increasing numbers of T4 cells are invaded and
destroyed, the body’s immune system is weakened, making the
individual prone to a variety of opportunistic infections, malignant
diseases and neuropsychiatry complications.
3.10.2 Transmission
HIV is transmitted by sexual intercourse, inoculation of infected body

fluids through skin or on to mucous membranes, transplantation of
tissues and transfusion of contaminated blood. It may also be
transmitted from mother to baby, either through the placenta or during
delivery. Transmission of HIV has occurred through blood, semen,
vaginal fluids and occasionally breast milk. Although HIV has been
isolated in tears, urine and saliva, the concentration is extremely low and
there is no documented evidence that the virus can be transmitted by
these secretions. HIV cannot be transmitted through casual contact such
as hugging, holding hands, crying, shared toilet seats, etc.
Table 3 Common Opportunisitc Infections in Persons with AIDS
Cause Usual Site Symptoms Common Therapy

Diagnostic
Tests
Protozoa
1. Pneumocyst Lungs Dry, non-productive Chest Trimethoprin
is carinii cough, shortness of radiography, Pentatamidine
breath, fever, night bronchoscopy Co-trimoxazine
sweats
2. Toxoplasm Brain Headache, seizures, CT scan (head) Sulfadiazine
a gondii neurological MRI scanning Pyrimethamine
deficits, behaviour
changes, may lead
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to dementia
3. Cryptosporidium GI tract Profuse, watery Stool cultures Spiramycin
diarrhoea, Antidiarrhoea
dehydration, Antiperistaltic
debility
Fungi
4. Candida albicans Mouth (thrush) Dysphagia Visible lesions Nystatin
scraped and Clotrimazole
cultured Ketoconazole
Oesophagus Endoscopy Fluconazole
Dysphagia (oral with biopsy
candida may not be and culture of
present) tissue
1. Crytococcus Brain Headache, fever, Lumbar Amphotericine
neoformans confusion, --puncture,
behaviour changes bone marrow
aspiration
Non-specific cough Chest Flucytosine
Lungs or fever, dyspnoea radiography,
sputum for
culture,
bronchoscopy
with culture
Viruses
6. Cytomegalovirus Eyes Retinitis, loss of Serology DHPG
Lungs vision testing Foscamet
GI tract Cough, dyspnoea, Bronchoscopy Ganciclovir
fever with biopsy
Abdominal pain, and culture
ulcer,
GL bleeding Endoscopy,
colonoscopy
Spinal cord Paraparesis, Analysis of
quadraparesis spinal fluid
7. Herpes simplex Skin Painful cold sore Histology and Aciclovir
virus clusters at mouth culture
and perianal area
Spinal cord Paraparesis, Analysis of

quadraparesis spinal fluid
Bacteria
8. Mycobacterium Disseminated, Fever, profuse Blood cultures, Isoniazid
avium many organs sweating, bone marrow Rifampicin
intracellulare affected: liver, productive cough, aspiration, Ethambutol
spleen, lungs, lymphadenopathy, stool for acid- Streptomycin
lymph nodes, diarrhoea, weight fast bacilli, Amikacin
bone marrow, loss endoscopy, Biofazimine
GI tract colonoscopy
with culture of
biopsy tissue
3.10.3 High-Risk Behaviours
The patterns of HIV infection and transmission vary in different parts of

the world. In Africa, transmission occurs mostly through heterosexual
activity, whilst in the USA and Europe infection has occurred mostly
amongst homosexual and bisexual men and injecting drug users.
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It is important to recognize that it is risk behaviours that place an

individual at risk of infection rather than association with a particular
group. The major route of transmission is by heterosexual and
homosexual intercourse, with specific sexual practices carrying varying
degrees of risk.
HIV can also be transmitted by infected blood or blood products. The

use of drugs or alcohol does not specifically put a person at risk, but
sharing needles to inject drugs with someone who is infected is risky
because small amounts of infected blood are transmitted in the injecting
equipment. Individuals, who suffer from clotting factor concentrates
manufactured from the pooled plasma of thousands of donors, are also at
risk of HIV infection. Routines screening for HIV antibodies and heat
treatment that inactivates HIV have greatly reduced the risk of
transmission by this route.
A small number of healthcare workers have acquired HIV following

percutaneous or mucous membrane exposure to blood or body fluids.
Surveillance of healthcare workers exposed to infected blood has shown
that the risk of acquiring HIV is less than 1%, with the greatest risk
associated with percutaneous exposure about 0.3%, or one case per 300
needlestick injuries. An infected health worker may transmit a
bloodborne virus to a patient as result of accidental injury during a
procedure such as surgery or dental practice that resulted in blood
entering the patient’s open tissue. Health workers who are infected with
HIV may therefore be advised to avoid performing invasive procedures.
3.10.4 Progression of HIV Infection
The rate at which symptoms develop in people with HIV infection is

unpredictable and varies a great deal between individuals. Some people
may develop an acute illness 2 – 6 weeks after infection. Symptoms
include fever, myalgia, arthralgia, headache, diarrhoea, sore throat,
lymphadenopathy and a maculopapular rash. After about three months,
it is possible to detect antibodies to the virus in the blood; this is known
as seroconversion.
In some cases, seroconversion may take six months or longer. The

presence of infection is detected, using a test called the enzyme-linked
immunosorbert assay (ELISA) and confirmed with the more specific
Western blot test. Both of these tests detect antibodies to HIV in the
serum.
Being tested for HIV can have far-reaching implications and place the
individual under considerable stress. Issues include how the result may
affect their sexual behaviour, potential problems with housing, insurance
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or employment, and people in whom they might confide if the test is

positive. Inadequately prepared individuals may become extremely
distressed, acutely anxious, severely depressed or suicidal. It is therefore
crucial that the person receives professional counseling, both before and
after the test.
The counselor should act as a confidential listener, questioner and

source of information and support. The pre-test counseling session is
an opportunity to:
• provide information about HIV infection

• explore the risks and benefits of being tested
• discuss the meanings of the test (Box 8.7)
• Help the individual to develop a plan to maximize the benefits
and minimize risks.
It also gives the counselor an opportunity to assess the individual’s

support system and provides some preventive education related to safer
sexual practices and drug use.
The counselor can also put the individual in touch with support groups
set up by people with HIV. These groups may run advice centres or
alternative therapy clinics as well as providing opportunities to discuss
issues with others in the same situation.
HIV Disease
Current data suggest that the majority of individuals infected with HIV
will eventually become severely immunosuppressed develop AIDS. The
main diseases associated with AIDS are unusual infections caused by
microorganisms that are not pathogenic in people with a competent
immune system (opportunistic infections) and various cancers. A case
definition of AIDS has been developed by the Centres for Disease
Control in the USA and is recognized internationally it is estimated that
40% of HIV-infected individuals will have developed AIDS eight years
after seroconversion, 99% after 15 years. They will remain infectious
throughout the course of the disease, although they are probably more
infectious during the latter stages (Heptonstal et al 1993a). The
progressive impairment of the immune response is caused by the gradual
depletion of the CD4+ T-lymphocytes, which coordinate a number of
important immune functions. There is a strong association between the
number of CD4+ T-lymphocytes and the development of serious
opportunistic illness. CD4 counts are therapeutic management. In the
UK, zidovudine is licensed for use in patients with a neutrophil count of
less than 0.5 x 109/litre.
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Usually, the first clinical signs of infection are fever, night sweats, skin
rashes, diarrhoea, unexplained weigh loss or respiratory symptoms. The
type and extent of symptoms with which the individual presents will
depend on the degree of immunodeficiency. A debilitating syndrome of
weight loss, diarrhoea, fever and night sweats may be caused directly by
HIV by secondary infection. The most common opportunisatic infection
in individuals with AIDS is Pneumocystis carried pneumonia. The most
common neoplasm is Kaposi sarcoma, which is most likely to develop
in homosexual or bisexual men. Table 8.3 and 8.4 outline the common
opportunistic infections and neoplasms associated with AIDS.
Issues around Testing for HIV
There are many things that need to be considered when planning to have
an HIV test:
• It may be stressful not to know your HIV status.
• Knowing whether the individuals are HIV positive can help to

make decisions about the direction of their lives.
• Early treatment of HIV can delay onset of AIDS.
• You can protect yourself and your partner by using safer sex and/
or drug use.
• It may enable the individual to have sex with his/her partner

without using condoms.
• It may be stressful to know that the individual could become ill at

any time.
• It can be difficult to tell friends, family, and partners if the

individual are HIV positive.
• The individual may have difficulties obtaining a mortgage or

insurance.
• There may be strains on your relationship with your partner if

you is HIV positive.
• The individual may need to assess the risks associated with

having a baby.
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Facts About the HIV Antibody Test
The AIDS virus (usually called HIV) may cause serious disease
resulting from the body’s inability to fight infection. The antibody to the
AIDS virus is a protein the body produces in response to an infection by
the AIDS virus.
A positive test indicates that the antibody to the AIDS virus has been
found in your blood. The test is not always accurate. A small percentage
of persons tested may be told they have the antibody when in fact they
do not. A small percentage of persons with negative test results have in
fact been infected with the AIDS virus. The blood will be tested more
than once to minimize the risk of making such an error.
A positive antibody test result means that:
• The blood sample has been tested more than once and the tests
indicate that antibodies to the AIDS virus are present.
• The individual has been infected with HIV, the virus that causes
AIDS, and his body has produced antibodies to it.
• You should assume that you are infectious and capable of passing
the virus to others.
A Positive to AIDS
• You have AIDS or an AIDS-related condition.
• You will get AIDS or AIDS-related complex (ARC).
• You are immune to AIDS.
A negative antibody test result means that no antibodies to the AIDS

virus have been found at this time.
There are three possible explanations for this:
1. You have not been in contact with the virus.
2. You have come in contact with the virus, but have not become
affected. Repeated exposure to the virus through high-risk
behaviour greatly increases the likelihood of your becoming
infected.
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3. You have been infected with the virus but have not produced
antibodies yet. It may take several weeks to months to produce
antibodies. A small number of persons who become infected
never produce antibodies.
A negative antibody test does not mean that:
• You are immune to the virus
• You have not yet been infected with the virus (you may have
been infected and have not yet produced antibodies)
• You should stop worrying about being infected by the AIDS

virus if you participate in high-risk behaviours.
Modified from Gauthier and Turner (1989)
HIV Disease in Women and Children
HIV infection may appear differently in women, with many of the

symptoms focused on gynaccological problems such as persistent and
virulent yeast infections, irregular menstrual periods, pelvic
inflammatory disease and cervical cancer. Women often do not have
what they require to make informed decisions about safer sex, intimacy,
childcare and reproductive rights.
Children who are born to mothers who are HIV infected are likely to
carry passively acquired maternal antibodies of HIV, making an
accurate diagnosis of infection difficult until the child is approximately
15 months old. Maternal antibody in the infant is usually lost at between
six and nine months, but may persist until 15 months. Symptoms of HIV
infection usually appear when the child is between six months and two
years of age.
A child with HIV infection will live approximately two years from the
time of diagnosis. Problems associated with infection are characterized
by failure to thrive and delays in development. The child is particularly
prone to recurrent bacterial infections, recurrent oral thrush and chronic
diarrhoea, chronic parotid swelling, and pulmonary lymphoid interstitial
pneumonitis, thought to be linked to the Epstein-Barr virus, is found
frequently in children with AIDS. The major cause of morbidity in these
children is lung disease.
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4.0 CONCLUSION
Natural protection of the body against invasion by organisms and

damage by injury is ensured by the process of inflammation and the
immune system.
5.0 SUMMARY
1. Inflammation occurs following the presence of any foreign

irritating matter in the body in an attempt to remove or resist this
foreign material.
2. An allergen is a substance that gives rise to hypersensitivity or

allergy.
3. The patterns of HIV infection and transmission vary in different

parts of the world. In Africa, transmission occurs mostly through
heterosexual activity, whilst in the USA and Europe infection has
occurred mostly amongst homosexual and bisexual men and
injecting drug users.
4. It is the risk behaviours that place an individual at risk of infection

rather than association with a particular group.
Explain the roles of the kidney and lung in the body mechanism.
Barbara, C. Long and Wilma, J. Phipps (1985). Essentials of Medical-

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UNIT 5 SHOCK
CONTENTS
1.0 Introduction
2.0 Objectives
3.0 Main Content
3.1 Definition
3.2 Causes of Shock
3.3 Pathophysiology of Shock
3.4 Common Types of Shock
3.6 Management of Shock
3.6.1 First Aid Management of Shock
3.6.2 Medical and Nursing Management of Shock
3.7 Complications of Shock
3.7.0 Haemorrhage
3.7.1 Causes of Hemorrhage
3.7.3 Classification
3.7.3.1 Situational of Hemorrhage
3.7.3.2 Sources of Haemorrhage
3.7.3.3 Time of Haemorrhage
3.7.4 Types of Haemorrhage
3.7.5 Signs and Symptoms of Haemorrhage
3.7.6 First Aid Management
3.7.6.1 Internal Haemorrhage
3.7.6.2 External Haemorrhage
3.7.6.3 Dangers Associated with the Application of
Tourniquet
3.7.7 Pressure Points in the Body
4.0 Conclusion
5.0 Summary
1.0 INTRODUCTION
The organs and tissues of the body are supposed to be adequately

supplied with blood to enhance their effective functioning, apart from
oxygen and nutrients derived by these structures from blood circulation.
Certain pathophysiological conditions may bring about hypotension and
subsequent reduction in blood supply to most vital structures in the
body. This state is accompanied by serious reduction in the delivery of
oxygen and other essential substances to a level below that needed for
normal and effective cellular activities.
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2.0 OBJECTIVES
• define shock
• identify various types of conditions that can lead to shock
• identify the clinical manifestation of a patient with shock
• distinguish between the various types of shock
• utilize nursing process to manage a patient with shock
• discuss the role of the nurse in psychosocial support of both the
patient experiencing shock and the family.
3.0 MAIN CONTENT
Key Concept
1. Anaphylactic Shock
This results from a severe allergic reaction producing an overwheming

systemic vasodilation and relative hypovolemia:
2. Cardiogenic Shock
This is due to impairment or failure of the myocardium.
3. Circulatory Shock
This results from displacement of blood volume creating a relative

hypovolemia and inadequate delivery of oxygen to the cells. It is also
called distributive shock.
4. Neurogenic Shock
Refers to a shock state resulting from loss of sympathetic tone causing

relative hypovolemia.
5. Septic Shock
Results from overwhelming infection, causing relative hypovolemia.
6. Anoxia
Refers to lack of oxygen in the body.
7. Anoxemia
Refers to lack of oxygen in the blood.
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8. Anuria
This is the absence of urinary secretion.
9. Thrombosis
Refers to possible emboli, due to blood stasis.
3.1 Definition
Shock is an abnormal physiological state in which there is wide spread,

serious reduction of tissue perfusion that if prolonged, will lead to
generalized impairment of cellular function. Shock has also been
described as a clinical state of peripheral circulatory failure
characterized by a fall in blood pressure. Cellular destruction and
deterioration in tissue and organ functions are possible outcomes.
3.2 Causes of Shock
1. Loss of body fluid

2. Blood loss
3. Inadequate fluid intake
4. Congestive cardiac failure
5. Myocardial infarction
6. Pulmonary embolism
7. Cardiac arrhymias
8. Spinal anaesthesia
9. Infections with the release of endotoxins
10. Antigen – antibody reaction with release of histamine.
3.3 Pathophysiology of Shock
The cardiac output and the peripheral vascular resistance normally

maintain arterial blood pressure. When there is reduction in cardiac
output and a subsequent decrease in arterial pressure sufficient to
produce a wide spread reduction in tissue perfusion, the body attempts
to compensate for the changes that follows in the body. The ultimate
importance of this compensatory mechanism is to restore adequate
circulation to the vital structure of the body. The response of these
systems varies from individual to individual. Vasoconstriction and
increase in the heart rate with increase in both peripheral resistance and
cardiac output causes additional blood circulation to the vital organs.
Haemodilution occurs due to secretion of antidiuretic hormone, and
subsequent retention of fluid and sodium helps to improve blood
volume. Improved cardiac output and myocardial contractility occur due
to increased production of carbon-dioxide occasioned by limited tissue
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oxygenation. The increased carbon dioxide causes the coronary arteries

to dilate resulting in increased myocardial perfusion.
When the compensatory mechanism cannot effectively sustain the

body’s physiologic functioning, shock progresses and multiple
physiological changes ensue. A progressive shock produces multiple
systemic changes as a result of decreased cardiac output, hypovolemia,
and limited cardiac perfusion. These changes produce alteration in
oxygenation, fluid and electrolytes metabolism and the body’s defence
against bacterial invasion. In the early stages, cerebral hypoxia produces
restlessness, apprehension, and anxiety, and may be replaced by apathy
and confusion and verbal response becoming inappropriate as cerebral
hypoxia increases. In the irreversible stage, unconsciousness manifests
with no response to painful stimuli.
The skin is pale, cold and clammy reflecting poor perfusion of the
superficial tissue and sympathetic activity to the sweat glands
respectively. There is cyanosis, showing a reduction in cardiac output
and decreased oxygen saturation. Initially the pulse is rapid and thread,
but later becomes slower, irregular and imperceptible.
In response to hypoxia, respirations increase in rate and depth. In severe

cases, there is depression of the respiratory centre resulting in shallow
and irregular respiration. Severe respiratory dysfunction accounts for
complications such as atelectasis, pulmonary emboli, interstitial
congestion and oedema, which develops about three to six days after the
event that initiated the shock. The complication is referred to as ‘shock
lung’ or adult respiratory distress syndrome (ARDS). Subnormal
temperature is characteristic of shock. This is due to reduction in cellular
metabolism and heat production caused by hypoxia. However, exception
is noticed in septic shock. Oliguria ensues due to decreased renal
perfusion. Urinary output might be less than 30mls per hour, resulting in
the retention of urea, nitrogen and creatinine. Decreased bowel sounds
indicating reduced peristalsis develops due to sympathetic innervation
and vaso constriction. Reduction in tissue perfusion and the resulting
hypoxia accounts for the anaerobic metabolism which causes
accumulation of metabolic acids. This eventually leads to acidosis.
Myocardial failure and cardiac arrhythmia may develop if acidosis is
prolonged.
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Cellular edema
Efflux of K
Increased membrane
permeability
Lysosomal membrane
rupture
Influx of Na+ and H2O
Cell damage and death
Mitochondrial damage
(swelling)
Normal
Effects of shock
Cellular effects of shock. The cell swells and the cell membrane becomes more permeable, and fluids
and electrolytes seep from and into the cell. Mitochondria and lysosomes are damaged, and the cell dies.
Source: Jones, D.A. et al, (1978) Medical–Surgical Nursing, A

Conceptual Approach. Megraw-Hill, P. 959.
3.4 Common Types of Shock
1. Hypovolaemic Shock (Decrease in Blood Volume). This is due

to a decrease in blood volume which may be caused by
haemorrhage, dehydration due to vomiting and diarrhoea, loss of
plasma in burns, inadequate fluid intake, and excessive use of
diuretics. When intravascular volume drops, there is decrease in
tissue perfusion, decreased venous return, and low cardiac output
and blood flow through the tissue becomes inadequate.
2. Carcinogenic Shock (Decreased Cardiac Output). This

indicates a severe impairment in the efficiency of the heart as a
pump. There is decreased ability of the heart to pump out blood
into circulation. This results in decrease in stroke volume and
cardiac output. Cardiogenic shock may be occasioned by
congestive cardiac failure, pulmonary embolism, myocardial
infaction, pneumothorax cardiac arrhythmias, or pericardial
tamponade.
3. Neurogenic Shock. This develops as a response to autonomic

nervous system activity resulting in reflex vasodilatation and loss
of arteriolar tone with subsequent pooling of blood in the dilated
vasculature. This result is deceased venous return to the heart.
This type of shock is usually due to spinal anaesthesia,
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barbiturate injection, hyperrinsulinism, spinal cord injury, severe

pain, accidental injury or extreme fright. Septic or bacteraemic
shock, toxic shock, anaphylactic shock occurs essentially
following the same phenomena as in neurogenic shock. It is
characterized by dry, warm skin rather than the cool, moist skin
seen in hypovolemic shock. Another characteristic is bradycardia,
rather than the tachycardia that characterizes other forms of
shock.
4. Circulatory Shock
Circulatory or distributive shock occurs when blood volume is

abnormally displaced in the vasculature––for example, when blood
volume pools in peripheral blood vessels. The displacement of blood
volume causes a relative hypovolemia because not enough blood returns
to the heart, which leads to subsequent inadequate tissue perfusion. The
ability of the blood vessels to constrict helps return the blood to the
heart. Thus, the vascular tone is determined both by central regulatory
mechanisms, as in tissue demands for oxygen and nutrients. Therefore,
circulatory shock can be caused either by a loss of sympathetic tone or
by release of biochemical mediators from cells. Pooling of blood in the
periphery results in decreased venous return. Decreased venous return
results in decreased stroke volume and decreased cardiac output.
Decreased cardiac output, in turn, causes decreased blood pressure and
ultimately decreased tissue perfusion.
5. Septic Shock
Septic shock is the most common type of circulatory shock and is

caused by widespread infection. The source of infection is an important
determinant of the clinical outcome. The greatest risk of sepsis occurs in
patients with bacteremia (bloodstream) and pneumonia other infections
that may progress to septic shock include intra-abdominal infections,
wound infections, bacteremia associated with intravascular catheters.
6. Anaphylactic Shock
Anaphylactic shock occurs in patients already exposed to an antigen

who have developed antibodies to it. An antigen––antibody reaction-
provokes mast cells to release potent vasoactive substances, such as
histamine or bradykinin, that cause widespread vasodilation and
capillary permeability. Therefore, patients with known allergies need to
understand the consequences of subsequent exposure to the antigen and
should wear medical identification that lists their sensitivities. This
could prevent inadvertent administration of a medication that would lead
to anaphylactic shock.
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1. Restlessness
2. Apathy and confusion
3. Unconsciousness
4. Rapid thready pulse followed by weak pulse
5. Decreased blood pressure
6. Increased respiratory rate, shallow respirations
7. Subnormal temperature
8. Cold and clammy skin
9. Decreased urinary output (oliguria)
10. Cyanosis
11. Decreased bowel sounds or absence of bowel sounds
3.6 Management of Shock
3.6.1 First Aid Management of Shock
In the presence of major external haemorrhage,
- Stop the bleeding.

- Apply firm pressure over the wound or artery involved.
- Apply a firm pressure bandage.
- Immobilize the extremity to control the bleeding.
- Elevate the part.
If hemorrhage is internal
- Blood transfusion and surgery may be indicated.

- Tourniquet is the last resort.
Other actions include
- Keep the patient laid flat or place him on shock position (head
lower than its feet) to improve blood supply to the brain.
- Give analgesics to reduce pain.
- Take patient to hospital as fast as you can.
- Keep crowd away from patient.
- Give reassurance.
- Keep patient warm.
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3.6.2 Medical and Nursing Management of Shock
Management in all types and phase of shock should include the

following:
• Fluid replacement to restore intravascular volume

• Vasoactive medications to restore vasomotor tone and improve
cardiac function
• Nutritional support to address the metabolic requirements that are
often dramatically increased in shock.
Assessment
The management of shock should be rapid to prevent the condition from

becoming irreversible. A good and careful assessment of the patient’s
general/physical health status is paramount. Blood pressure, respiration,
pulse, urinary output, skin colour should be noted. The blood pressure
and pulse rate should be monitored every 15 minutes. This reflects the
cardiac functioning and cardiac output. An indwelling catheter is passed
to facilitate the measurement of the urinary output hourly. In the adults,
the urinary output is expected to range between 30 and 60ml/hour. A
decrease in this value indicates poor renal perfusion. Oliguria may lead
to anuria. The hourly urinary output is useful in assessing patients’
cardiovascular status. Except in septic shock in which the body
temperature may be elevated in the early stages, patients with other
types of shock usually record a subnormal temperature and remain same
as shock progresses. The body temperature should be monitored
continuously and recorded every one to two hours.
The rate and volume of respirations should be monitored and recorded

15 to 30 minutes. This is particularly important as hyperventilation
occurs in the early stages of shock while respiration may become slow,
irregular and shallow as a result of ischaemia of the respiratory centre.
Secretions in the respiratory tract should be removed promptly through
suctioning. The skin should be observed for lessening of pallor, warmth
and quick refilling of the capillaries and veins, following compressions
which are signs of improvement. Conversely, signs of subcutaneous
bleeding may indicate disseminated intravascular coagulation in severe
shock, and especially that associated with sepsis. The level of
consciousness should be determined at regular intervals, using Glasgow
coma scale. This reflects blood and oxygen supply to the brain.
Treatment
Usually, treatment is directed towards improving tissue perfusion and

oxygenation as well as treating the specific cause accordingly. The
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contractile ability of the heart is strengthened to increase cardiac output

in cardiogenic shock. Adrenalin is useful as a cardiac stimulant.
Fluid Replacement
Fluid replacement is administered in all types of shock. The type of

fluids administered and the speed of delivery vary, but fluids are given
to improve cardiac and tissue oxygenation. Fluid replacement is
paramount in all types of shock, especially in hypovolaemic shock. The
fluids administered may include crystalloids (electrolyte solutions that
move freely between intravascular spaces), colloids (large-molecule
intravenous solutions), or blood components.
Initially a crystalloid solution e.g. Ringers lactate solution or Normal

saline is used. Colloid solutions of whole blood or fresh plasma may be
used in conjunction with the crystalloid solutions. The aim is to expand
intravascular volume. If the cause is due to haemorrhage, efforts should
be made to arrest bleeding by giving whole blood or fresh plasma so that
blood pressure is raised and tissue perfusion restored.
Close monitoring of the patient during fluid replacement is necessary to

identify side effects and complications. The most common and serious
side effects of fluid replacement are cardiovascular overload and
pulmonary edema. Patients receiving fluid replacement must be
monitored frequently for adequate urinary output, changes in mental
status, skin perfusion, and changes in vital signs. Lung sounds are
auscultated frequently to detect signs of fluid accumulation.
Adventitious lung sounds, such as crackles, may indicate pulmonary
edema.
Vasoactive Medication Therapy
Vasoactive medications are administered in all forms of shock to

improve the patient’s hemodynamic stability when fluid therapy alone is
inadequate. Specific vasoactive medications are prescribed to correct the
particular hemodynamic alteration that is impeding cardiac output.
These medications help to increase the strength of myocardial
contractility, regulate the heart rate, reduce myocardial resistance, and
initiate vasoconstriction.
Nutritional Support
Nutritional support is an important aspect of care for the patient with

shock. Increased metabolic rates during shock increase energy
requirements and therefore caloric requirements. The patient in shock
requires more than 3,000 calories daily. The release of catecholamines
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early in the shock continuum causes glycogen stores to be depleted in

about eight to ten hours. Nutritional energy requirements are then met
by breaking down lean body mass. In this catabolic process, skeletal
muscle mass is broken down, even when the patient has large stores of
fat or adipose tissue. Loss of skeletal muscle can greatly prolong the
recovery time for the patient in shock. Parenteral or enteral nutritional
support should be initiated as soon as possible, with some form of
enteral nutrition always being administered.
A stress ulcer occurs frequently in acutely ill patients because of the

compromised blood supply to the gastrointestinal tract. Therefore,
antacids, histamine-2 blockers (e.g., famotidine [Pepcid], ranitidine
[Zantac]), and antipeptic agents (e.g., sucralfate [Carafate]) are
prescribed to prevent ulcer formation by inhibiting gastric acid secretion
or increasing gastric pH.
Nursing Care
Possible nursing diagnosis includes:
1. Altered nutrition, less than body requirements

2. Impaired mobility
3. Fluid volume deficit
4. Altered comfort
5. Altered urinary output
6. Ineffective breathing pattern
Altered Nutrition
The patient should not be given anything orally because of paralytic

ileus, instead a nasogastric tube is inserted to drain the stomach contents
and prevent abdominal distension. The nutritional status is maintained
primarily by intravenous infusions. Oral feeding is commenced only in
the presence of bowel sounds.
Impaired Mobility
Complications such as thrombosis, circulatory stasis, decubitus, ulcer,

flexion contractures and atelectasis may develop due to immobility. The
patient’s position should be changed every one to two hours (where
permitted). Skin should be inspected for redness and pressure areas
treated accordingly. This promote circulation, relieves pressure and
drainage of pulmonary secretions. Patient is positioned in good body
alignment to prevent contractures and foot drop. Passive exercise,
especially of the lower limbs, is also useful. A bed cradle will be useful
in lifting the weight of the bed clothes thus preventing pressure.
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Fluid Volume Deficit
Frequent observation of the patient’s reaction and flow of the infusion

used should be carried out by the nurse. Intake and output record should
be maintained. Oral fluids should be avoided because of poor gastro-
intestinal absorption.
(Altered Comfort) or Self-Care Deficit (bath, and oral care and

grooming). Physical care such as bathing and oral hygiene are necessary
as they promote relaxation and ensure prevention of sores, ulcers and
infection respectively. An analgesic is administered intravenously to
relieve pain. The patient should be observed for the respiratory
depressive effect of analgesic used. Light linen should be used to keep
patient comfortably warm, but overheating and chilling should be
avoided.
Altered Urinary Output
Impaired urinary elimination occurs due to inadequate renal perfusion.

To maintain adequate urinary output, an indwelling catheter is passed
using aseptic technique. This is to facilitate the measurement of hourly
urinary output. Hourly urinary output less than 30mls (in adult) should
be reported to the appropriate personnel.
Ineffective Breathing Pattern
A patient airway should be established immediately and oxygen given

through nasal cannulae or mask. When the patient is able, he should be
encouraged to carry out deep breathing and coughing exercises at
frequent intervals. Change in positions hourly is beneficial as it
decreases the possibility of consolidation developing thereby promoting
effective gas exchange.
In order of priority in shock management, restoration of tissue perfusion

by way of I.V. fluid administration takes precedence over other
measures. This is followed by adequate tissue oxygenation, i.e. ensuring
a patent airway and adequate gaseous exchange.
3.7 Complications of Shock
1. Metabolic acidosis
2. Cardiac failure
3. Cardiac arrhythmias
4. ‘Shock lung’
5. Uraemia
6. Cerebral damage
7. Susceptibility to infection
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3.7 .1 Haemorrhage
Definition
This is an escape of blood from the blood vessels and this may be
internal or external.
3.7.2 Causes of Haemorrhage
It may occur due to one of the three causes:
1. Direct injury to the blood vessel wall as a result of a wound or

surgical intervention.
2. Disease of the blood vessel wall. This may be caused by infection

or malignancy.
3. Disease of the blood itself e.g. haemophillia. Haemophilia is a
condition characterised by delay in the coagulation time of blood,
it is due to lack of a specific blood clotting factor in the blood
which is necessary for satisfactory clotting. This factor is known
as anti-haemophillic factor.
3.7.3 Classification
Haemorrhage may be classified in different ways
1. According to its situation

2. According to its source
3. According to the time it occurred.
3.7.3.1 Situational of Haemorrhage
External Haemorrhage
In this instance, the blood escapes from the blood vessel into the surface
of the body and can be seen.
Internal or Unseen Haemorrhage
In this type of haemorrhage, blood escapes from the blood vessels into a
cavity or organ of the body or into the tissues. The simplest example of
this type of haemorrhage is a bruise or heamatoma. It is possible for an
internal to eventually become visible. If blood escapes from the
alimentary tract, the person may eventually vomit all the blood or if
there is bleeding from the respiratory tract the person may eventually
cough off the blood.
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3.7.3.2 Sources of Haemorrhage
Haemorrhage may be classified according to the type of blood vessel

involved:
Arterial Bleeding
If an artery is severed, the blood will be:
a. Bright red in colour due to the presence of oxygen in the blood.

b. Spurting from the wound, each spurt coincides with the heart
beat.
c. Escaping from that part of the wound nearest to the heart.
d. Escaping from the wound under great pressure.
Venous Bleeding
If a vein is severed, the blood will be:
a. Dark red in colour, this is due to the small amount of oxygen

present in the blood.
b. Flowing from the wound in a steady stream and will not be under
great pressure.
c. Escaping from the part of the wound farthest away from the
heart.
Capillary Bleeding
This occurs in superficial wounds, e.g. in a graze or a scrape and the

blood will be:
a. Oozing from the wound.

b. Neither bright red nor dark-red in colour.
c. Welling up from all ever the wound.
3.7.3.3 Time of Haemorrhage
This may occur at the time of injury or it may occur later.
1. Primary Haemorrhage
This occurs at the time of injury or operation or when the blood vessel
has been damaged by disease.
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2. Reactionary
It is important to note that up to 24hrs after an injury or operation,

bleeding may commence again, this bleeding is due to reaction of the
body. If there had been a haemorrhage, nature employs strategies to
prevent serious loss of blood. These strategies include:
(a) The blood pressure is reduced resulting in diminished flow of

blood to that part.
(b) A blood clot forms, these clots of blood vessels further limiting
loss of blood.
(c) The blood vessel wall turns in to hold the clot in position and
prevents further loss.
3 Secondary Haemorrhage
This type of haemorrhage seldom occurs but if it does, it takes place

within seven to ten days. It is slow to develop after the injury or
operation and is often due to infection. It is extremely dangerous and
shows the important of keeping wound absolutely clean.
3.7.4 Types of Haemorrhage
1. Ante Partum Haemorrhage
This starts before labour and is associated with placenta previa and
abruptio placenta.
2. Cerebral Haemorrhage
This is collection of blood in a cavity within the cranium, which may be

extradural, subarytenoid or cerebral.
3. Post-Partum Haemorrhage (Primary)
This refers to bleeding that occurs between 12 and 24hrs of delivery

which measures 500ml or more.
4. Secondary Post-Partum
This refers to excessive bleeding after 24hrs of delivery
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3.7.5 Signs and Symptoms of Haemorrhage
The Skin
It becomes pale and white and feels cold and clammy to touch. This is
due to the constriction of the superficial blood vessels. Physiological
adjustments are made to improve the blood supply to deeper more vital
organs such as brain, kidneys, heart and liver, because of this restricted
blood supply also the temperature becomes subnormal i.e. 35°C or 95°F.
The Pulse
This is rapid and weak. How rapid and weak, depends on the severity of
the haemorrhage.
Respiration
This is unique and unmistakable and is described as “air hunger” (deep

sign of respiratory). The patient is signing and grasping for air.
Facial Expression
The patient, if conscious, will look anxious, afraid and will be restless.
Effect on the Brain
Brain tissue may suffer hypoxia, due to the brain not receiving enough
blood supply, the patient may show or complain of the following signs
and symptom.
a. Dimmed or blurred vision

b. Buzzing and ringing in the ears
c. Dilated pupils
d. Mental confussion
Thirst
The patient commonly complains of thirst. This is the reaction of the

body to lost of fluid. During bleeding, fluid is withdrawn from tissues
into the blood stream resulting in dehydration...
3.7.6 First Aid Management
It is important for any first aid worker to recognize signs and symptom
of haemorrhage.
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3.7.6.1 Internal Haemorrhage
1) Lie patient flat either on the bed, floor or couch.

2) Reassure the patient since he/she will be anxious.
3) Lower the head of the bed. This will help flow of blood by
gravity to the head thus prevent fainting or unconsciousness.
4) Undo tight clothing rounded neck, chest and waist. This will
allow the patient to breath more easily and prevent suffocation.
5) Contact a doctor as soon as possible for further treatment or pain
management.
6) If signs and symptoms are severe, then get the patient to the
hospital with minimum amount of movement and handling.
7) Keep crowd away from patient.
8) Keep patient warm.
3.7.6.2 External Haemorrhage
The general care will be the same as the internal haemorrhage with the
following special emphasis.
2. Stop the bleeding.
3. Any open wound must be covered immediately with a clean

dressing. This prevents infection.
4. Immobilise extremities to the bleeding if the part that is bleeding

involved is a limb, it should be raised as high as possible and
maintain in that position. This limits the amount of blood flowing
to that part; thus reduces the amount of bleeding.
5. Apply firm pressure, this may be directly on the wound, using a

pad and placing it over the wound and bandaging it firmly into
position. A pad can be made from any available material.
6. Digital pressure can be applied to the nearest artery known to

supply the part.
7. Only at a last resort is a tourniquet applied:
(1) It must be tight enough.
(2) There must be a piece of material between the tourniquet and the
skin.
(3) It must not be left on longer than 15 minutes.
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(4) An indication of the presence of a tourniquet must be made

obvious. This might be done by putting the letter T and the time
of application in the patient’s forehead.
3.7.6.3 Dangers Associated With the Application of Tourniquet
1. Damage nerves and muscles.
2. If it is not tight enough, it may only limit venous blood flow and
may not stop arterial blood flow.
3. Damage the skin.
4. Death of the affected part if the tourniquet is kept on for longer

than 20 minutes.
3.7.7 Pressure Points in the Body
These are points in the body when an artery passes superficially over a
bone.
1. Temporal Artery
This artery supplies the side of head. The thumb or tip of fingers may be
used to apply pressure here, by placing it over the zygomatic process of
the temporal bone. It is about one inch in front of the external auditory
meatus. The pressure here will stop bleeding on the superficial side of
the scalp.
2. Facial Artery
This artery supplies the side of the face passing at the side of the jaw in
front of the angle. The artery can be pressed against the mandible thus,
limiting the flow of blood to the face.
3. Brachial Artery
This artery supplies the arm, and passes down the inner aspect of the
humerus just beside the inner border of the Bicep muscles. It is easier
done if the nurse stands behind the patient.
4. Radial Artery
This is the artery most commonly used for recording the pulse. Digital
pressure can be applied by pressing the fingers very firmly on the artery
as it passes across the radius.
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5. Femoral Artery
This is the main artery of the leg; it passes down the front of the groin.
To compress it, the patient should be lying down with the knee flexed,
grasp the patient’s thigh with both hands placing both thumbs one on top
of the other in the centre fold of the groin.
4.0 Conclusion
Any condition that prevents cells from receiving an adequate blood

supply, /or interfere with this metabolism produces.
5.0 Summary
• Shock may be classified as hypovolemic, cardiogence or

vasegenic.
• Liver, heart, kidney and brain are major organism that can easily
be damaged by shock.
Define shock and discuss in detail the various types of conditions that
can lead to shock.
Brunner & Suddarth. Medical Surgical Nursing. (10th ed) Lippincott

Wilkins, 2004.
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UNIT 6 NEOPLASM
CONTENTS
1.0 Introduction
2.0 Objectives
3.0 Main Content
3.1 Terms Relating to Proliferative Patterns of Cell Growth
3.1.2 Normal Immune Response
3.1.3 Classification of Tumors or Neoplasms
3.1.4 Routes of spread of Malignant Neoplasms
3.1.5 Etiology of Malignant Neoplasms
3.1.6 Clinical Manifestation of Malignant Neoplasms
3.1.7 Diagnosis of Malignant Neoplasms
3.1.8 Imaging Tests Used to Detect Cancer
3.1.9 Detection and Prevention of Cancer
3.1.10 Treatment of Malignant Neoplasms
3.1.10.1 Surgery
3.1.10.2 Radiation
3.1.10.3 Chemotherapy
3.1.10.4 Hormonal Agents
3.1.10.5 Alkylating Agents
3.1.10.6 Antimetabolites
3.1.10.7 Mitotic Poisons
3.1.10.8 Antibiotics
3.1.11 Nursing Process: The Patient with Cancer
3.1.11.1 Assessment
3.1.11.2 Nursing Diagnoses
3.1.11.3 Planning
3.1.11.4 Nursing Intervention
4.0 Conclusion
5.0 Summary
1.0 INTRODUCTION
Normal cells proliferate to replace worn out tissue. The process is

increased after illness or injury and then slows to normal again.
Sometimes, certain body cells begin to multiply more rapidly than
normal which has no relationship to growth and maintenance of body
tissue. This new growth is called neoplasm. Neoplasm is a disease that is
universal in scope. It affects human wherever they live and regardless of
race – colour – level of education and affluence. However, there is some
variation with regard to sex, age and geographical location. The unit
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highlight, some neoplasm conditions with special emphasis on the nurse

role in cancer prevention.
2.0 OBJECTIVES
Ay the end of this unit, you should be able to:
• compare the structure and function of the normal cell and the cancer
cell
• differentiate between benign and malignant tumors
• identify agents and factors that have been found to be carcinogenic
• describe the special nursing needs of patients receiving
chemotherapy
• use the nursing process as a framework for care of patients with
cancer.
3.0 MAIN CONTENT
3.1 Terms Relating to Proliferative Patterns of Cell Growth
Perplasia, an increase in the number of cells of a tissue, is a common

proliferative process during periods rapid body growth and during
epithelial and bone marrow regeneration. It is a normal cellular response
when a physiologic demand exists and an abnormal response when
growth exceeds the physiologic demand.
Metaplasia occurs when one type of mature cell is converted to another

type by means of an outside stimulus that affects the parent stem cell.
The changes may be reversible or may progress to dysplasia.
Dysplasia is bizarre cell growth resulting in cells that differ in size,

shape, or arrangement from other of the same type of tissue. It can
precede irreversible neoplastc change.
Anaplasia is a lower degree of differentiation of dysplastic cells.

(Differentiation refers to the extent to which the cells differ from their
cells of origin and to their degree of maturity.) Anaplastic cells are
poorer differentiated; irregularly shaped, or disorganized with respect to
growth and arrangement. They lack no cellular characteristics and are
nearly always malignant.
Neoplasia, described as uncontrolled cell growth that follows no

physiologic demand, can be either benign or malignant. Benign and
malignant neoplastic growths are classified and named by tissue of
origin. The degree of anaplasia (lack of differential of cells) ultimately
determines the malignant potential.
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Cancer cells grow larger and divide more rapidly than normal cells, and
serve no useful purpose. They are metastasized by way of the circulation
through the blood or lymphatics, by accidental transplantation from one
site to another during surgery, and by local extension.
Cancer is a disease process that begins when an abnormal cell is

transformed by the genetic mutation of the cellular DNA. This abnormal
cell forms a clone and begins to proliferate abnormally, ignoring
growth-regulating signals in the environment surrounding the cell. The
cells acquire invasive characteristics, and changes occur in surrounding
tissues. The cells inflitrate these tissues and gain access to lymph and
blood vessels, which carry the cells to other areas of the body. This
phenomenon is called metastasis (cancer spread to other parts of the
body).
Cancer is not a single disease with a single cause; rather, it is a group of
distinct diseases with different causes, manifestations, treatments, and
prognoses.
3.1.2 Normal Immune Response
Normally, an intact immune system has the ability to combat cancer

cells in several ways. Usually, the immune system recognizes as foreign
certain antigens on the cell membranes of many cancer cells. These
antigens are known as tumor-associated antigens (also called tumor cell
antigens) and are capable of stimulating both cellular and humoral
immune responses.
Along with the macrophages, T lymphocytes, the soldiers of the cellular

immune response, are responsible for recognizing tumor-associated
antigens. When T lymphocytes recognize tumor antigens, other T
lymphocytes that are toxic to the tumor cells are stimulated. These
lymphocytes proliferate and are released into the circulation. In addition
to possessing cytotoxic (cell-killing) properties, T lymphocytes can
stimulate other components of the immune system to rid the body of
malignant cells.
Certain lymphokines, which are substances produced by lyphocytes, are

capable of killing or damaging various types of malignant cells. Other
lymphokines can mobilize other cells, such as macrophages, that disrupt
cancer cells. Interferon (IFN), a substance produced by the body in
response to viral infection, also possesses some antitumor properties.
Antibodies produced by B lymphocytes, associated with the humoral
immune response, also defend the body against malignant cells. These
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antibodies act either alone or in combination with the complement

system or the cellular immune system.
Natural killer (NK) cells are a major component of the body’s defense
against cancer. NK cells are a subpopulation of lymphocytes that act by
directly destroying cancer cells or by producing lymphokines and
enzymes that assist in cell destruction.
3.1.3 Classification of Tumors or Neoplasms
Neoplasm can be classified into benign and malignant forms.
Characteristics of Benign and Malignant Neoplasms
Characteristics Benign Malignant

Cell characteristics Well-differentiated Cells are
cells that resemble undifferentiated and
normal cells of the often bear little
tissue from which the resemblance to the
tumor originated. normal cells of he
tissue from which they
arose.
Mode of growth Tumor grows by Grows at the periphery
expansion and does not and sends out
infiltrate the processes that infiltrate
surrounding tissues; and destroy the
usually encapsulated. surrounding tissues.
Rate of growth Rate of growth is Rate of growth is
usually slow. variable and depends
on level of
differentiation; the
more anaplastic the
tumor, the faster its
growth.
Metastasis Does not spread by Gains access to the
metastasis. blood and lymphatic
channels and
metastasizes to other
areas of the body.
General effects Is usually a localized Often causes
phenomenon that does generalized effects,
not cause generalized such as anemia,
effect unless its weakness, and weight
location interferes with loss.
vital function.
Tissue destruction Does not usually cause Often causes extensive
tissue damage unless its tissue damage as the
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location interferes with tumor outgrows its

blood flow. blood supply or
encroaches on blood
flow to the area; may
also produce
substances that cause
cell damage
Ability to cause Does not usually cause Usually causes death
death death unless its location unless growth can be
interferes with vital controlled.
functions.
3.1.4 Routes of Spread of Malignant Neoplasms
a. direct extension to adjacent tissues

b. extension through lymphatic system or blood stream
c. diffusion within a body cavity.
3.1.5 Etiology of Malignant Neoplasms
Certain categories of agents or factors implicated in carcinogenesis

include viruses and bacteria, physical agents, chemical agents, genetic or
familial factors, dietary factors, and hormonal agents.
Viruses and Bacteria
Viruses as a cause of human cancers are hard to determine because

viruses are difficult to isolate. However, infectious causes are
considered or suspected, when specific cancers appear in clusters.
Viruses are thought to incorporate themselves in the genetic structures
of cells, thus altering future generations of that cell population––perhaps
leading to a cancer.
Herpes simplex virus type II, cytomegalovirus, and human

papillomavirus types 16, 18, 31 and 33 are associated with dysplasia and
cancer of the cervix. The hepatitis B virus is implicated in cancer of the
liver; the human T-cell lymphotropic virus may be a cause of some
lymphocytic leukemias and lymphomas; and the human
immunodeficiency virus (HIV) is associated with Kaposi’s sarcoma.
Physical Agents
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Physical factors associated with carcinogenesis include exposure to

sunlight or radiation, chronic irritation or inflammation, and tobacco
use.
Excessive exposure to the ultraviolet rays of the sun, especially in fair-

skinned, blue- or green-eyed people, increases the risk for skin cancers.
Factors such as clothing styles (sleeveless shirts or shorts), use of
sunscreens, occupation, recreational habits, and environmental variabels,
including humidity, altitude, and latitude, all play a role in the amount of
exposure to ultraviolet light.
Chemical Agents
About 75% of all cancers are thought to be related to the environment.

Smoking is strongly associated with cancers of the lung, head and neck,
esophagus, pancreas, cervix, and bladder. Tobacco may also act
synergistically with other substances, such as alcohol, asbestos,
uranium, and viruses, to promote cancer development.
Chewing tobacco is associated with cancers of the oral cavity and

primarily occurs in men younger than 40 years of age.
Genetic and Familial Factors
Almost every cancer type has been shown to run in families. This may
be due to genetics, shared environments, cultural or lifestyle factors, or
chance alone. Genetic factors play a role in cancer cell development.
Abnormal chromosomes, too few chromosomes, or translocated
chromosomes. Specific cancers with underlying genetic abnormalities
include Burkitt’s lymphoma, chronic myelogenous leukemia,
meningiomas, acute leukemias, retinoblastomas, Wilms’ tumor, and skin
cancers, including malignant melanoma.
In cancers with a familial predisposition, individuals may develop

multiple cancers; commonly, two or more first-degree relatives share the
same cancer type.
Dietary Factors
Dietary factors are thought to be related to 35% of all environmental

cancers. Dietary substances associated with an increased cancer risk
include fats, alcohol, salt-cured or smoked meats, and foods containing
nitrates and nitrites, and a high caloric dietary intake. Food substances
that appear to reduce cancer risk include high-fiber foods, cruciferous
vegetables (cabbage, broccoli, cauliflower, Brussels sprouts, kohlrabi),
carotenoids (carrots, tomatoes, spinach, apricots, peaches, dark-green
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and deep-yellow vegetables), and possibly vitamins E and C, zinc, and

selenium.
Obesity is associated with endometrial cancer and possibly

postmenopausal breast cancers. Obesity may also increase the risk for
cancers of the colon, kidney, and gallbladder.
Hormonal Agents
Tumors growth may be promoted by disturbances in hormonal balance

either by the body’s own (endogenous) hormone production or by
administration of exogenous hormones. Cancers of the breast, prostate,
and uterus are thought to depend on endogenous hormonal levels for
growth. Diethylstilbestrol (DES) has long been recognized as a cause of
vaginal carcinomas. Oral contraceptives and prolonged estrogen
replacement therapy are associated with increased incidence of
hepatocellular, endometrial, and breast cancers, whereas they appear to
decrease the risk for ovarian and endometrial cancers.
3.1.6 Clinical Manifestation of Malignant Neoplasms (7 danger

signals)
1. Early symptoms are often slight and therefore easily overlooked. It

is important to recognize early signs as when there is pain or drastic
change. Pain is usually a late stage.
Change in bowel or bladder.

A sore that does not heal
Unusual bleeding or discharge.
Thickening or lump in breast or elsewhere
Indigestion or difficulty in swallowing.
Obvious change in wart or not
Nagging cough or hoarseness.
2. Systemic Symptoms – vague symptoms such as fatigue, weight

loss, loss of appetite, and anemia which may be seen in many other
conditions.
3. Specific Symptoms – are related to the site of the body where they
are located and will be studied later.
3.1.7 Diagnosis of Malignant Neoplasms
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1. Regular physical examination, even in absence of symptoms

should be done if possible, for women over 35 and man over 45.
The exam should include: careful medical history; head to toe
physical exam with careful examination of breasts, genitals, and
rectum in women and rectum tests and prostate in men. Half of
all cancer occurs in sites accessible to palpation or visualization.
2. Laboratory and X-ray, according to the findings of the physical

examination:
a. Endoscopy
b. Cytology
c. Diagnostic x-rays (i.e. barium enema) chest
d. Radio-isotope scanning
e. Ultrasound – high frequency sound waver to detect internal
abnormal reaction of body organ or structure (leakage
f. Haematological examination – serum alkaline and acid phorphatic
metatastic bone ca of liver
g. Radiographic CAT SCAN (corepa
3. Biopsy – A microscopic exam of tissue is usually needed for

conclusive diagnosis. This may be done through any of the
methods of biopsy, including exploratory surgery.
3.1.8 Imaging Tests Used to Detect Cancer
Test Description Diagnostic uses

Magnetic Use of magnetic fields and Neurologic, pelvic,
resonance imaging radiofrequency signals to create abdominal, thoracic
(MRI) sectioned images of various body cancers.
structures.
Computed Use of narrow beam x-ray to scan Neurologic, pelvic,
tomography (CT successive layers of tissue for a cross- skeletal, abdominal,
scan) sectional view. thoracic cancers.
Fluoroscopy Use of x-rays that identify contrasts in Skeletal, lung,
body tissue densities; may involve the gastrointestinal cancers.
use of contrast agents.
Ultrasonography High-frequency sound waves echoing Abdominal and pelvic
(ultrasound) off body tissues are converted cancers.
electronically into images; used to assess
tissues deep within deep within the
body.
Endoscopy Direct visualization of a body cavity or Bronchial,
passageway by insertion of an gastrointestinal cancers.
endoscope into a body cavity or
opening; allows tissue biopsy, fluid
aspiration and excision of small tumors;
both diagnostic and therapeutic.
3.1.9 Detection and Prevention of Cancer
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Nurses and physicians have traditionally been involved with tertiary

prevention, the care and rehabilitation of the patient after cancer
diagnosis and treatment. In recent years, researchers have placed greater
emphasis on primary and secondary prevention of cancer. Primary
prevention is concerned with reducing the risks of cancer in healthy
people. Secondary prevention involves detection and screening to
achieve early diagnosis and prompt intervention to halt the cancer
process.
Primary Prevention
By acquiring the knowledge and skills necessary to educate the

community about cancer risk, nurses in all settings play a key role in
cancer prevention. Assisting patients to avoid known carcinogens is one
way to reduce the risk for cancer. Another way involves adopting
dietary and various lifestyle changes that epidemiologic and laboratory
studies show influence the risk for cancer. Nurses can use their teaching
and counseling skills to encourage patients to participate in cancer
prevention programmes and to promote healthful lifestyles.
Secondary Prevention
Individuals who have inherited specific genetic mutations have an

increased susceptibility to cancer. Women in whom the BRCA-1 and
BRCA-2 genes have been identified have an increased risk for breast
and ovarian cancer. To provide individualized education and
recommendations for continued surveillance and care in high-risk
populations, nurses need to be familiar with ongoing developments in
the field of genetics and cancers.
Numerous factors, such as races, cultural influences, access to care,

physician-patient relationship, level of education, income and age,
influence the knowledge, attitude, and beliefs people have about cancer.
These factors also influence the type of health-promoting behaviours
they practice. Nurses can use this type of information in planning
education, prevention, and screening programmes.
Public awareness about health-promoting behaviours can be increased in

a variety of ways. Health education and health maintenance programmes
are sponsored by community organizations such as churches, senior
citizen groups, and parent–teacher associations. Secondary prevention
programmes may promote breast and testicular self-examination and
Papanicolaou (Pap) tests.
3.1.10 Treatment of Malignant Neoplasms
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Introduction
The choice of treatment will depend on the histology of the tumor, the
site, and the extent of growth.
Forms of Therapy
3.1.10.1 Surgery
Wide excision of tumor and surrounding tissue such as lymph node.

Specific types of surgery performed will be discussed with the specific
types of cancer. Surgical removal of the entire cancer remains the ideal
and most frequently used treatment method. The specific surgical
approach, however, may vary for several reasons. Diagnostic surgery is
the definitive method of identifying the cellular characteristics that
influence all treatment decisions. Surgery may be the primary method of
treatment, or it may be prophylactic, palliative, or reconstructive.
Diagnostic Surgery
Diagnostic surgery, such as a biopsy, is usually performed to obtain a

tissue sample for analysis of cells suspected to be malignant. In most
instances, the biopsy is taken from the actual tumor.
Surgery as Primary Treatment
When surgery is the primary approach in treating cancer, the goal is to

remove the entire tumor or as much as is feasible (a procedure
sometimes called debunking) and any involved surrounding tissue,
including regional lymph nodes.
Prophylactic Surgery
Prophylactic surgery involves removing no vital tissues or organs that

are likely to develop cancer. The following factors are considered when
electing prophylactic surgery:
• Family history and genetic predisposition.

• Presence or absence of symptoms.
• Potential risks and benefits.
• Ability to detect cancer at an early stage.
• Patient’s acceptance of the postperative outcome.
Colectomy, mastectomy, and oophorectomy are examples of

prophylactic operations.
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Palliative Surgery
When cure is not possible, the goals of treatment are to make the patient
as comfortable as possible and to promote a satisfying and productive
life for as long as possible. Palliative surgery is performed in an attempt
to relieve complications of cancer, such as ulcerations, obstructions,
hemorrhage, pain and malignant effusions (Table 16-5).
Reconstructive Surgery
Reconstructive surgery may follow curative or radical surgery and is

carried out in an attempt to improve function or obtain a more desirable
cosmetic effect. It may be performed in one operation or in stages.
3.1.10.2 Radiation
1. Definition Use of radioactive rays to destroy cancer tissue

without unduly harming surrounding tissues.
2. Action Works on the basis that rapidly dividing cells (tumor

cells) are more sensitive to radiation than those that divide
slowly.
3. Uses For cure, palliative, or control of spread, or for relief of

pain.
4. Types
a. External beam therapy – x-ray or cobalt

b. Radioisotopes
(1) Implanted in applicators as seeds such as radium

(2) Orally such as radioactive iodine
(3) Interstitial or intracavitary injection as radioactive gold
(4) Orally or intravenously, as radioactive phosphorus
5. Criteria for use
a. Tumor must be radiosensitive rather than radio resistant.

Cell that are radiosensitive are those that are:
(1) Rapidly dividing
(2) Poorly differentiated, embryonic, and immature

(3) Characterized by increased metabolic activity.
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a. Tumors must be located in areas where they can be treated with

fairly large doses of radiation without causing serious injury to
neighboring tissues.
b. Tumors most sensitive to radiotherapy include medulloblastoma

(tumor of cerebellum); lymphomas; metastatic breast cancer;
tumors of skin, lip, mouth, tongue; uterine, cervix, urinary
bladder, larynx, tonsils, nasopharynx, and sinuses.
6. Dangers
a. Damage to the normal cells. The larger the area and the more intense
the dose at one time, the greater the chance of more normal cells
being destroyed.
b. Radiation sickness: Nausea and vomiting; malaise; purpura;

petechiae, diarrhoea, and inflammation of mouth and nose.
c. Skin reactions: Erythema, desquamation and abnormal pigmentation

may develop in the area exposed to the therapy.
d. Bone marrow depression.
e. Increased susceptibility: to cancer in irradiated areas – usually 20 or

more years before development.
f. Birth defects: due to genetic mutation. If pregnant woman’s gonads

are exposed from two to six weeks gestation, the patient’s baby may
be born with congenial defects.
3.1.10.3 Chemotherapy
Definition: Drugs used to slow the progress of the disease and relieve
distressing symptoms. The principle of chemotherapy is the selective
injury by systemic agents to one type of cell and not another. Most are
toxic to normal tissues as well as cancer tissue.
Administration: Oral; IV; IM; Perfusion
3.1.10.4 Hormonal Agents
Estrogens used in treatment of cancer of prostate and breast in

postmenopausal women.
Effects
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Relief from discomfort and prolonging of life in 60-80% cases of

prostate cancer.
Side Effects
Nausea and vomiting; fluid retention; enlargement of breasts, uterine

bleeding and general feminization of the male.
Androgens used in the treatment of breast cancer
a. Therapeutic effects
Relief of bone pain, regression of soft tissue mass; decalcification of

bone lesions; increase in sense of well-being; increased appetite and
weight gain.
b. Side effects
Lowering of voice; hirsutism; edema; increased sexual desire; some

dangerous rise of calcium in blood.
Adrenal (ACTH; Cortisone)
a. Action
Depresses the bone marrow especially WBC. Mechanism not fully

understood.
b. Uses
Dramatic short remission in patients with acute leukemia and

advantageous in advanced cases of chronic lymphatic leukemia and
multiple myelma.
c. Side Effects
Fluid retention, hypertension and coma, hypergeyamia moon face,

hirsutism and increased susceptibility to infection.
3.1.10.5 Alkylating Agents
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(1) Action: powerful cytotoxic agents active against rapidly dividing

cells, particularly blood cells.
(2) Examples: Nitrogen mustard; Myleran; Leukeran. Cytoxian.
(3) Use: malignant lymphoid tissue (Hodgkins and lymphosarcoma);

advanced breast and ovarian cancer; myelogenous leukemia.
3.1.10.6 Antimetabolites
(1) Action
The compounds used are all similar to important constituents of cell

metabolism. They act by replacing the substances they mimic thus
driving out essential metabolites.
(2) Examples
Methotrexate inhibits Folic Acid. 5-flurouracil inhibits thymidiliac

components of DNA.
(3) Uses
Acute leukemias of adult and children; lymphomas; Hodgkins; solid

tumors; choriocarcinoma
3.1.10.7 Mitotic Poisons
(1) Action
Their exact mode of action is unknown but they form crystalline

structures which bind to proteins of low molecular weight and inhibit
both DNA and RNA synthesis.
(2) Examples
Vineristine (Oncovin) and Vinblastine (Velban)
(3) Uses
Leukemia; Hodgkins
3.1.10.8 Antibiotics
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1. Action
Potent immunosuppresive agents thought to act by binding to DNA on

the site where RNA ordinarily functions.
2. Examples
Aotinomycin D. Adriamycin; Bleomycin
3. Uses
Melanoma, Wilm’s tumor; lymphomas, leukemias
4. Side Effects
Potentiates the action of radiotherapy and very severe skin reations may
occur in patients on both treatments.
Side effects of antineoplastic drugs
1. G.I. Effects
Nausea and vomiting; diarrhoea; anorexia; oral ulceration.
2. Hematological Effects
Bone marrow depression. If platelet depression or RBC: bleeding &

easy bruising; anemia which will be treated with transfusion of RBC or
platelets. If WBC decreased, there is decreased resistance to infection
and treated with reversed isolation.
3. General
Fatigue; alopecia
4. Supportive therapy
This may include special diets, blood transfusions, analgesics,

electrolytes, vitamins, and Intravenous fluid
3.1.11 Nursing Process: The Patient with Cancer
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3.1.11.1 Assessment
Regardless of the type of cancer treatment or prognosis, many patients

with cancer are susceptible to the following problems and
complications. An important role of the nurse on the oncology team is to
assess the patient for these problems and complications.
Infection
In all stages of cancer, the nurse assesses factors that can promote
infection.
Bleeding
The nurse assesses cancer patients for factors that may contribute to
bleeding. Gross hemorrhage, as well as blood in the stools, urine,
sputum, or vomitus (melena, hematuria, hemoptysis, and hematemesis),
oozing at injection sites, bruising (ecchymosis), petechiae, and changes
in mental status, are monitored and reported.
Skin Problems
The integrity of skin and tissue is at risk in cancer patients because of

the effects of chemotherapy, radiation therapy, surgery, and invasive
procedures carried out for diagnosis and therapy.
Hair Loss
Alopecia (hair loss) is another form of tissue disruption common to

cancer patients who receive radiation therapy or chemotherapy. In
addition to noting hair loss, the nurse also assesses the psychological
impact of this side effect on the patient and the family.
Nutritional Concerns
Assessing the patient’s nutritional status is an important nursing role.

Impaired nutritional status may contribute to disease progression.
Pain
Pain and discomfort in cancer may be related to the underlying disease,

pressure exerted by the tumor, diagnostic procedures, or the cancer
treatment itself.
In addition to assessing the source and site of pain, the nurse also
assesses those factors that increase the patient’s perception of pain, such
as fear and apprehension, fatigue, anger, and social isolation.
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Fatigue
Fatigue is the most commonly reported side effect in patients who

receive chemotherapy and radiation therapy. The nurse assesses for
feelings weariness, weakness, and lack of energy, inability to carry out
necessary and valued daily functions, lack of motivation, and inability to
concentrate.
Psychosocial Status
Nursing assessment also focuses on the patient’s psychological and

mental status as the patient. The patient’s mood and emotional reaction
to the results of diagnostic testing and prognosis are assessed, along with
evidence that the patient is progressing through the stages of grief and
can talk about the diagnosis and prognosis with the family.
Body Image
Disfiguring surgery, hair loss, cachexia, skin changes, altered

communication patterns, and sexual dysfunction are some of the
devastating results of cancer and its treatment that threaten the patient’s
self esteem and body image. The nurse identifies these potential threats
and assesses the patient’s ability to cope with these changes.
3.1.11.2 Nursing diagnoses
Based on the assessment data, nursing diagnoses of the patient with

cancer may include the following:
• Impaired oral mucous membrane.

• Impaired tissue integrity.
• Impaired tissue integrity: alopecia.
• Impaired tissue integrity: malignant skin lesions.
• Imbalanced nutrition, less than body requirements.
• Anorexia.
• Malabsorption.
• Cachexia.
• Chronic pain.
• Fatigue.
• Disturbed body image.
• Anticipatory grieving.
3.1.11.3 Planning
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The major goals for the patient may include management of stomatitis,
maintenance of tissue integrity, maintenance of nutrition, relief of pain,
relief of fatigue, improved body image, effective progression through
the grieving process, and absence of complication.
Emotional Care
a. Cancer poses real threats to the individual. We must recognize

this. The fear of death, prolonged suffering, body mutilation, fear
of the cost of treatment.
b. Understand that the emotional aspects are often affected by the

patient’s and family’s attitudes and reactions, location and
impairment of body functions, stage of disease and prognosis.
c. Communication:
1. Do not avoid his questions

2. Listen to him and then decide how to answer
3. Be clear about what the doctor has told the patient.
4. Often a question as to whether to tell the patient.
d. Maintain dignity:
1. Respect the person

2. Do not expose patient, especially with disfiguring problems
3. Cleanliness
e. Encourage family to support patient.
f. Encourage patient in self help as long as he is able.
g. Do not show distaste at any procedure done because the patient is

very sensitive to the nurse’s reactions.
Physical Care
a. Of patient After Surgery give general post-operative care with

special considerations on the effect of cancer.
b. External radiotherapy
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i. Instruct patient not to remove or wash away any marks the

radiologist makes on the skin. These are to delineate the exact area of
the patient’s body that is to be radiated.
2. Skin Care
(1) Apply lanolin or petroleum jelly to skin if irritated but with

doctor’s order or permission.
(2) Do not allow extreme heat or cold to be on the place.
(3) Do not use soap or water on the area.
i. Observe for signs of radiation sickness and report.

ii. Do not allow visitors with infections to visit.
3. General
a. Promote bed rest.
b. If nausea and vomiting, give small frequent feeding of a high

caloric, high protein diet, and administer antiemetics.
c. Force fluids to 3000 ml. per day in order to maintain effective

kidney function and avoid uric acid crystalluria and possible
kidney shutdown.
d. Keep accurate intake and output.
e. Administer any drug that might be ordered. Vitamin B12;

sedatives; antihistamines.
Of Patients on Chemotherapy
1. Always give the ordered dosage and at the proper time. i.e. a drug
may be given only after the lab work has been done and reported.
2. Give gentle mouth care.
3. Bland soft diet if stomatitis is present.
4. Encourage nutritional and fluid intake.
5. Report early signs of infection (fever, sorethroat, chills), and

nausea, vomiting, diarrhoea.
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General Nursing Care
1. Stress the importance of follow up care.
2. Know the 7 warning symptoms of cancer.
3. In terminal cases, the relief of pain is very essential. Give large

doses of powerful analgesics (tolerance does develop).
4. Try to prevent complications. i.e. Bleeding in those with

decreased platelet or RBC count. Prevention of infection in those
with lowered WBC. Pathologic fractures in cancer of the bone.
5. Try to maintain nutrition.
4.0 CONCLUSION
Neoplasm is a disease that is unusual in scope, shows no respect for

economic and social statuses, but varies with regards to sex, age race
and geographic locations. It is also clear that cancer has many causes
and that a combination of many factors may be necessary for the actual
clinical appearance of the disease. A combination of factors favours
development that may include hereditary, hormonal state, and exposure
to carcinogens.
5.0 SUMMARY
• A Nurse plays a vital role in cancer prevention by assessing

individual at risk of and them about environment and personal risk
fact.
• Major cancer sites include breast, rectum, lung, month, skin uterus.
• Environment and personal factor influence the growth of ca cells.
• Early detection and reaction direct at ↓ inciting cause.
6.0. TUTOR-MARKED ASSIGNMENT
Discuss the role of a nurse in the treatment and management of cancer.
Brunner & Siddhartha. Medical Surgical Nursing. (10th Ed) Lippincott

Wilkins, 2004.
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UNIT 7 PAIN
CONTENTS
1.0 Introduction
2.0 Objectives
3.0 Main Content
3.1 Key words
3.1.1 Concept of Pain
3.1.2 Classification of Pain
3.1.3 Physiology of Pain
3.1.4 Theory of Pain Transmission
3.1.5 Component of Pain Experience
3.1.6 Factors Influencing the Pain Response
3.1.7 Nursing Process
3.1.7.1 Assessment of Pain
3.1.7.2 Data Analysis and Planning
3.1.7.4 Expected Patient Outcomes
3.1.7.6 Evaluation
3.1.8 Nontraditional Pain Treatment
4.0 Conclusion
5.0 Summary
1.0 INTRODUCTION
Pain has been described as a complex series of events occurring between

a noxious stimulus and the brain. Unlike other observations of a client,
the observation of pain depends mainly on the client himself and not the
nurse, hence the need for you to have a good knowledge of the concept
of pain and pain management.
2.0 OBJECTIVES
Ay the end of this unit, you should be able to:
• define pain
• explain the theories and mechanism of pain
• describe ascending and descending pain ways
• apply nursing process in the alleviation and management of pain.
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3.0 MAIN CONTENT
3.1 Key Concept
Pain Management
Alleviation of pain or reduction in pain to a level of comfort that is

acceptable to the patient.
Medication Management
Facilitation of safe and effective use of prescribed or over-the-counter

medicine.
Simple Relaxation Therapy
Use of techniques to encourage and elicit relaxation for the purpose of

decreasing undesirable signs and symptoms such as pain, muscle
tension, or anxiety.
Simple Guided Imagery
Purposeful use of imagination to achieve relaxation and/or direct

attention away from undesirable sensations.
Emotional Support
Provision of reassurance, acceptance, and encouragement during times

of stress.
Self-Esteem Enhancement
Assisting a patient to increase his or her personal judgment of self-

worth.
Pain Level
Severity of reported or demonstrated pain.
Comfort Level
Extent of physical and psychological ease.
Addiction
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A behavioural pattern of substance use characterized by a compulsion to

take the drug primarily to experience its psychic effects.
Dependence
Occurs when a patient who has been taking uploads experiences a

withdrawal syndrome when the opioids are discontinued; often occurs
with opioid tolerance and does not indicate an addiction.
Noreceptor
A receptor preferentially sensitive to a noxious stimulus.
Non-nociceptor
Nerve fiber that usually does not transmit pain.
Pain
An unpleasant sensory and emotional experience resulting from actual

or potential tissue damage. Overdue
Referred Pain
Pain perceived as coming from an area different from that in which the
pathology is occurring.
Tolerance
Occurs when a person who has been taking opioids becomes less
sensitive to their analgesic properties (and usually side effects).
Characterized by the need for increasing does to maintain the same level
of pain relief.
Pain Threshold
The point at which a stimulus is perceived as painful.
Pain Tolerance
The maximum intensity or duration of pain that a person is willing to

endure.
Patient-Controlled Analgesia (PCA)
Self-administration of analgesic agents by a patient instructed about the

procedure
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Referred Pain
Pain perceived as coming from an area different from that in which the
pathology is occurring.
Tolerance
Occurs when a person who has been taking opioids becomes less
sensitive to their analgesic properties (and usually side effects).
Characterized by the need for increasing does to maintain the same level
of pain relief.
3.1.1 Concept of Pain
There are different definitions of pain. Pain has been described as

psychological experience of events occurring within the patient’s body,
always unpleasant and often associated with the impression of damage
to the tissues. Another definition is that pain represents the suffering
induced by the psychic perception of real, threatened, or phantasied
injury. From these definitions, it can be seen that pain is the result of a
complex series of events occurring between a noxious stimulus and the
brain. Although these definitions imply the ideas of injury and suffering,
they do not mention actual physical injury. Unlike other observations of
a client, the observation of pain depends mainly on the client himself,
not the nurse...
3.1.2 Classification of Pain
Pain is usually classified as acute or chronic, mild or severe.
Acute Pain includes the sensation that results from a sudden injury e.g.
broken tooth or a sharp stab in the arm. It is felt at once, and gradually
diminishes either of its own accord or after treatment.
Chronic Pain is constant and intermittent pain that persist beyond the
expected healing time as is often due to a specific cause or injury. There
are different types of chronic pain. Intermittent chronic pain occurs only
at periods; at other times the person is pain-free (as seen in migraine
headaches). Persistent pain is always present, although there may be
periods when pain is less intense (as seen with low back pain). Chronic
pain is characterized by irritability (often compounded by insomnia),
which leads to decreasing interests and isolation from friends and
family. Added to that is the feelings of helplessness and hopelessness as.
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Table 1 Comparison of acute and chronic pain
Characteristic Acute Pain Chronic Pain

Experience An event A situation, state of
Source External agent or existence
internal disease Unknown or cannot be
changed or treatment is
prolonged or ineffective
Onset Usually sudden May be sudden or
develop insidiously
Duration Transient (up to six Prolonged (months to
Pain months) years)
identification Pain vs. nonpain areas Pain vs. nonpain areas
generally well identified less easily differentiated;
intensity becomes more
difficult to evaluate
(change in sensations)
Clinical signs Typical response pattern Response patterns vary;
with more visible signs fewer overt signs
(adaptation)
Meaning Meaningful (informs Meaningless; person
person something is looks for meanings
wrong)
Pattern Self-limiting or readily Continuous or
corrected intermittent; intensity
may vary or remain
constant
Course Suffering usually Suffering usually
decreases over time increases over time
Actions Leads to actions to Leads to actions to
relieve pain modify pain experience
Prognosis Likelihood of eventual Complete relief usually
complete relief not possible
Other types of Pain: Pain from Specific Sites
Pain may originate in the skin, subcutaneous tissue, muscles, or bones

(somatic pain) or in body organs (visceral pain).
Referred Pain
Referred pain is felt in areas than those stimulated. For example, the
person experiencing a heart attack may complain only of pain radiating
down the left arm when in fact the tissue damage is occurring in the
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myocardium. Referred pain seems to occur most often with damage or

injury to visceral organs.
Psychogenic Pain
Psychogenic pain is pain that cannot be accounted for physiologically; it

appears to originate in the person’s mind. Usually sensation is perceived
by the person as “pain,” and it can be just as intense as pain originating
from physical stimuli.
Phantom Limb Pain
Phantom limb is pain or discomfort perceived by the individual to be

occurring in an extremity that has been amputated. It is common with
persons that have had the limbs amputated.
Neurologic Pain
Pain in the neurologic system occurs in different forms. Neuralgia is

sharp, spasm like pain along the course of one or more nerves. Two
common areas ones are the trigeminal nerve in the face and the sciatic
nerve in the lower trunk.
Superficial Somatic
This refers to pain in body structures such as skin and subcutaneous

tissue; fascia and fibrous tissue encasing the limbs and trunk; and the
periosteum, ligaments, and tendon sheaths. These areas are well
supplied with receptors and fibers.
Ascending Descending
pathway pathway
Non-nociceptor
Nociceptor
Cutaneous
fibers
Visceral
fibers
Inhibilitory effect
+ Excitatory effect
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3.1.3 Physiology of Pain
Stimuli causing pain may be of chemical, thermal, electrical, or

mechanical origin. Nerve receptors respond to the stimuli and transmit
the impulses by two types of fibers (fast myelinated A-delta fibers and
slow unmyelinated C fibers) to the posterior horn (gray matter) of the
spinal cord. See Fig. 1 Within the cord, the impulses are transmitted to
the white matter on the opposite side, from which they ascend by the
lateral spinothalamic tract to the thalamus. Impulses are then sent to the
cerebral cortex (where perception takes place) by way of the
corticothalamic tracts.
Descending pain pathways from the brain are of two types. One
pathway, which descends from the brainstem reticular formation and
ends in the posterior horn of the spinal cord, has the ability to inhibit
pain transmission (by means of neurotransmitters resembling naturally
occurring opiates called endorphins). The second pathway sends signals
from the cortex through the spinal cord to the muscles to initiate action.
3.1.4 Theory of Pain Transmission
Numerous theories have been proposed over the years to explain pain
transmission. The most commonly accepted theory is the gate control
theory proposed by Melzak and Wall. This theory suggests that
transmission of pain impulses can be controlled by a gating mechanism
that, when open, permits the pain impulses to be transmitted, but which
can be partially or totally closed to inhibit some or all of the impulse
transmission.
According to the theory, pain transmission can be influenced by three

factors:
1. Effect of impulses transmitted over the two types of pain nerve

fibers (A-detal and C fibers) to the spinal cord.
2. Effect of impulses from the brainstem.
3. Effect of impulses from the cortex.
Stimuli travelling over the large fibers may block those from the slow
fibers. Endorphins are present in the brainstem and in the substantial
gelatinosa (gray matter in the dorsal horn of the spinal cord, where pain
fibers synapse). The endorphins have morphine like action that inhibits
pain transmission. The cortex may either inhibit or facilitate pain
transmission, depending on variables such as thoughts, attitudes, past
experiences. For example, believing that a pain will be controlled will
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usually result in less pain perception than believing that pain will not be
relieved.
3.1.5 Components of the Pain Experience
Initiation
For a long time is thought that pain occurred when a pain stimulus was
perceived by a pain receptor and was transmitted along pain pathways to
a pain centre in the brain. Today neurophysiologists discount that
theory, that stimulation of receptors must always bring forth pain. Such
a model, they point out, confuses the psychological experience with
physiological function.
A theory currently accepted is Melzack’s gate-control theory. This
theory holds that
When an input, whether coming from the body, the

environment, or from the body, the environment, or from
the mind (fantasy), is interpreted as signifying injury, the
movement of impulses to the areas of the brain mediating
avoidance and internal adjustment is facilitated, and the
total complex of pain as behaviour and subjective
experience is elicited.
Perception
In understanding the mechanisms of pain, it is important to remember

the concept of perception. Perception is the process through which we
understand something new by making it a part of our previous
knowledge and experience. The experience of pain involves interpreting
the sensory input in terms of previous experience, and the end result is
influenced by current and past psychological experience. For this
reason, two people can react differently to one stimulus, and the same
person can react differently to one stimulus, and the same person can
react differently at two different times.
In fact, a person can feel pain without even being actually injured. As
one author explains, “Pain is not a perceptual fact until, and unless,
psychological processing of underlying physical events in the nervous
system has taken place.”
According to the gate-control theory small-diameter fibers carry the pain

signals. At the same time, large-diameter cutaneous fibers (afferents)
may inhibit the transmission of these pain impulses from the spinal cord
to the brain. This is accomplished by a gating mechanism that regulates
the afferent patterns before the influence the central transmission cells in
the posterior (dorsal) horn of the spinal cord. The client perceives pain
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and responds to it when the output of the central transmission cells

reaches or exceeds a critical level. The gating mechanism thus balances
the stimulus due to pain signals against the inhibitory signals and
conveys the net result to the brain. If the activity in the small fibers is
greater than that in the large, pain is felt. If the activity in the large fibers
is greater, the pain stimulus in the smaller fibers is overcome.
Fiber activity is not the only influence on the transmission of impulses.

Brain activities set in motion by the afferent patterns in the dorsal
column systems are also important. This means that present and past
experiences also affect the system. The input is evaluated in terms of its
physical properties as its meaning to the individual. Then it is felt as
sensation.
Interpretation
The challenge to both nurse and physician is to interpret what a client

means when he reports himself in pain. Complaints may reflect one or
more of the following:
1. The present of local tissue injury or of a peripheral stimulus

approaching the threshold of tissue injury.
2. A local afferent input that has become associated in the mind

with the threat of injury or disease, so that a sensation not
previously felt as painful is felt and reported as pain. For
instance, a man who fears he has an ulcer may report a slight
stomach upset as pain.
3. Peripheral or central nervous system damage that interferes with

the normal modulation of small fiber afferent input (for example,
the neuralgias, causalgia, and “central” pain).
4. An unconscious psychological need to suffer or to be punished or

to assume the role of suffers.
5. A deliberate attempt to deceive others (malingering).
What is the case when the client says he feels no pain? Most obviously
he may have suffered no injury, tissue damage, or peripheral
stimulation. On the other hand, his receptors or pathways may by
damaged or the tissue or structure involved may have no afferent nerve
supply capable of transmitting impulses into the dorsal root system.
Possibly there is not enough stimulation to activate the receptors, fibers,
or connections of the dorsal root system.
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It is also possible that the client reports no pain because his level of
consciousness or attention is dulled. For psychological reasons he may
reject the notion of injury or suffering, and therefore does not feel pain
or does not wish to report it.
3.1.6 Factors Influencing the Pain Response
A person’s pain experience is influenced by a number of factors,

including past experiences with pain, anxiety, culture, age, gender, and
expectations about pain relief. These factors may increase or decrease
the person’s perception of pain, increase or decrease tolerance for pain,
and affect the responses to pain.
Past Experience
The way a person responds to pain is a result of many separate painful

events during a lifetime. For some, past pain may have been constant
and unrelenting, as in prolonged or chronic and persistent pain. The
individual who has pain for months or years may become irritable,
withdrawn, and depressed. The undesirable effects that may result from
previous experience point to the need for the nurse to be aware of the
patient’s past experiences with pain. If pain is relieved promptly and
adequately, the person may be less fearful of future pain and better able
to tolerate it.
Culture
Beliefs about pain and how to respond to it differ from one culture to the
next. Early in childhood, individuals learn from those around them what
responses to pain are acceptable or unacceptable. Factors that help to
explain differences in a cultural group include age, gender, education
level, and income. In addition, the degree to which he or she will adopt
new health behaviours or cling to traditional health beliefs and practices.
The main issues to consider when caring for patients of a different
culture are:
• What does illness mean to the patient?

• Are there culturally based stigmas related to this illness or pain?
• Are traditional pain-relief remedies used?
• Does the patient have any fears about the pain?
Nurses need to avoid stereotyping patients by culture and provide

individualized care rather than assuming that a patient of a specific
culture will exhibit more or less pain. In addition to avoiding
stereotyping, health care providers need to individualize the amount of
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medications or therapy according to the information provided by the

patient.
Age
The effect of age on pain is inconsistent. Experts in the field of pain

management have concluded that if pain perception is diminished in the
elderly person, it is most likely secondary to a disease process (e.g.,
diabetes) rather than to aging.
The way an older person responds to pain may differ from the way a
younger person does. Because elderly people have a slower metabolism
and a greater ratio of body fat to muscle mass than younger people,
small doses of analgesic agents may be sufficient to relieve pain, and
these doses may be effective longer. Judgments about pain and the
adequacy of treatment should be based on the patient’s report of pain
and pain relief rather than on age.
Gender
Researchers have studied gender differences in pain levels and in

responses to pain. Once again, the results have been inconsistent.
3.1.7 Nursing Process
3.1.7.1 Assessment of Pain
This will involve both subjective and objective data.
Subjective Assessment of Acute Pain. This Include:
Pain Intensity
This can be determined by various means. One way is to ask the patient
to describe the pain or discomfort. Another method is to ask the patient
to describe the severity of the pain or discomfort using a pain scale. The
pain scale score can be recorded on a flow chart to provide ongoing
assessment of progression of the pain. A third approach is to ask the
patient to mark an X on a visual analog scale (Fig. 1)
Pain Scale
0––No pain* 0––No pain 0––No pain
1––Mild pain 1––Mild pain 1––Slight pain
2––Discomfort 2––Moderate pain 2––Moderate pain
3––Distressing 3––Severe pain 3––Severe pain
4––Horrible 4––As bad as it could be
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5––Excruciating
No pain
Mild Moderate Severe
Mild Moderate Severe
Fig. 1. Visual analog pain scales. Person marks line describing intensity
of pain
When acute pain has subsided, further data can be collected about the
meaning of pain for the person.
Timing
Sometimes the etiology of pain can be determined when time aspects are
known. Therefore, the nurse inquires about the onset, duration,
relationship between time and intensity, and whether there are changes
in rhythmic patterns. The patient is asked if the pain began suddenly or
increased gradually. Sudden pain that rapidly reaches maximum
intensity is indicative of tissue rupture, and immediate intervention is
necessary. Pain from ischemia gradually increases and becomes intense
over a longer time. The chronic pain of arthritis illustrates the usefulness
of determining the relationship between time and intensity, because
people with arthritis usually report that pain is worse in the morning.
Location
The location of pain is best determined by having the patient point to the
area of the body involved. Some general assessment forms have
drawings of human figures, and the patient is asked to shade in the area
involved. This is especially helpful if the pain radiates (referred pain).
The shaded figures are helpful in determining the effectiveness of
treatment or change in the location of pain over time.
Quality
The nurse asks the patient to describe the pain in his or her own words
without offering clues. For example, the patient is asked to describe
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what the pain feels like. Sufficient time must be allowed for the patient
to describe the pain and for the nurse to carefully record all words that
are used.
Personal Meaning
Patients experience pain differently, and the pain experience can mean
different things. It is important to ask how the pain has affected the
person’s daily life. Some people can continue to work or study, while
others may be disabled. The patient is asked if family finances have
been affected. For others, the recurrence of pain may mean worsening of
the disease, such as the spread of cancer. The meaning attached to the
pain experience helps the nurse understand how the patient is affected
and assists in planning treatment.
Aggravating and Alleviating Factors
The nurse asks the patient what if anything makes the pain worse and
what makes it better and asks specifically about the relationship between
activity and pain. This helps detect factors associated with pain. For
example, the patient is asked if pain is influenced by or affects the
quality of sleep or anxiety. Both can significantly affect the quality of
sleep or anxiety. Knowledge of alleviating factors assists the nurse in
developing a treatment plan.
Pain Behaviors
When experiencing pain, people express pain with many different

behaviours. These nonverbal and behavioral expressions of pain are not
consistent or reliable indicators of the quality or intensity of pain, and
they should not be used to determine the presence of or the degree of
pain experienced. Patients may grimace, cry, rub the affected area, guard
the affected area, or immobilize it. Others may moan, grunt, or sigh. Not
all patients exhibit the same behaviours, and there may be different
meanings associated with the same behaviour.
Objective Data
Objective data assist the nurse in identifying possible pain or discomfort

in a person who has not reported pain and in helping to clarify the
subjective response. Behavioral manifestations of pain must be watched
out for. This includes holding the body rigid, moving restlessly,
frowning, gritting teeth, clenching fists, crying and moaning.
Other data collected may include the following:
1. Demographic data
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2. Sociocultural data
3. History of the pain pattern from time of onset
4. Factors perceived to increase or decrease the pain

5. Effects of the pain on the person’s life-style
6. Meaning of the pain for the person
7. Effects of the patient’s pain on other family members or friends
8. Measures used in the past and present for pain relief.
3.1.7.2 Data Analysis and Planning
Data gathered must be analyzed and appropriate care planned. This plan
must incorporate measures the patient thinks may help relieve the pain,
even if these measures are different from those usually carried out in
that institution. This may include non-prescription liniments, special
applications of heat and cold, unusual positioning, or favourite
homemade foods or drinks. That must be that if there are no
contraindications. In some situations it may be appropriate for the
patient to help plan the use of pain relief measures. For example, the
patient may wish to receive potential analgesics at bedtime to improve
sleep.
Possible nursing diagnosis includes:
1. Ineffective breathing pattern related to pain in chest or abdomen

2. Anxiety related to increasing pain
3. Self-care deficit related to pain
4. Sexual dysfunction related to pain
5. Sleep pattern disturbance related to pain
3.1.7.4 Expected Patient Outcomes

1. The patient states that comfort is improved.
2. If pain is still present when patient is discharged, the patient or

significant other can:
a. Describe general measures for pain relief (for example, exercises)

b. Explain prescribed medications (actions, dosages, frequency, side
effects)
c. Describe when to seek medical assistance if pain is not relieved
as expected
3. The person with chronic pain can:
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a. State plans to participate in ongoing therapies

b. State plans for increasing independence in activities of daily
living.
Anticipate and Prevent Painful Stimuli
The nurse can use varied methods in alleviating the source of pain.
However, the technique she chooses will depend on the pathology of the
client’s disease. Anticipating and meeting the client’s needs can help
reduce painful stimuli and reduce the client’s anxiety. Examples of
simple measures that can reduce pain include making sure the client is in
a comfortable and proper position, giving the client back rubs to relieve
tension and muscle aches, offering a bedpan for use, answering to call
signal promptly, keeping the room clean and at a comfortable
temperature are all ways to do this.
Relieve Pain Source
The goal is to break the circuit of pain at its source. For example, if a
client with prostate hypertrophy is suffering from a distended bladder,
the responsibility of the nurse is to empty the bladder by helping him
void, by asking him to stand. This stimulates sensory nerves that bring
about reflex contraction of muscles of the bladder wall. Several topical
anesthetics can also be used to decrease the transmission of anxious
stimuli that accompany some painful procedures. Foods can also be used
to relieve pain. A glass of milk will often relieve burning sensations in
the stomach, eating small fragment meals at a time, reduces gastric
ulcer.
Decrease Pain Stimulus
This is done by changing position of the patient this reduces the

intensity of the stimulation of pain receptors. She can also support the
weight of the extremities on pillows and provide emotional support.
Block Pain Pathway
Pain pathway can be blocked with surgery, such as a nerve block or

cordotomy, or injection of a drug to inhibit transmission of nerve
impulses.
Decrease pain perception, modify pain interpretation, and decrease

pain reaction
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Another way that the nurse can relieve the suffering client is to decrease
his perception of pain by raising the threshold of pain perception. This
can be done, using analgesics, hypnotics, or distraction.
Generally, environment, state of mind, and bodily condition act in
concert to intensify the pain experience. If a client is anxious, angry,
bored, or lonely, it is likely that his pain threshold will be lowered,
likewise his pain threshold will also be reduced,if he is hungry, thirsty,
or tired. Similarly, glaring lights, unpleasant odours, excessive noise
tend to aggravate pain.
Drugs play an important part in interrupting the pain pathway. Narcotic

analgesics given in the presence of existing pain generally act only at the
cortical level to modify pain interpretation or decrease pain reaction. If
the same drugs are given earlier, they tend to act at both the cortical and
thalamic levels to decrease pain perception.
Hypnotics, such as phenobarbital, both modify pain interpretation and

decrease pain reactions when given in small doses. On the other hand,
pain perception is decreased by the administration of large-dose
hypnotics, such as sodium tipental and amobarbital, which act as general
anesthetics.
Tranquilizers, such as reserpine and chlordiazepoxide, decrease pain

reactions, as do mild sedatives or hypnotics. However, chlopromazine
and related phenothiazines decrease both pain perception and pain
reactions through their action at the thalamic and hypothalamic levels.
They may also act at efferent nerve endings. Muscle relaxants, such as
mephenesin, block the efferent skeletal muscle pathways and thus
decrease skeletal muscle reaction. Antibiotic drugs, such as penicillin,
relieve pain at the source.
Sometimes the nurse can help relieve pain by simply helping the client
to relax. Besides reducing pain, relaxation may help the client sleep
better and may aid in the reduction of tensions and anxiety.
3.1.7.6 Evaluation
It is vital that the effectiveness of the interventions be assessed to

determine whether the interventions should be continued, modified,
replaced with another intervention, or discontinued. The essential
questions in acute pain are as follows:
1. Does the patient still have pain?
2. If so, how does it compare with the pain experienced before the
intervention?
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3. If it is better but still present, should the same intervention(s) be

continued unchanged or modified?
4. Should new interventions be added?
5. If it is not better, was sufficient data obtained in the initial

assessment to determine the cause of pain?
6. Is there new data to indicate a different diagnosis?
What are the pain and the modes of intervention?
One method of assessing the extent of pain relief is to ask the patient to
rate the pain relief on a scale of 0 to 4. The answers can be documented
on a flow chart to provide an ongoing assessment of effectiveness of
pain relief. The essential questions for chronic pain are as follows:
1. To what extent is the patient participating in the planned therapeutic

programme?
2. What is the patient’s assessment of present pain?
3.1.8 Nontraditional Pain Treatments
1. Acupuncture is a detailed science of the treatment of disease that

originated in China thousands of years ago. As a form of pain
treatment, it has increased in popularity in recent years. There are
approximately 1,000 acupuncture points, each connected with a
part of the body. It is thought that in insertion of a needle into one
or more of these points will help block the transmission of pain
and will help cure the particular disease. The points can be used
in both the diagnosis and treatment of disease.
2. Transcutaneous nerve stimulation is another treatment that

attempts to block pain pathways. Electrodes are attached to one
or more “trigger zones” on the client’s body and are then
stimulated by electricity. This is another radical treatment that is
used only if other pain treatments have failed. It is particularly
used in cases of advanced cancer.
4.0 CONCLUSION
Pain experience is influenced by a number of factors, including past

experiences with pain, anxiety, culture, age, gender, and expectations
about pain relief. These factors may increase or decrease the person’s
perception, tolerance and responses to pain.
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5.0 SUMMARY
• Pain transmission can be influenced by three factors, effect of

impulses transmitted over the two types of pain nerve fibers (A-detal
and C fibers) to the spinal cord, effect of impulses from the
brainstem and effect of impulses from the cortex.
• In assessing a client’s pain, the nurse elicits where the pain is

located, how intense, when it began, how long it lasts, and how it
feels.
• How a client experiences pain depends, not only on physiological

processes, but also on his physical condition, previous experiences,
cultural attitudes, and emotional needs. All of these must be taken
into account when the nurse assesses patient description of pain.
1. What is pain?
2. How can a nurse help in the alleviation of pain in a
patient?
3. Discuss three theories of pain known to you.
Malinda, Murray. Fundamentals of Nursing. 2nd Edition. New Jersey:

Prentice-Hall, Inc., Englewood Cliffs, 1980.
Barbara C, Long and Wilma J. Phipps. Essentials of Medical-Surgical

Nursing: A Nursing Process Approach. St.Loius: The C. V.
Mosby Company, 1985.
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MODULE 3 DIAGNOSTICS AND INVESTIGATIONS

OF MEDICAL – SURGICAL
CONDITIONS

Surgical Conditions
Unit 2 Clinical Observations
Unit 3 Pre-operative intervention
Unit 4 Post Operative Nursing Care
UNIT 1 DIAGNOSTIC AND LABORATORY

INVESTIGATIONS IN MEDICAL SURGICAL
CONDITIONS
CONTENTS
1.0 Introduction
2.0 Objectives
3.0 Main Content
3.1 Endoscopy Oesophagoscope, Gastroscopy, and
Bronchscopy
3.2 Anoscopy, Proctoscopy, Sigmoidoscopy
3.3 Cystoscopy
3.4 Laparoscopy
3.5 X-Ray Special Procedures
3.6 Kidney Function Tests
3.7 Urine Concentration and Dilution Test
3.8 Urea Concentration
3.9 Urea Clearance
3.10 Creatinine Clearance
3.11 Liver and Biliary
3.12 Fractional Test Meals
3.13 Insulin (Hollander) Test
3.14 Cerebrospinal Fluid Examination
3.15 Electrocardiogram (EKG, ECG)
3.16 Electroencephalogram (EEG)
3.17 Radioactive Scans
4.0 Conclusion
5.0 Summary
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1.0 INTRODUCTION
This unit introduces you to diagnostic and laboratory investigations

done on patients. Diagnostic and laboratory investigations are used as
adjunct in the treatment of patients. They compliment physical
examination and nutritional assessment. They are usually used to
confirm or rule out a patient’s complaints.
2.0 OBJECTIVES
• explain each of the various diagnostic procedures

• identify the tools and equipment used for the procedures
• explain the significance and factors affecting each procedure
mentioned
• explain the precautionary measures involved in collection of
specimen for investigation
• explain the need to record all findings from diagnostic procedures
accurately.
3.0 MAIN CONTENT
Endoscopy
a. This is the examination of certain organs through a hollow

instrument one of the body’s openings.
b. Purpose
1. To locate a disease process

2. To obtain specimens for microscopic study
3. To remove foreign objects that may be lodged in an opening (ES:
coin, pin, stone)
4. To make pictures of an area
5. To provide treatment or perform operative procedure for certain
conditions.
c. Types
3.1 Oesophagoscope, Gastroscopy, and Bronchscopy
a. Definitions: a visualization of the oesophagus, gastric muscoa,

trachea, and two major bronchi.
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b. Procedure:
1. Explain the procedure to the patient well, asking him to be very

still and to breathe through the nose. It is very essential to get the
patient’s cooperation. Children and patients with unpredictable
behavior may need to be restrained or put under general
anesthesia.
2. Written permission is obtained or put in some hospitals.
3. NPO 6 – 8 hours prior to exam to prevent regurgitation and to

make muscosa visible.
4. Remove eyeglasses and dentures.
5. Give sedatives and atropine as ordered to lessen apprehension

and decrease secretions.
6. Assist in holding the patient’s posterior pharynx with a local

anesthesia to inactivate the gag reflex and lessen local reaction to the
instrument. IV Valium may be given.
7. Assist in holding the patient’s head as the doctor may indicate.
8. After the procedure, have patient rest one to two hours, and do not
allow him to eat or drink until gag reflex returns reaction.
9. Observe for expectoration or vomiting of blood due to perforation, or

dyspnea due to laryngeal edema.
10. Advise patients with hoarseness of voice to talk little as possible and
to use warm saline gargles.
3.2 Anoscopy, Proctoscopy, Sigmoidoscopy
a. Definition: Visualization of the mucosa of the anus, rectum, and

sigmoid colon.
b. Procedure:
1. Instruct patient to low residue diet the evening before the

procedure.
2. Give laxative and enemas to clean patient’s bowel.
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3. Explain the procedure to the patient and tell him that he will feel
some discomfort and may feel a desire to defecate.
4. Keep on NPO liquids (clear) the morning of the procedure.
5. Help position patient – usually knee – chest position – and drape

him adequately.
6. If patient has gas pain after the procedure, put him in knee – chest
position to help expel the gas.
3.3 Cystoscopy
a. Definition: Visualization of the inside of the urinary bladder.
b. Procedure:
1. Force fluids on the patient before the procedure unless general

anesthesia is anticipated (i.e. child). If so, Intravenous fluids will
be given to insure adequate urine in the bladder.
2. x – rays are to be taken, the bowel is cleansed by enemas or

laxatives or both before.
3. Give sedative as ordered for relaxation.
4. Obtain written permission if required by hospital.
5. The patient is placed in lithotomic position and draped.
6. The procedure should be explained to help patient relax because

tension may cause spasms of the vesical sphincters and increase
the pain.
7. Force fluids post procedure to lessen irritation to the lining of the

urinary tract.
8. The patient can expect painful micturation.
3.4 Laparoscopy
a. Definition: Endoscopic examination of the peritoneal cavity

performed through a transabdominal puncture site.
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b. Procedure
1. Patient is kept NPO and given a light pre-op med.
2. Procedure is explained to the patient, and reason why it is done.

If done for tubal ligation, an operative permit for sterilization is
needed.
3. Catheterization is done in the theatre.
4. Incision can be done by one or two techniques. The point of

inferior aspect of umbilical rim, with second incision at hairline
of moons. Veneris.
5. CO2 (about 2 – 41) is introduced into the anterior peritoneal

cavity, which pushes the bowel away from field of examination
treatment. This permits safe introduction of instruments.
6. The procedure is done and then the air is removed.
7. The patient can leave hospital late in an afternoon or morning of

the next day.
8. Assuming the knee – chest position can be helpful if patient has

pain due to any gas that remains.
c. Complications
1. Pneumoperitoneum problems – cardiac and respiratory

embarrassment, subcutaneous and mediastinal emphysema.
2. Trocar insertion problems – organ perforation, hemorrhage, and

omental herniation
3. Bleeding.
3.5 X-Ray Special Procedures
Barium Gastrointestinal Series (Barium swallow meal)
1. Definition
This is the visualisation of the esophagus, stomach, and sometimes the

upper small intestines by use of barium sulfate, fluoroscopy, and x-ray.
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2. Technique
Barium is given mouth in the x-ray department. Barium, an opaque

substance, outlines the GI tract as the doctor views the passing of the
barium under fluoroscopy from the esophagus into the stomach. Many
x-rays are taken at this time. Sometimes an x-ray is taken four to six
hours after the administration of the barium.
Barium Enema
1. Definition
Introduction of barium sulfate into the colon for the purposes of

outlining the colon on fluoroscopy and X-Ray.
2. Procedure
Barium is given by enema while lying under the fluoroscope X-ray

pictures are taken as indicated. Patient expels the enema before leaving
the x-ray department.
Cholecystogram or Gallbladder Series (GBS or GBV)
Definition: Visualisation of the gallbladder by fluoroscopy and x-ray

after a dye has been gallbladder by fluoroscopy and x-ray after a dye has
been given.
Chlangiogram (Bile Duct Visualization)
Definition: The visualisation of the bile duct after an injection of an

opaque substance (Urokon) into the duct through a tube surgically
placed in the duct, and then an x-ray is taken.
Intravenous Pyelogram (IVP)
1. Definition
The introduction of a radiopaque substance (Hypaque) intravenously.

Since it is eliminated by the kidneys, a series of x-ray films are made at
intervals to note the concentration of the contrast medium in the pelvis,
uterus, and bladder.
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2. Implications
After the test, fluids should be forced to flush any remaining dye from
the urinary tract. The drug used contains iodine, the patient should be
observed carefully for allergic reactions.
3. Preparation
See procedure book “K”
Retrograde Pyelogram
1. Definition
The introduction of a radiopaque solution into the Ureters and renal

pelvis through catheters that have been placed in the Ureters by means
of a cystoscopy.
2. Preparation
Same as for cystocopy plus cleaning of the bowel.
3.6 Kidney Function Tests
(The above two tests – IVP and Retrograde pyelogram – are also
considered kidney function test).
a. BUN (Blood Creatine and Uric acid)
These are tests done on blood taken through a venapuncture

They are products normally excreted by the kidneys, but rise in the
blood and tissues when the nephrons fail to eliminate them.
Deterioration in renal function is manifested chemically by the rise in
these products, but there must be a 50 – 75% decrease in renal function
before the value rise.
Normal: BUN 8 – 16%

Creatinine 0.8 – 1.7 mg%
Uric Acid 4 – 5.5 mg%
b. Electrolyte Determination
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This is a test done on venous blood determine levels of electrolytes

present in the serum. Although other conditions may cause electrolyte
disturbance in renal failure these determinations are greatly disturbed.
Normal: Sodium 137 – 148 mEqL (low in
renal disease)
Potassium 3.9 – 5 mEqL (high in
renal disease)
Calcium 4.5 – 5.5 mEqL (lower
in renal disease)
Chloride 95 – 103 mEqL
CO2 combining power 20 – 30 mEqL
c. Urine Concentration and Dilution Tests
In normal kidney function, the kidney has the ability to regulate the
amount of water leaving the body dependent on the body’s needs. EX:
In excessive loss of body fluid or restricted intake more water is
reabsorbed by renal tubules and specific gravity of urine is high. With
large fluid intake, less water is reabsorbed, and volume of urine is
greater with a specific gravity lower than normal. Normal specific
gravity is 1.003 – 1.030. In tubular damage, this mechanism is impaired.
Concentration test determines the kidney’s ability to concentrate urine
when fluid intake is restricted. Fluids are restricted over a specified
time.
Two to three urine specimens are collected, and the specific gravity is
determined on each. If kidneys are normal, specific gravity is not less
than 1.024. Dilution test evaluations, the kidney’s ability to dilute the
urine, following a large intake. Patient remains in bed. First morning
specimen is desired. Patient drinks one liter of fluid over a period of ½
hour, then voids at 1,2,3,4 hours and all urine is submitted to the
laboratory. The time of voiding is indicated on each specimen. Specific
gravity of first specimen voiding is indicated on each specimen. Specific
gravity of first specimen should be about 1.002 with a gradual increase
occurring in the others.
d. Phenolsulfonphthalein Test (PSP)
1. This test indicates the excretory ability of the renal tubules.

Phenolshonpthalein, a red dye, is given intravenously and is
completely excreted at a short time by normal kidneys. Less than
total excretion of the amount given indicates tubular damage and
inefficiency or obstruction of urinary now through the renal pelvis or
lower urinary tract.
2. Procedure
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a. Give patient 500 ml. of water, and have him void and discard.
b. USP is injected IV.
c. Urine specimens are collected in 15, 30, 60 and 120 minutes after
dye is injected. All urine voided is included in specimen.
d. Each specimen is labelled as to the time and sent to lab.
e. Normally 40 – 50% of de is excreted in hr., and 75% in two hrs.
3.7 Urine Concentration and Dilution Test
Purpose
To test the ability of the kidney to vary the specific gravity of the urine.
This importance function enables the body to deal with changes in the
fluid intake, with the needs of the skin in changing temperatures, and
with other emergencies in the fluid balance. The loss of ability to
concentrate the urine indicates a late stage of renal failure, as in chronic
nephritis.
Method
Many modifications of this test are in use; this is a typical one, not too
rigorous. Nothing to eat or drink is allowed from 6 p.m. on the evening
before the test. At 6 a.m. and 7 a.m. the bladder is emptied. The specific
gravity of at least one of these specimens should reach 1.022.
The dilution part of the test follows; it is not ordered for patients who
have odema. 1,000 ml. of water is drunk in the next half hour, and
specimens are collected hourly for the next four hours. Normally most
of this litre of water will have been excreted during this period, and a
specific gravity of 1.003 or less is attained. If there is severe impairment
of kidney function, the specific gravity of the urine usually remains
fixed at about 1.010.
3.8 Urea Concentration
Purpose
The output of urea in the urine should rise if the amount of urea in the
blood increases, and this test investigates the ability of the kidney to do
this.
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Method
Nothing is given after 9 p.m. until the test is complete on the following
morning. At 6 a.m., the bladder is emptied, and 15 G. of urea is given
dissolved in 100 ml. of water. At 7, 8 and 9 a.m. specimens 1, 2 and 3
are collected and sent to the laboratory. The amount of urea should
exceed 2% in two of these if urea concentration is to be considered
satisfactory.
3.9 Urea Clearance
Purpose
This is a test of glomerular function, and depends on the fact that urea is
cleared from the blood into the urine at a steady rate, so that if the blood
urea is known, and also the amount of urea per hour excreted into the
urine, a satisfactory estimate of the filtration power of the kidneys can
be made.
Method
No coffee or tea (which is diuretics) should be given on the morning of

the test. At 10 a.m., the bladder is emptied and the specimen discarded.
At 11 a.m., specimen one is collected, and at noon specimen two. The
blood urea is estimated at 11 a.m. Specimens one and two are sent for
examination, and the whole amount passed must be included.
For an accurate result, specimens must be obtained with strict

punctuality. If there is any delay (e.g. if the patient is unable to
micturate) the exact time when the urine was passed should be put on
the label.
3.10 Creatinine Clearance
Purpose
This is another and more reliable test of glomerular function.
Method
No preparation is required. A 24-hour specimen of urine is collected,

and a sample of this and a note of the total volume are sent to the
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laboratory. 10 ml. of blood are collected on the same day. Sometimes

the pathologist may ask for two 24-hour specimens: this is because
collection for 24 hours is subject to fallacy because of loss of a
specimen, especially if the patient is spending time out of the ward in
connection with other examinations.
Renal Biopsy
Microscopic examination of small portions of kidney tissue obtained by

needle biopsy may be a great help in diagnosis. An intravenous
pyelogram is performed beforehand, unless the biopsy is to be done
under X-ray control, to establish the position of the kidneys. The
patient’s blood group is ascertained, and a bottle of blood cross-matched
and kept ready for emergency use. The prothrombin time and platelet
count must be estimated, because abnormal findings indicate a risk of
undue bleeding. If a local anesthetic is used, adequate sedation must be
given beforehand. The following equipment is needed.
2 gallipots.
Gauze and wool swabs.
2 pairs of dressing forceps.
French’s or handling forceps.
Paper towels.
5 ml. syringe.
Needles size 1 and 20.
Vim-Silverman or Menghini biopsy needle.
Exploring needs (e.g. lumbar puncture needle).
Masks, gowns, gloves.
Cleaning lotion (e.g. chlorhexidine 1 in 200 in spirit).
(All the above are sterile)
Adhesives.
Preservative for biopsy specimen.
The patient lies face downwards on a firm surface for the puncture. The
right kidney is a little lower than the left, and so easier to reach but the
liver is close by, and may be punctured in error. The skin is cleaned and
anaesthetized, and then the exploring needle is passed to find the depth
at which the kidney lies; when the needle is in the right place, it will
move with each breath. It is then withdrawn, and the biopsy needle is
passed along the same track. Cores of renal tissue are obtained and put
into the preservative, and an adhesive dressing is obtained and put into
the preservative, and an adhesive dressing is applied.
Bleeding down the ureter is common, and brisk bleeding is often seen.
The patient is kept at rest in bed, and encouraged to drink freely to keep
the urine diluted. If bleeding is free, clotting will occur, and the patient
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will suffer from colic as the clots pass down the ureter and an analgesic
must be given. The pulse and blood pressure must be taken hourly, and
each urine specimen is saved separately to see if bleeding is getting less.
Profuse haematuria or colic, falling blood pressure, rising pulse rate or
sweating must be reported at once. Bleeding usually ceases
spontaneously, and surgery is rarely necessary.
3.11 Liver and Biliary Test
Several tests are used to netermine whether or liver or disease is present.

Liver function tests are used to determine the presence, and extent of
liver damage, and to check the progress of liver disease. Since the liver
has many functions, which are closely related, single tests of liver
function usually give information about the efficiency of several of the
organ’s activities. Most liver tests involve taking samples of blood urine,
or stool; taking of drugs, and fasting before procedures.
a. Protein Metabolism Tests
1. Serum albumin – globulins (A/G Ratio)
Albumin is produced by the liver and globulin by lymphoid tissue.

Normally the A/G ration 3:1. In liver disease, albumin decreases and
globulin increases, which reverses the ration. Patient is NPO; 10ml of
blood is withdrawn.
NORMALLY: Total protein: 6-8.2 mg%

Albumin: 3.8-6.7 mg%
Globulin: 1.2-3.2 mg%
2. Prothrombin
Blood is withdrawn and plasma is for tested prothrombin content.

Several plasma proteins involved in blood coagulation are made by the
liver. Capacity to male prothrombin depends on availability of Vitamin
K ingested with food or formed by intestinal bacteria. It requires bile
salts for absorption.
In liver cell damage, impairment is due to a deficiency in bile liver

damage and obstructive jaundice, prothrombins time is prolonged.
3. Blood ammonia
This is increased in a failing liver because it cannot detoxify this

endogenous waste product of intestinal protein metabolism, which is a
normal liver function
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Normal: 01-05 mg%
4. Flocculation tests
i. Cephalin floc is performed to distinguish jaundice due to liver

disease from jaundice due to obstruction. Patient is NPO before
blood is withdrawn. Normal is 1-14 U (no precipitation should be
present). Abnormal results occur in hepatitis (except if mild and
in cirrhosis (except if arrested). It is negative in non-infective,
extra – hepatic biliary obstruction, even with associated hepatic
damage.
ii. Thymol turbidity tests concentration of Gamma Globulin which

may be elevated in liver damage. Normal is 0-5 U. Abnormal
values suggest hepatitis and cirrhosis rather than obstructive
disorders. It is of limited value for it can be high in other
diseases.
b. Billiary excretion test
1. Serum bilirubin
Fasting blood is the serum which shows the functional capacity of the
liver in breaking down, reusing, and excreting bile pigments. Normally,
liver cells extract pigments from blood and convert it to a water soluble
compound before excreting it in the bile. Hemoglobin released from old
or injured red blood cells is reduced to the compound called
“unconjugated” or “indirect” bilirubin, which is carried by the blood to
the liver where chemical processes transform it into “conjugated” or
“direct” bilirubin is increased in hemolytic jaundice. Direct bilirubin is
increased in obstructive jaundice.
Normal: Total 0.2-1.4 mg%

Direct 0.1-0.8 mg%
Indirect 0.1-0.6 mg%
2. Urinary Bilirubin
Unconjugated Bilirubin is not excreted in urine because it is not water

soluble. Pigment is present in urine in obstructive jaundice, but absent in
hemolytic jaundice.
3. Urinary urobilinogen
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Conjugated bilinogen is changed to urobilinogen by bacterial action

when bile reaches the small intestine. Most is excreted in faeces and
remainder is absorbed. The small amount that is absorbed is excreted in
bile. If liver’s cells are damaged, they do not reclaim it and the amount
of urobilinogen excreted by the kidneys is increased. Amount is
decreased in obstructive jaundice when bile is not reaching intestine, or
if bacteria content as a two–hour afternoon urine specimen since
maximal excretion is in afternoon and evening and Normal is below 4
mg. per 24 hours.
4. Serum cholestol
Since cholesterol is synthesized and excreted by the liver, the

conception falls in liver disease when cell function is impaired. It rises
in obstructive jaundice and cancer because of inhibited excretion and
increased hepatic formation. A low cholesterol diet is given the day
before the blood is taken. Normal: 135 – 260 mg depending on age and
sex.
c. Enzyme Tests
1. Alkalin phoshatase
This is an enzyme that is normally excreted in bile by hepatic cells. It is

increased both in obstructive jaundice and liver damage, due to its return
to blood stream with bile in obstruction.
Normal: 2 – 4.5 U. There is less elevation with hepatitis than

obstruction.
2. Serum transaminases
Liver cells contain Serum Blutamic Oxaloacetic Transminase (SGOT)

and Serum Glutamic Pyruvic Transaminase (SGPT). Both are released
into the blood when liver cells are damaged. Concentration can be used
to estimate liver damage.
Normal: SGOT 6 – 40 U
SGPT 6 – 30 U
d. Metabolism of foreign substances
Bromsuphalein Excretion Test (BSP – Rosenthal’s method)
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a. Description
BSP is a dye that is normally excreted by the liver into bile. The dye is
injected IV: blood is withdrawn in a prescribed amount of time (45
minutes to one hour) to determine the amount of time dye that has not
been utilized by the liver and remains in the blood one hour later.
Amount of dye is based on Kg of body weight. Rate of removal is
influenced by hepatic blood flow function capacity of polyzonal cells
and freedom from biliary obstruction.
b. Policy
1. NPO after midnight except water.

2. In exceptional cases, the test may be done four hours after last
eating.
3. Do not allow patient to take food until lab has finished the test.
4. Dye is injected and all specimens are collected by lab.
5. Person may not leave the bed without permission of lab
personnel.
6. Medication carried out as ordered by the doctor. Patients must be
weighed before examination is begun since medication dose is 2
mg/Kg body weight.
3.12 Fractional Test Meals
Purpose
To investigate the quality of the gastric juice, and usually to assess the
response of the stomach to food intake. The principle is to pass a Ryle’s
tube into the stomach of a fasting patient, and then to give some kind of
“meal” and by serial withdrawals discover its effect on gastric secretion.
The meal can consist of a pint of thin strained cereal, or 50 ml. of 7%
alcohol.
The information that may be gained is
1. The amount of resting juice, i.e. the secretion in the stomach after a
twelve-hour fast. It may be excessive in pyloric stenosis.
2. The amount of free and total hydrochloric acid in the stomach.

Excessive acid (hyperchlorhydria) is characteristic of duodenal ulcer.
Absence of acid (acholrhydria) is found in pernicious is found in
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pernicious and some iron-deficiency anaemias, and usually in cancer

of the stomach.
3. The response of the stomach to food. Normally there is a rise in the

acid secretion, followed by a steady return to normal. In duodenal
ulcer there is a steep rise and excessive free HCI is present
throughout the test.
4. The response of the stomach to subcutaneous injection of histamine,

if no acid is found at first. A histamine-fast achlorhydria is found in
pernicious anaemia. Not all physicians like histamine.
5. The speed with which the stomach empties; the hyperchlorhydria of

peptic ulcer is usually associated with quick emptying.
6. The amount of residual fluid, i.e. the amount left after two hours. In
pyloric stenosis some of the meal may still be left in the stomach.
7. The presence of excessive mucus or blood, as in gastric ulcer or

cancer of the stomach.
Preparation of the Patient. The patient is told of the test, and of the
valuable information to be gained, to secure his co-operation. He must
fast overnight.
The internal at which specimens are taken depends on individual dochar

on local custom. Six specimens, withdrawn at twenty-minute intervals,
is a usual number, and not more than 5 ml. should be taken at each
aspiration, or the supply will be exhausted before the required number
has been obtained. Each is put into a test tube, labelled with the time,
and tested with litmus paper for acidity. If none is found in the first two
specimens, the nurse may be asked to give histamine 0.5 mg. by
hypodermic injection. This sometimes causes uncomfortable flushing
and headache, and if this is severe, it may have to be relieved by giving
one of the anti-histamine drugs.
3.13 Insulin (Hollander) Test
a. Use: To determine the completeness of a vagotomy in inhibiting

acid output of the stomach. Insulin normally stimulates production of
HCI.
b. Test: Dose of 0, 2 U/Kg of Regular Insulin is given IV or subq.
Blood and gastric secretion are collected and acid output after Insulin
is compared with proceeding baal secretion.
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c. Nursing Care: Observe closely for hypoglycemia. If it occurs, 50%

Glocose may be given.
3.14 Cerebrospinal Fluid Examination:
Cerebral spinal fluid is normally a clear, colorless fluid with a pressure

of 7 – 10 mm Hg when the patient is in horizontal position. It is obtained
through a lumbar puncture, and should be tested immediately because
the cells tend to clump on standing giving wrong results.
Normal: WBC 0 – 5 – elevated in bacterial infections

RBC 0 - - - - indicates bleeding in CNS if present
Total protein20 – 40 mg – increased in infection and tumor
Glucose 60 – 80% of blood level – lower in
bacterial and TB infection.
Serology negative – positive in syphilis
3.15 Electrocardiogram (EKG, ECG)
This test records the electrical impulses generated by the heart onto
special paper by a machine. Rhythm, position of heart, size of ventricles
and presence of injury are revealed by the EKG tracing. The patient is at
rest and feels no pain during the procedure. No special prep required.
Leads from the machine are connected to the patient’s chest and
extremities.
3.16 Electroencephalogram (EEG)
Definition
This test records the electrical impulses of the brain cells onto a special
paper for interpretation of possible abnormalities in the CNS. No pain is
involved. Leads are attached to the patient’s scalp. Readings are taken
with him awake, asleep, and hyperventilating. Takes about two hours to
complete.
Preparation of Patient
1. Patient takes no coffee, tea, coke, or other stimulants, and no alcohol

for some time before test.
2. No medication is taken unless by special order of doctor.
3. Hair and scalp are washed well to remove all hair dressing and
natural oils
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3.17 Radioactive Scans
Definition
This is the use of radioactive substances to examine specific organs or

tissue which show function of the organ or tumors present. The thyroid,
kidneys, brain, liver, lungs, pericardium, and bone may be examined.
Method
A radioisotope, called tracer, is given orally or parentally. The drug will

concentrates at the site of the tumor if one is present. It is then traced by
a sensitive apparatus and records the concentration on sensitized paper
by a synchronously moving pen. The apparatus may include Geiger –
Muller counter, scintillation counters, specimen counters, scanners,
gamma cameras and whole body encounters.
Radioactive Drugs
1. The drugs given for this purpose have a short half-life. They expend
their energy rapidly and are excreted rapidly by the body.
2. The drugs given have a certain affinity for the particular organ being
studied. EX: Radioactive iodine (1131) __thyroid; 198 Au___liver;
radioactive mercury – brain.
3. The drugs are administered in minute dosage so there is no cellular

destruction.
Procedure
2. The patient is given a trace dose of the appropriate radioisotope.
3. A period of waiting is necessary depending on the drug given. Varies

from one hour for radioactive gold to 18 – 48 hours after injection of
RIHSA (Radioiodized Human Serum Albumin).
4. During scanning, the patient is asked to be still and breathe normally

while the scintillator measures the radioactive atoms concentrated in
the organ under study and records its finding. If a patient is restless
or agitated, sedation may be given to help him relax.
5. The procedure is painless, and is not harmful to those around the

patient.
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4.0 CONCLUSION
Laboratory investigations are done to test the fischoral ability of an

organ in the body with the hope to institute correct measures.
5.0 SUMMARY
• The role of the nurse in laboratory investigation is to ensure the

comfort of the patient.
• All investigation done must be documented and kept in patient’s file

for use by all the health team.
1. Discuss the importance of diagnosis in nursing.

2. List and explain three equipments used in diagnostic
investigation.

Brunner & Suddarth’s. Medical Surgical Nursing. (10th ed) Lippincott

Wilkins: 2004.
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UNIT 2 CLINICAL OBSERVATIONS
CONTENTS
1.0 Introduction
2.0 Objectives
3.0 Main Content
3.1 General Observation
3.2 Vital Signs
3.3 Observation of Urine
3.4 Observation of Stool
3.5 Observation of Cough
3.6 Observation of Sputum
3.6.1 Observation of Vomitus
3.6.2 Collection of Specimen
3.7.1 Collection of Urine
3.7.2 Collection of Stool
3.7.3 Collection of Sputum
3.7.4 Collection of Blood
3.7.5 Collection of Pus
3.7.6 Collection of Tissue
3.7.7 Blood Determinations
3.8 Basal Metabolic Rate
3.9 Glucose Tolerance Test
3.10 Tuberculin Skin Tests
3.11 Cardiac Catheterisation
4.0 Conclusion
5.0 Summary
1.0 INTRODUCTION
Two topics are discussed in this unit –clinical observation and collection
of specimen for investigations. The term “clinical observations” is used
to describe the initial and basic observation of the temperature, pulse
and respiration rate, in relationship to other significant changes in an
individual. For newly admitted patient, the nurse must observed the
following; his attitude in bed, his colour, and his state of nutrition;
orientation to his surroundings, fear and anxiety or indifference She
must also notice the feel of his skin and his muscle tone, his voice and
conversation to know what part of the country he/she comes from, and
educational status. This observation must be done within the context of
nurse/patient relationship. Precautionary measures involved in collection
of specimen for investigation are also explored in this unit.
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2.0 OBJECTIVES
• explain the significance of clinical observation

• identify the tools and equipment used for the observation
• explain the significance and factors affecting each procedure
mentioned
• explain the precautionary measures involved in collection of
specimen for investigation
• explain the need to record all findings from diagnostic procedures
accurately.
3.0 MAIN CONTENT
3.1 General observation
Colour
The skin may be pale, suggesting anaemia, shock or fear; it may show
cyanosis (blueness), indicating sub-oxygenation of the blood; a flush
may suggest that the temperature is high; jaundice means yellowness,
and is due to accumulation in the tissues of the pigments normally
excreted in the bile.
Attitude
Patients with colic, whether of intestine, ureters or bile duct, tend to be

restless with each attack with the hips flexed to slacken the tension of
the abdominal muscles. Movement increases the pain, so they lie still,
watching those around with alert anxiety. Patients with cerebral
irritation often display dislike of light (photophobia). They lie on the
side in an attitude of flexion, actively resenting any attempt to move or
examine them.
3.2 Vital Signs
Temperature
The normal body temperature is said to be 98.4°F. (36.9°C.), but the

temperature varies in different parts of the body. The skin temperature
(usually taken in the axilla) may, in healthy people, be no more than
97°F. (36.1°C.), while the mouth temperature is usually a degree higher,
and the rectal temperature may be 99°F. (37.2°C.). The temperature is
usually a degree higher in the evening than in the morning because of
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muscular and metabolic activity. The same site should always be used
for the thermometer, or the chart will display unnatural variations.
Methods of Taking Temperature
Axillary Temperature
This method is not used if the patient is very thin, or if there is any local
inflammation. Small children of one or two may resent having the arm
held at the side, and the thermometer may then be placed in the groin,
using the same technique as for the axillary method. This method is used
if the patient is unconscious or not well-orientated.
Oral Temperature
It is used for all patients but contraindicated for the very old people,
those with mental illness and any patient who cannot breathe through
the nose. Hot or cold drinks affect the mouth temperature.
Rectal Temperatures
The rectal route is used for babies and for those subjected to low-
temperature techniques. It is the most reliable site after head operations.
When in use, the bulb is inserted an inch. into the anal canal and held
there for the time indicated.
Recording Temperatures
It is usual to record temperatures graphically on a chart by making a

spot in ink at the appropriate level and in the column that indicates the
time and date.
The quickest way in which a temperature can rise and fall is seen in the
rigor. Rigor can be describe as a sudden onset of fever in which the
temperature may rise four or five degrees because of shivering, and it
falls again because of sweating. The whole episode may be over in half
an hour. Rigors are common in malaria; at the onset of a few infections
like pyelitis and lobar pneumonia; as a reaction to the injection of
foreign protein, either intramuscularly or intravenously.
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Figure 13: Some Temperature Patterns
The Pulse
The pulse is the wave of distension generated in an artery by the

contraction of the heart, and it can be felt in any artery big enough or
near enough to the surface to the surface to be palpable. It is usually
taken in the radial artery at the wrist, a place convenient both for patient
and nurse.
The points to be observed about the pulse are as follows:
1. Rate: The average adult rate is 72 beats per minute. In a baby it

is 120 to 140, and at 12 years has fallen to 80.
2. Rhythm: This should be regular, the beats being evenly spaced.
3. Volume: This refers to the amount of blood distending the artery

with each beat and only experience can tell the nurse if it is
within normal limits.
4. Tension: This refers to the compressibility of the pulse, i.e. the

ease or otherwise with which the flow can be interrupted by
pressure. Unlike the other characters of the pulse, which are
produced by the heart, tension is a property of the artery wall.
Respiration
A newborn baby breathes from 32 to 50 times a minute, an adult 16 to

20. The pulse rate is usually about four times quicker than the
respiration rate, and disturbance of this relation between them is
characteristic of some diseases (e.g. lobar pneumonia). The muscles
involved in inspiration are the intercostals (supplied by nerves from the
thoracic part of the spinal cord) and the diaphragm (supplied by the
phrenic nerves).
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Normal respiration is regular in rhythm and almost noiseless and the

chest movement, or excursion, falls within easily recognized limits. The
rate and the excursion are both increased by exercise and by rise in the
temperature, and by emotion. Shallow breathing is noted in shock; in
pleurisy; and in peritonitis. Deep breathing is characteristic of acidosis
in uncontrolled diabetes. Sighing and yawning are signs of acute blood
loss, and may be a valuable indication of internal haemorrhage.
Torturous breathing is due to vibration of flaccid cheek and throat
muscles, and is often noted in those unconscious after a stroke. Wheezy
or bubbly breathing is due to secretions in the bronchi and is heard in
bronchitis, pneumonia and broncchietasis.
Estimation of the Blood Pressure
The blood pressure is the pressure within the arteries, measured in

millimeters of mercury. It is at its highest (systolic) when ventricular
contraction sends more blood into the arteries, and at its lowest
(diastolic) when that force is spent. The normal range of systolic
pressure is 110-130 mm. Hg, and the diastolic is 70-90. The levels are
influenced by emotion, by posture and by age as well as by pathological
processes. The difference between the diastolic and systolic readings is
the pulse pressure A fall in blood pressure is characteristic of shock,
haemorrhage, fainting and Addison’s disease. A rise is seen in essential
hypertension, kidney disease, such as acute or chronic nephritis; raised
intracranial pressure, and toxaemia of pregnancy.
The apparatus used to measure bloopressure is called the

sphygmomanometer.
3.3 Observation of Urine
Urine contains in solution all the by-products of body metabolism

except carbon dioxide. In addition, pus and blood may also be found.
Examination of the urine may yield information of the greatest value in
diagnosis, and such examination should be compulsory made for all new
patients on admission, and afterwards at such intervals as their condition
suggests. It is especially important before an anaesthetic is given, since
it is quite common to discover undiagnosed diabetes mellitus in people
admitted with some other condition. The amount in 24 hrs varies greatly
with the fluid intake and the external temperature. Increased output
(polyuria) is common in diabetes insipidus and uncontrolled diabetes
mellitus. Oliguria or decreased urinary secretion is found in acute
nephritis, congestive heart failure and dehydration. It is also normal in
the first twenty-four hours after operation, owing to increased output of
anti-diuretic hormone from the pituitary due to the surgical stress.
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Cessation of urinary secretion is called suppression, or anuria. It may be

caused by malignant pelvic growth involving both ureters, crushing
injuries, acute nephritis, eclampsia, sulphonamide ureteric
crystallization, and incompatible blood transfusion.
3.4 Observation of Faeces/Stools
Faeces are by-product of digestion. They are composed mainly of food

residue, bacteria, salts and water. The bowels are normally opened once
or twice a day. The faeces of a baby are soft and yellow but in an adult,
they are well formed in consistency (neither hard nor fluid) and brown,
because of bile pigments.
Abnormalities of Stools
Type of Stool
The stools may be:
- Black if iron medicine is being taken;

- Pale or clay-coloured in obstructive jaundice;
- Grey, bulky and offensive in caeliac disease;
- Green in babies with intestinal upsets.
- Or melaena. Melaena is a term used to describe the presence of
altered blood in the stools.
The stool is black, tarry and sticky, with the characteristic smell of
blood. It is caused by bleeding from the upper intestinal tract...
Unusual Content of Stool
- If faeces contain bright blood, this indicates that there is a lesion

low down in the alimentary canal, probably from piles, or
possibly a carcinoma of rectum.
- Mucus is not normally observable in the stools but may be

obvious in pelvic abscess, faecal impaction or ulcerative colitis.
- Pus is present in ulcerative colitis or if an abscess ruptures into

the rectum.
- Undigested food indicates small intestinal indigestion.

- Sloughs may be seen in the later stages of typhoid fever when
they are separating from the typhoid ulcers.
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- “Rice water” stools are used to describe abundant pale watery

stools of cholera.
- Foreign bodies may also be present in faeces if swallowed. They

may be passed out. Example of foreign bodies includes safety
pins, beans, beads or chalk. All stools of a patient with a history
of swallowing a foreign body must be inspected.
3.5 Observation of Cough
A cough is a reflex act whose primary function is to protect the airway

from the entry of foreign material. Its centres are in the medulla. A
cough begins with a deep inspiration; the diaphragm is fixed, the glottis
closed and a strong expiratory movement forces the cords apart and the
breath is audibly expelled.
Causes of coughing are:
1. Irritation of the larynx by fluid or particles of food; smoke, or

fog; chemical fumes like ammonia.
2. Inflammation of the larynx, trachea or bronchi (bronchitis,

whooping-cough).
3. The presence of secretion in the airway (chronic bronchitis,

bronchiectasis).
4. Irritation of the vagus nerve endings in the lung by pneumonia,

tuberculosis, etc.
5. Pressure on the trachea or bronchi.
6. Nervous causes. Such as a cough common before interviews.
Classification of Cough
Coughs may be classified as:
(a) Dry, if no sputum is produced.
(b) Productive, if sputum is expectorated. The aim of the treatment

expulsion of the sputum by expectorant mixtures.
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The points to be noted in connection with coughing are as follows
1. The time at which it occurs, e.g. whether the patient is kept

awake at night, or coughing is most frequent early in the morning
after sleep, when sputum has tended to accumulate, or is only
paroxysmal.
2. Length of attacks. Some coughs, e.g. in tuberculosis, are

persistent and exhausting, even if non-productive.
3. Presence or otherwise of cyanosis. Those with heart failure or

pneumonia may become blue during coughing attacks.
4. Presence or Absence of Pain. Early acute laryngitis or tracheitis

causes a dry cough obviously very painful to the sufferer. Acute
pleurisy (as in lobar pneumonia, pulmonary infarct, and
tuberculous pleurisy) makes the patient endeavour to cut short the
cough in order to avoid the painful pleural friction, and the
suppressed cough is often followed by a groan.
5. The nature of the sputum, if any.
6. Any special characteristics. The cough in acute laryngitis has a

brassy, ringing note; in a child it often heralds an attack of
measles. In asthma, it is tight and wheezy. Patients with
bronchiectasis have spells of coughing with production of
abundant sputum and cough-free intervals during which the
sputum is accumulating again.
3.6 Observation of Sputum
This is produced from the respiratory tract by coughing and can be

classified under these headings.
1. Mucus – This is the normal bronchial secretion, and is present in

excess in very acute inflammation of the upper respiratory tract.
Very soon, it becomes cloudy as infection supervenes.
2. Mucous – This contains mucus and pus and occurs in the later
stages of such infections, e.g. bronchitis.
3. Pus. This occurs in bronchiectasis or lung abscess...
4. Blood – Coughing up blood is called haemoptysis. The blood is

bright red in colour and is seen in early pulmonary tuberculosis.
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Observations of the Sputum Include:
The amount;
The viscosity;
The odour,
The presence of any material or blood.
A suitable container for sputum must be provided and put within easy
reach for patients that are coughing.
3.6.1 Observation of Vomitus
Vomiting is a reflex act, of which the centre lies in the medulla, and
involves emptying the stomach and sometimes the upper part of the
small intestine by reversed peristalsis. The main purpose is to rid the
stomach of harmful material.
Causes of vomiting
- Irritation of the stomach by chemical or bacterial
- Stimulation of the vomiting centre e.g. by raised intracranial

pressure, as in cerebral growths or injuries
- Intestinal obstruction, in which it is a leading sign; by
- Nervous stimuli, such as severe pain, or even the sight or thought

of something the patient finds revolting.
The points to be noted are:
1. The amount.
2. The presence or absence of nausea. Vomiting occurs with little or

no nausea when a brain tumor is present.
3. The force with which the material is vomited. In congenital

hypertrophic pylonic stenosis vomiting is projectile.
4. The constituents of the vomitus:
(a) Stomach contents - Food is vomited if it has been taken recently

or mucus if the stomach is empty, as in sea-sickness.
(b) Bile - Clear greenish fluid from the duodenum is characteristic of

post-operative vomiting.
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(c) Intestinal contents is seen in intestinal obstruction, when fluid

from the small intestine wellsback into the stomach.
(e) Blood. Vomiting of blood is called haematemesis. This may

come from a stomach lesion, such as a peptic ulcer, or from the
oesophagus, as in oesophageal varices, or from blood swallowed,
e.g. after tonsillectomy. If the bleeding is acute, the blood is
vomited unchanged. If the blood is digested by the gastric juice it
is known as coffee-ground vomitus.
3.7 Observation/Collection of Specimen
Examination by the pathologist of specimens submitted to him will often

provide the diagnosis, and in many cases, decide the treatment of the
patient concerned. It is, therefore, of the greatest importance that
material sent to the laboratory is of the kind wanted, in suitable quantity,
and as fresh as possible. The doctor will request the examination he
wants and sometimes collects the specimen; the nurse’s duties include
providing his equipment, or the collection of material, and the labelling
and dispatch of the specimen to the laboratory. The containers used
should be suitable for the purpose, firmly closed, and labelled clearly
with the name of the ward and patient; the nature of the material; the
examination requested, and the date. Contamination of the outside of the
container must be avoided in the interest of those who have to handle it.
Specimens must be sent as some as possible after collection, with the
signed requested card.
3.7.1 Specimens of Urine
Types of Urine Specimen
A. Ward Specimen
The urine is usually passed into a clean, dry receptacle and a specimen
glass filled from it. The bottom of this glass is conical so that small
amounts of sediment are easily seen. The bed number is attached using
self-adhesive labels.
B. Clean Specimen
A specimen of urine is passed into a sterile container, after cleansing the

urethral meatus. It is then examined for deposit and bacteria.
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C. Catheter Specimen
These are used much less often than clean specimens, because of the
risk of urinary infection.
D. Twenty-four-hourly Specimen
A Winchester bottle is labelled with the name of the ward and patient,
and the date and times of collection. The patient empties the bladder
early in the morning (e.g. 6 a.m.) and the urine is discarded. All urine
passed up to and including the 6 a.m. specimen on the following
morning is measured and put into the Winchester bottle. The amount
passed is recorded and sent to the laboratory. The commoner indication
for collecting a 24-hour specimen of urine is for estimation of excretion
of 17-ketosteroids derived from the steroid hormones.
E Aschheim-Zondek Test
About 210-180 mls of an early-morning specimen is sent to the

laboratory. This urine is very concentrated and is used in the diagnosis
of early pregnancy, or certain malignant growths of the reproductive
system.
3.7.2 Specimens of Stool
Specimens of Stool are usually collected for
Examination for Occult Blood
Blood in the stools may be indistinguishable to the naked eye but can be
detected chemically. Specimens of three consecutive stools are collected
for this test and examined.
Organisms
A small sample of stool is taken and examined for any abnormality,

such as pus or blood.
3.7.3 Specimens of Sputum
Specimens of Sputum may be examined for pus, blood, or tubercle

bacilli. In collecting sputum for examination for tuberculosis, phlegm
must be collected and not saliva. This is because the organism resides in
the phlegm from the chest and not inside saliva. If examination is to be
made for tubercle bacilli, three consecutive specimens are collected and
sent. Specimens of sputum are best expected directly into a carton. If a
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specimen is taken from a sputum container, it must be one with no

disinfectant in it. If a patient is unable to provide sputum, a Ryle’s tube
is passed through the nose or mouth into the stomach, 5 or 10 ml. of
normal saline is injected with a syringe, and all the fluid in the stomach
withdrawn for examination. This is best done early in the morning.
3.7.4 Specimens of Blood
Capillary Blood
Capillary Blood is used to estimate

The haemoglobin level
The red and white blood cell counts.
Blood-sugar estimation
And the nurse may be asked to collect it, since the fasting blood-sugar
level is an important one and must be taken early before technicians are
normally at work.
The blood is drawn into a special pipette and labeled, giving the time of
collection as well as patient data. Estimation of the blood sugar may also
be made by a paper dip-and-read test such as Dextrostix. A large drop of
capillary or venous blood is spread over the end of the test-strip. After
one minute the blood is rinsed off, and the colour of the test compared
with a colour chart. Such a quickly-performed test is of great value in
the speedy diagnosis of causes of unconsciousness, and in diabetic
clinics.
Whole Blood
Whole blood is used for many investigations. Usually 5-10 ml. is taken.
3.7.5 Specimens of Pus
A throat swab may be dipped in pus from a wound, returned to its tube,
and sent at once to the laboratory. Such swabs dry quickly and become
useless, so it is important that the swab is well charged with pus if
possible, and dispatched without delay. If pus is abundant, it may be
transferred to a plain sterile tube with a pipette; it should never be
scooped up with a tube. This soils the outside of the tube with organisms
dangerous to the nurse and the technicians who will handle it, and to the
patients to whom they may spread the infection.
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3.7.6 Specimens of Tissue
Biopsy means the removal of tissue for examination. The amounts are
often small if taken during sigmoidoscopy or bronchoscopy, and such
fragments should be put into normal saline in a test tube, closed with a
cork, not a swab.
Larger specimens (e.g. organs removed at operation) may be sent at

once to the pathologist in a covered bowl, or enclosed in a polythene bag
to prevent drying. Accurate labelling and careful handling of such
specimens is vital, since, in many cases, the surgeon wants to know
weather the condition is a malignant one or not.
Nurse’s Responsibility in Fixation of Biopsy Specimens:
1. Any tissue given to the nurse should be carefully preserved.
2. As quickly as possible, pour fixative liquid over the specimen.

The fixative is usually alcohol 80% and formation 10%. The
recommended amount is about 10 times the volumes of the
specimen.
3. Label with name, hospital number, and type of specimen. Fill out
slip that with this. If any, send to the laboratory.
Specific Types of Biopsy:
1. Liver Biopsy: a special biopsy needle is passed into the liver through
the skin either in subcostal or 9th – 10th intercostals area to obtain
tissue for examination in cases of severe liver disease.
a. Contraindications:
i. Low prothrombin level

ii. Bleeding tendency
iii. Obstructive jaundice (may result in hidden hemorrhage or bile
leakage from biopsy site)
b. Procedure:
i. Collect tray and assist doctor

ii. Explain procedure to the patient
iii. Patient should sign consent form
iv. Type and cross-match blood as precaution
v. Administer any sedative ordered
vi. Take vital signs before procedure for baseline
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vii. Patient should lie on right side after the procedure with small
pillow under costal margin in order to apply pressure to the
biopsy site, with the right arm extended.
viii. Patient should maintain bedrest for 24 hours after test
ix. Take vital signs for 24 hours – every 15 min for two to three
hours
x. Observe for abdominal pain, tenderness and rigidity and the
report any, since bile may be leaking from the liver.
2. Bone marrow biopsy: This is the insertion of a special needle into

the red bone marrow to obtain specimen for examination to
determine the number and characteristics of cell content
a. Sites used: Sternum and iliac crest
b. Procedure:
i. Explain procedure to patient, and obtain consent.

ii. Shave, if needed, and clean skin over site to be used.
iii. Obtain needed equipment from CSP and notify lab personnel
when doctor is ready to do the biopsy.
iv. The physician injects to local anesthetic and then introduces an
aspiration needle. The stylet is removed and syringe attached.
v. After the specimen has been obtained and the needle is removed,
a small dressing is applied over the site.
vi. The lab personnel take the specimen immediately for analysis.
3.7.7 Blood Determinations
Coagulation Tests – This is done on capillary blood.
1. Clotting time is the time is takes blood to clot.
2. Bleeding time is the time it takes bleeding to stop naturally. Normal

is 0 – 5 minutes.
3. Prothrombin time is the time it takes for coagulation following the

addition of thromboplastin and calcium to the specimen. Normal is
based on the control.
4. Fibrinogen level: Normal is 200 mg/100 ml of blood.
a. Erythrocyte sedimentation rate (Sed rate or ESR): This is the

rapidity with the RBC’s settle out of clotted blood in one hour. It
is a non – specific test done on venous blood and is used as a
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rough index of the progress of an inflammatory disease,

especially rheumatoid arthritis, rheumatic fever, and respiratory
infections. Normal varies with method used, but is higher in
women.
b. C – Reactive protein is used to diagnose and evaluate

inflammatory disease (particularly rheumatoid arthritis,
myocardia infaction, and active widespread malignant disease). A
protein similar to that found in pneumococcus is present in the
above diseases. Graded in degrees of 1+ to 4+.
3.8 Basal Metabolic Rate
Purpose
Basal metabolism is the amount of metabolism going on in a person

lying at rest, having fasted overnight. It is affected by the height, weight
and sex, and by the activity of the endocrine glands, especially the
thyroid and the pituitary. It can be estimated from knowledge of the
oxygen taken in and the carbon dioxide expired, and is expressed as a
plus or minus percentage. The commonest cause of a rise in the basal
metabolic rate is fever, and the temperature should be normal when the
test is conducted. Thyrotoxicosis causes a rise, and myxaedema a fall.
Method
The patient’s height and weight are ascertained overnight, and he is told
that it is a simple breathing test, causing no more discomfort than having
nothing to eat from supper time till after the test. Reassurance is
especially needed for the toxic patient. Early in the morning the screens
are drawn, the bladder may be emptied, and the patient is asked to rest
quietly till the technician comes with his apparatus. An oxygen supply
must be available. The patient simply breathes in and out of a bag for a
few minutes. The results are calculated from the figures obtained and the
data supplied by the nurse. Changes of less than 10% are not considered
of much significance. Some physicians now prefer to estimate the level
of the protein-bound iodine (for which only a blood sample is required)
or to perform a radioactive iodine uptake test to give information on the
metabolic rate.
3.9 Glucose Tolerance Test
Purpose
To investigate the ability to metabolise sugar. Normally the fasting

blood sugar, estimated before breakfast, is about 80 mg. per cent, and if
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sugar is taken there is a steep rise, followed by a gradual fall to normal

in two hours as insulin action causes its removal to the liver. If the blood
sugar rises above 180 mg. per cent, sugar will appear in the urine. In
diabetes mellitus, the fasting blood sugar is often high, and taking sugar
causes a rise without the steady return to normal. This test is used to
distinguish diabetes from other causes of glycosuria.
Method
If the patient is ambulant, it may be more convenient for him to go to the

laboratory. He fasts overnight, and at 9 a.m. a specimen of blood for
fasting blood sugar is taken, and the bladder is emptied. He then drinks
50 G. of glucose in a glass of water flavoured with lemon juice. The
blood sugar is estimated after ½ hour, 1 hour, 1½ hours and 2 hours, and
specimens of urine are collected at 10 a.m., 11 a.m. and noon and sent
for examination. It is unusual for the blood sugar to exceed the renal
threshold level of 180 mg. per cent.
3.10 Tuberculin Skin Tests
People who have had an overt or sub-clinical infection with the tubercle
bacillus become sensitized to tuberculin, and will respond with a
reaction if it is injected into or applied to the skin. A negative reaction
indicates that the subject has never been exposed to such infection and is
therefore susceptible. Most adults in urban communities show a positive
reaction, but with the decline in tuberculosis now taking place, there are
increasing numbers who are negative. A proportion of students taking
up nursing or medicine will be negative reactors, and in view of their
occupational risk it is common practice to immunize them with B.C.G.
(Bacille Calmette-Guerin), a weak strain of the tubercle bacillus.
Mantoux Test
This is the commonest and most reliable skin test. The doctor will bring
his own sterile glass syringes, tuberculin, and normal saline. He should
be supplied with swabs and ether. He injects 0.2 ml. of tuberculin, 1 in
1,000, intradermally into the skin of the forearm, and a corresponding
amount of control solution into the other. A positive reaction is the
development of a red reaction with a central zone of aedema at least 1.5
cm. across on the tuberculin side.
Patch Test
A piece of strapping containing tuberculin is applied to the back, usually

of a baby, and the result read after forty-eight hours. It is not very
reliable.
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3.11 Cardiac Catheterization
A fine plastic catheter is introduced into the heart to enable the

physician to obtain samples of blood from different parts of the heart
and great vessels, and to measure pressure. Children usually need a
general anaesthetic to prevent restlessness during the long examination,
but adults only require a sedative. Antibiotic cover is sometimes
necessary. Full aseptic precautions are taken during the introduction of
the catheter.
The right heart can be reached by inserting the catheter into an arm vein,
whence it can usually be manoeuvred without difficulty into the superior
vena cava, the right atrium and the right ventricle, and thence into the
pulmonary artery. The progress of the catheter is checked on a screen.
The catheter can be introduced into the femoral artery by puncturing this
vessel in the groin with a large bore needle, threading a guide wire
through this into the artery, and passing the catheter over it. The catheter
is then guided up the aorta, valve into the left atrium and the left
ventricle. After the examination, the catheter is withdrawn and firm
pressure applied over the puncture site for ten minutes. An alternative
method is to pass a long needle up the catheter when it is lying in the
right atrium, puncture the septum, and pass the catheter over the needle
into the left atrium.
Complications are not common after right heart examination, but
catheterization of the left heart is more dangerous. The benefit to the
patient of accurate assessment of his condition must be considered by
the physician as greater than the risk involved. Disorders of cardiac
rhythm, especially ventricular fibrillation or cardiac arrest, must be
continually watched for, and the means available to deal with them.
When the patient returns to the ward, the pulse rate and rhythm are
observed every half hour, and the temperature is taken four hourly. The
puncture site should be inspected regularly for signs of haematoma
formation.
Among the facts that can be learned from cardiac catheterization are the
presence, site and size of septal defects; lesions of he heart valves; the
cardiac output; and the pulmonary resistance. In addition,
angiocardiography may be performed by injecting hypaque 85% through
the catheter and taking films.
4.0 CONCLUSION
Clinical observations describe the initial and basic observation of the

temperature, pulse and respiration rate, in relationship to other
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significant changes in an individual. This observation must be done

within the context of nurse/patient relationship.
5.0 SUMMARY
• Whatever specimens to be collected for investigation must be of the

kind wanted, in suitable quantity, and as fresh as possible.
• The doctor will request for the examination he wants and sometimes
collects the specimen.
• The nurse’s duties include providing his equipment or the collection

of material, and the labelling and dispatch the specimen to the
laboratory.
• The containers used should be suitable for the purpose, firmly

closed, and labeled clearly with the name of the ward and patient; the
nature of the material; the examination requested, and the date.
• Specimens must be sent as soon as possible after collection, with the

signed requested card.
• All observations must be recorded.
1. Explain the significance of clinical observation

2. Identify the tools and equipment used for clinical observation

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UNIT 3 PRE-OPERATIVE INTERVENTION
CONTENTS
1.0 Introduction
2.0 Objectives
3.0 Main Content
3.1 Classification of Surgical Intervention
3.2 Purposes of Surgical Intervention
3.3 Effects of Surgical Intervention
3.4 Phases of Pre-operative Period
3.5 The use of the Nursing Process
3.5.1 Pre-operative Assessment
3.5.2 Physical Preparation of the Surgical Patient
3.6 Data Analysis and Planning
3.7 Expected Outcome
3.8 Nursing Implementation/Intervention
3.8.1 Informed Consent
3.9 Evaluation of Safety of the Surgical Patient
3.10 Transportation to the Operating Room
4.0 Conclusion
5.0 Summary
1.0 INTRODUCTION
Surgery is one of the major medical interventions of medical therapy. It

is a stressful experience affecting a patient and members of his family.
The nurse is in a position to assist the person to cope with the stressors,
to seek relief from the pain, and to return to optimal functioning.
2.0 OBJECTIVES
• explain the purposes of performing surgery on an individual

• understand the psycho-social effect of surgery
• describe the phase of pre-operative nursing care
• apply the nursing process in the assessment and physical
preoperating patient for surgery.
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3.0 MAIN CONTENT
Keywords
Common Surgical Suffixes
-ectomy Removal of an organ or gland

-rrhapy Suturing or stitching
-ostomy providing an opening (stoma)
-otomy Cutting into
-plasty Plastic repair
-scopy Looking into
3.1 Classification of Surgical Intervention
Surgeries may be classified in several ways, such as by
1. Location
2. Extent
3. Purpose of the surgery.
Location
Surgery may be performed externally or internally. In external surgery,

surgery is on the skin or underlying tissues are readily accessible to the
surgeon. External surgery has disadvantages; it may result in scarring or
disfiguration that may be readily visible, leading to great concern and
distress for some patients. Plastic surgery is an example of external
surgery and is directed toward reconstruction and repair of deformed
tissues.
Internal surgery involves penetration of the body. The scars of internal

surgery may not be visible but may lead to complications such as
adhesions. Surgery of major internal organs may lead to decreased
function if sufficient tissue is removed.
Surgery may also be classified by location of body parts or systems,

such as cardiovascular surgery, chest surgery, neurologic surgery, and so
on.
Extent
Surgery may be classified as minor or major. Minor surgery presents

little risk to life and is under local anesthesia. It may be done in an
outpatient. Many minor surgeries are performed but general anesthesia
may also be used. Although the operation is termed “minor,” it is
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frequently not viewed as a minor episode by the patient and may evoke
fears and concerns.
Major surgery is usually performed under general anesthesia in an

inpatient surgical suite. It is more serious than minor surgery and may
involve risk of life. There is a trend toward an increased number of
surgical procedures being performed in hospital ambulatory centres in
which persons are admitted to the centre on the morning of surgery,
remain there for their immediate post-operative care, and are then
discharged to their homes before the end of the day. Some major
surgical procedures, such as herniorrhapy, are now being performed in
this manner.
3.2 Purpose of Surgery
There are several purposes for performing surgery. These include:
a. For diagnostic and curative reason. In this regard, the surgery is

done to determining the causes of the symptoms so that the
affected organ can be removed or appropriate intervention done.
For example exploration.
b. Restorative Purposes. Restorative surgery is done to remove a

dead organ or part of an organ for maximum functioning. In some
cases, restorative surgery may also be done to strengthen a
weakened part of the body to correct any deformities. For
example, herniarrhophy.
c. Palliative Surgery: This is often done to relieve symptom

without living disease. For example, radical mastectomy
(removal of a cancerous breast may be done not to be the disease,
but to offer some pain relief.
d. Cosmetic Surgery: This is done for aesthetic reasons, often to

improve appearance. For example, surgery may cure done to
remove extra fat from the stomach or scars from the face. They
are often called plastic surgery.
3.3 Effects of Surgery on the Patient
Surgery is a potential or actual threat to a person’s integrity and thus

may produce both physiologic and psychological stress reactions. The
physiological stress reaction is directly related to the extent of the
surgery, that is, the more extensive the surgery, the greater the
physiologic response. The psychological response, however, is not
directly related. A relatively minor surgical procedure, such as removal
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of a cyst from the face, may evoke a greater psychological response than
removal of an organ such as the spleen because of the former’s potential
for scarring. Removal of the uterus, however, may evoke a greater
response than would, removal of the spleen. This is because of the
implications and values attached to uterus.
Physiologic Responses
Major surgery is a stressor to the body and evokes a neuroendocrine

response. The response, which consists of sympathetic nervous system
and hormonal responses (Table 17-2), serves to protect the body from
the threat of injury. When the stress to the system is severe or if blood
loss is excessive, the body’s compensatory mechanisms are
overwhelmed, and shock is the result. Certain types of anesthesia used
may also contribute to shock formation.
Metabolic responses
Metabolic responses also occur. Carbohydrates and fats are metabolized

to produce energy. Body proteins are broken down to provide a supply
of the amino acids used to build new tissues. Those amino acids that are
not used are broken down to nitrogen end products, such as urea, and
excreted. This leads to a negative nitrogen balance; that is, nitrogen loss
exceeds nitrogen intake. This accounts for the weight loss after major
surgery. A high protein intake is necessary for healing and for
restoration of optimal functioning.
Psychological responses
Persons differ in the way they perceive the meaning of surgery, and thus
they respond in different ways. Some of the fears underlying pre-
operative anxiety are elusive, and the person may not be able to identify
the cause. Others are more specific.
Fear of the unknown is most common. “Going to sleep and never

waking up.” Fears concerning pain, disfigurement, or permanent
disability may be realistic or may be influenced by myths, lack of
information, or lurid stories told by friends. The patient may also have
other concerns related to hospitalization, such as job security, loss of
income, and care of family.
3.4 Phases of Peri-operative Period
The surgical experience can be classified into three stages: pre-

operative, intra-operative, and post-operative periods.
Pre-operative Phase
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The pre-operative phase begins when the decision to proceed with

surgical intervention is made and ends with the transfer of the patient
onto the operating room table. The scope of nursing activities during this
time can include establishing a baseline evaluation of the patient before
the day of surgery by carrying out a pre-operative interview (which
includes not only a physical, but also an emotional assessment, previous
anesthetic history, and identification of known allergies or genetic
problems that may affect the surgical outcome), ensuring that necessary
tests have been or will be performed (preadmission testing), arranging
appropriate consultative services, and providing preparatory education
about recovery from anesthesia and post-operative care. On the day of
surgery, patient’s teaching is reviewed, the patient’s identity and the
surgical site are verified, informed consent is confirmed, and an
intravenous infusion is started. If the patient is going home the same
day, the availability of safe transport and the presence of an
accompanying responsible adult are verified. Depending on when the
preadmission evaluation and testing were done, the nursing activities on
the day of surgery may be as basic as performing or updating the pre-
operative patient assessment and addressing questions the patient or
family may have.
Intra-operative Phase
The intra-operative phase begins when the patient is transferred onto the
operating room table and ends when he or she is admitted to the
postanesthesia care unit (PACU). In this phase, the patient’s safety,
maintaining an aseptic environment, ensuring proper function of
equipment, providing the surgeon with specific instruments and supplies
for the surgical field, and completing appropriate documentation. In
some instances, the nurse can provide emotional support by holding the
patient’s hand during general anesthesia induction, or assisting in
positioning the patient on the operating room table.
Post-operative Phase
The post-operative phase begins with the admission of the patient to the
PACU and ends with a follow-up evaluation in the clinical setting or at
home. The scope of nursing care covers a wide range of activities during
this period. In the immediate post-operative phase, the focus includes
maintaining the patient’s airway, monitoring vital signs, assessing the
effects of the anesthetic agents, assessing the patient for complications,
and providing comfort and pain relief. Nursing activities then focus on
promoting the patient’s recovery and initiating the teaching follow-up
care and referrals essential for recovery and rehabilitation after
discharge. Each phase is reviewed in more detail in the three chapters of
this unit.
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3.5 The Use of the Nursing Process
3.5.1 Pre-operative Assessment
Data is collected in the pre-operative period to identify the patient’s (1)

knowledge of events that will occur, (2) psychological readiness for
surgery, and (3) physiologic status before surgery.
Psychological readiness for surgery
Both subjective and objective data are collected to assess the anxiety.
Subjective Data includes possible changing in sleep pattern, religion

and its meaning for patient, while
Objective Data includes observation of speech patterns and physical

changes. There are increased pulse and respiratory rate, excessive hand
movements, clammy hands and restlessness.
Physiologic Status
Data are collected in the pre-operative period concerning the patient’s

physiologic status to obtain baseline data for comparison in the intra-
operative and post-operative phases and to identify potential post-
operative problems requiring pre-operative intervention. Good sources
of pertinent data are admission histories and physical examinations.
Other pertinent assessment includes:
- Ability to see and hear, use of aids

- Ability to communicate effectively. If patient is unable to
communicate in English an interpreter is sought.
- Respiratory rate
- Ease and symmetry of respirations
- Presence and character of lung sounds
- Presence of upper respiratory tract infection
- Smoking habit
- Pulse rate, rhythm, and strength
- The height to weight ratio indicates whether the patient is

overweight of underweight. The obese person presents numerous
risks during the surgical experience. They also have greater
difficulty expanding their chests, moving in bed, and walking.
Fluid and electrolyte imbalances occur with dehydration and
prolonged vomiting and diarrhoea. Undernourished persons
already have diminished reserves of carbohydrates and fats.
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Wound healing becomes considerably delayed in undernourished

persons. In some cases if surgery is not an emergency, it is
delayed until the patient’s nutritional status is improved.
- Presence of nausea or vomiting
- Signs of dehydration (decreased skin turgor, dry mucous

membranes, and high hematocrit level
- History of chronic constipation
- Bowel movement decreased activity after surgery predisposes a

patient to constipation. Persons with a history of chronic
constipation have a higher risk for developing constipation post-
operatively.
- Diarrhoea
- Oxygenation. The ability to carry out deep breathing exercises.

Circulatory data is particularly important for determining the risk
for post-operative atelectasis or pneumonia.
- Activity Mobility and ambulation are important activities in the

post-operative period for preventing post-operative
complications. The patient’s ability to move and walk pre-
operatively will determine actions that must be taken to enhance
maximum mobility.
1. Nursing History
The nursing history obtained before surgery provides client data that
help the nurse to plan pre-operative and post-operative care. The history
should include the following:
a. Physical Condition – Note the weight, hydration status

and colour. Problems, such as obesity, malnutrition and
dehydration may indicate the need for therapy, prior to
surgery. For instance, the dehydrate client may need fluids
administered intravenously.
b. Mental Altitude – Anxiety is a normal response to

surgery. However, extreme anxiety can increase surgical
risk and needs to be reported to the physician.
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c. Smoking Habits – The lung tissue of a person who

smokes is chronically irritated, and a general aesthesis
irritates further.
d. Use of Alcohol – Heavy, consistent use of alcohol can

lead to problems during an anesthesia, surgery and
recovery.
2. Pre-operative teachings
Is more effective at this time when there is no pain. Pre-operative

teaching improves the individual’s coping skills by enhancing a sense of
personal control. Effective pre-operative teaching helps reduce post-
operative anxiety and discomfort. Pre-operative teaching includes
moving, leg exercises, and coughing and deep TCDB breathing
exercises:
a. Moving – Turning in bed and early ambulation are

encouraged to help clients maintain blood circulation,
stimulate respiratory functions, and decrease the stasis of
gas in intestines.
b. Leg exercises – leg exercises help prevent

thrombophlebitis due to slowed venous circulation
(venous stasis). The major danger of thrombophlebitis is
that thrombi can become embolic and lodge in the arteries
of the heart, brain or lungs, causing serious injury or death.
c. Coughing and Deep Breathing Exercises: Deep

breathing exercises help remove mucus, which can form
and remain in the lungs due to the effects of general
anesthetic and analgesics. These drugs depress the action
of both cilia of the mucous membrane lining the
respiratory tract and the respiratory center in the brain.
Deep breathing also aerates lung tissue and thereby helps
prevent pneumonia, which may result from stagnation of
fluid in the lungs. Deep breathing frequently initiates the
coughing reflex. Voluntary coughing in conjunction with
deep breathing facilitates the movement and expectoration
of respiratory tract secretions. If client will have an
incision that will be painful when coughing, demonstrate
how client can support it (splint) as the client coughs.
Coughing uses the abdominal and other accessory
respiratory muscles. Splinting the incision may reduce
pain while coughing, if the incision is near any of these
muscles.
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3.5.2 Physical Preparation of the Surgical Patient
1. Diagnostic Procedures: Diagnostic tests and procedures are

often ordered for a patient before surgery. Baseline information
from various tests (e.g. urinalysis, chest x-ray) helps pinpoint
problems before surgery.
2. Pre-operative Skin Preparation: Preventing microbial

contamination of a surgical wound reduces the risk of wound
infection. Surgical skin preparation (called“prep”) includes
cleansing the skin and, usually removing hair from areas
surrounding the operative site. The skin prep is performed
according to the health care facility policy. In some facilities,
only specially trained personnel prep the skin. In others, the staff
nurses perform the preps. Hair removal from the surgical site is
controversial. Shaving the hair, the evening before surgery, has
long been the standard practice. However, research indicates
razor shaving contributes to increased rates of surgical wound
infection. It has been suggested that a depilatory cream or an
electric clipper be used instead.
3. Preparing the Gastrointestinal Tract: The G.I. tract is emptied

or cleansed before surgery to reduce the risk of vomiting and
aspiration during anesthesia, prevent contamination of the
operative site from fecal material during bowel surgery, and to
reduce post-operative nausea and vomiting, gastric distension and
obstruction. Restricting foods and fluids during the pre-operative
phase prevents vomiting. An empty stomach lessens the risk of
aspirating vomits into the lungs during anesthesia. Food and fluid
are usually prohibited 8 – 10 hours before surgery. Hospitalized
persons are usually NPO after midnight. If a person accidentally
eats or drinks before surgery, immediately inform the surgeon
and anesthesiologist. Bowel preparation is essential for surgeries
involving the GI tract or abdomen, cleansing the colon prevents
contamination of the peritoneal cavity by spillage of fecal
material during surgery. The surgeon may order an enema, or
rectal suppository. Oral antibiotics may be ordered for two to
three days before surgery to reduce the number of bacteria in the
bowel. The insertion of gastric and intestinal tubes may be
necessary to remove GI contents by suction.
4. Preparation for Anesthesia: Anesthetist or anesthesiologist

needs to visit the patient to assess the person’s physiologic
condition related to the safety of anesthesia (e.g. smoking history,
upper respiratory tract infection, and cardiopulmonary
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dysfunction). He should also explain the complete procedure to

him.
5. Promotion of Rest and Sleep: Promote rest by ensuring physical

and emotional comfort. Give a back rub to aid relaxation.
Encourage the person to discuss concerns or questions. A
sleeping medication may be ordered for the patient.
3.6 Data Analysis and Planning
Nursing Diagnoses
After collecting the assessment data, the nurse identifies nursing

diagnoses based on specific patient data. Possible nursing diagnoses
might include the following:
Anxiety
Fear of death, disfigurement
Knowledge deficit
Potential injury
3.7 Expected Patient Outcomes
Expected patient outcomes might include the following:
1. Demonstrates no more than moderate anxiety.
2. Can explain (if conscious) the surgery to be performed and has

signed the operative consent for (consent on chart).
3. Can explain sequence of events and physical activities expected

in the early post-operative period (turning, deep breathing and
coughing).
4. Has had a baseline assessment and current vital signs taken and
charted.
5. Has had any significant physical or psychological changes

reported to the surgeon.
3.8 Nursing Implementation/Intervention
Assisting with medical interventions or correction of existing

deficiencies
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Dehydration from vomiting and diarrhoea is treated with potential fluids

to reestablish fluid and electrolyte balance.
Patients with chronic diseases should be at their optimal health level
before surgery. The undernourished patient is placed on a high-protein,
high-carbohydrate diet rich in vitamins B1, C, and K. Supplementary
vitamins may be ordered. If an oral is poorly tolerated or poorly
absorbed, total parenteral nutrition (TPN) will be initiated. The obese
patient is placed on a weight-reducing diet. Both the undernourished and
the obese patient should understand the rationale for the diets. They may
need considerable support and encouragement to maintain the diets.
Diet
Patient undergoing bowel surgery may be placed on a low residue diet,

but no food is allowed eight hours before surgery. This is because the
presence of food or fluids in the stomach increases the possibility of
aspiration of gastric contents. If it should be discovered that the
patient has consumed food or fluids when ordered “nothing by
mouth” (NPO), the surgeon should be notified. This may necessitate
rescheduling the surgical procedure.
Patients who are dehydrated will usually have parenteral fluids initiated
before surgery. A nasogastric tube may be inserted before surgery, in
case of abdominal surgery.
Bowel Preparation
The purpose of the pre-operative enema is to prevent injury to the colon

and to provide better visualization of the surgical area. If a pre-operative
enema is ineffectual, it may be repeated.
Skin Preparation
The purpose of pre-operative skin preparation is to free the operative site

of as many microorganisms as possible.
A depilatory may be used if the skin is not sensitive to the depilatory.

Shaving of the hair may be ordered either the night before or
immediately before surgery. A sharp disposable razor is used with good
lighting. Shaving must be against the grain of the hair shaft for a closer
shave. The skin should not be scratched or nicked since microorganisms
can harbor in broken skin surfaces.
Shaving of hair on certain areas of the body may have a special meaning
for some persons. These areas include face, head, and pubic area. Pubic
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hair is shaved only when necessary; the regrowth of this hair is

uncomfortable to many patients.
Psychologic Counseling and Teaching
Both patient and family need opportunities to discuss their concerns and
fears about the forthcoming surgery. The assessment of the patient’s
psychologic readiness for surgery provides the nurse with data about the
patient’s specific fears or concerns. Fear of the unknown can be
decreased by an understanding of the events that will occur. The amount
of information to give pre-operatively depends on the background,
interest, and stress level of the patient and the family. A good rule to
follow is to ask patients what they would like to know about
forthcoming surgery and to base responses on the types of questions
asked. Teaching is an important function of the nurse in the pre-
operative phase and helps to allay anxiety when the patient knows what
to expect.
Deep Breathing and Coughing Exercises
Deep breathing and coughing exercises are recommended for persons at

high risk for developing post-operative pulmonary complications such
as atelectasis or pneumonia.
The method for deep breathing and coughing exercises is listed as

follows:
1. Lie in semi-Fowler or high Fowler’s position with knees flexed to

relax abdomen and allow full chest expansion.
2. Place a hand lightly on the abdomen.
3. Breathe in slowly through nose, letting chest expand and feeling

abdomen rise against hand.
4. Hold breath for three seconds.
5. Exhale slowly through pursed lips (abdomen contracts with

inspiration).
6. Inhale and exhale three more times. Following last inspiration,

cough forcefully to expel any secretions.
7. Rest.
8. Repeat steps 3 through 7 two more times.
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Leg Exercise
This is required for persons who will be on bed rest for several days
after surgery. To maintain muscle tone and facilitate ambulation and
prevent various stasis in the operative period. Quadriceps drills and
gluteal tightening exercises are taught.
Assisting With Comfort
Anxiety often causes sleeplessness and restlessness. If the patient is

extremely restless, a transquiliser may be given for one to two days
before surgery. Ambulation is encouraged before surgery to give the
patient a feeling of well-being, to stimulate circulation and ventilation,
and to maintain muscle tone. Fatigue is to be avoided, and patients with
chronic illnesses may need planned periods of rest.
The person should be permitted to sleep on the morning of surgery for

as long as possible and to rest undisturbed until shortly before
administration of pre-anesthetic medication.
Pre-operative Investigations
Special pre-operative tests may be ordered to establish baselines and

detect presence of disease that can affect patient responses in intra-
operative or post-operative phases. The temperature, pulse and
respiration, and the weight are recorded, and the condition with regard
to an anesthetic assessed. A chest X-ray may be needed, the hemoglobin
level and the blood group may be ascertained, Patients often need
explanations concerning the necessity for the sometimes numerous tests.
Pre-anesthetic Medication
A sedative is usually ordered the night before surgery to ensure a full

night’s sleep. If additional sedation or medication for pain is given
during the night, it must be given at least four hours before the pre-
anesthetic medication. Pre-anesthetic medications, commonly referred to
as premedication, are given when the patient is “on call” for the
operating room (usually about 45 to 90 minutes before surgery is
anticipated). These are given to decrease anxiety, to provide a smoother
induction and maintenance of anesthesia, and to diminish undesirable
reflexes during emergence from anesthesia. Adults frequently receive a
combination of drugs. Dosages may be decreased in the elderly.
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All pre-operative routines should be completed before the pre-anesthetic

medication is given. The patient should remain in bed following
administration of the medication to promote maximum effect and to
prevent falls from dizziness.
Commonly used pre-anesthetic medications are (1) Sodium (Nembuta)

is used to reduce anxiety, promotes relaxation and sleep, (2) Trazepam
is used to promote relaxation and sleep (3) Narcotics Morphine sulfate
reduces anxiety, promotes relaxation, decreases pre-operative pain,
decreases amount of anesthetic needed, (4) Vagolytic agents Atropine
sulfate or Scopolamine hydrochloric ride (Hyoscine) is used for
decreased secretions, prevention of laryngospasms.
3.8.1 Informed Consent
Informed consent is a basic legal consideration for individual

undergoing surgery. This is a written permission obtained from the
patient for each operation. The consent implies that the patient has been
provided with the knowledge necessary to understand (1) the nature of
the procedure to be performed, (2) the available options, and (3) the
risks associated with each option. Informed consent must be obtained in
that the signed permission protects the patient from undergoing
unauthorized surgery. It also protects the surgeon and hospital against
claims of unauthorized surgery or that the patient was unaware of the
risks involved. The physician is usually responsible for explaining the
surgery, options, and risks. The role of the nurse is to ensure that the
consent form has been signed and witnessed before the patient is sent to
surgery. Patient is allowed to consult with close family member or
friend before signing the operative permit.
A patient’s right to self-determination is protected by informed consent

that is the right to decide whether surgery is in one’s best interest. Every
person having surgery, no matter how minor the procedure, must give
written consent. Voluntary and written informed consent from the
patient is necessary before any planned surgery can be performed. Such
written consent protects the patient from unsanctioned surgery and also
protects the surgeon from claims of an unauthorized operation. The
nurse may ask the patient to sign the form and may witness the patient’s
signature. It is the physician’s responsibility to provide appropriate
information.
Before the patient signs the consent form, the surgeon must provide a
clear and simple explanation of what the surgery will entail. The
surgeon must also inform the patient of the benefits, alternatives,
possible risks, complications, disfigurement, disability, and removal of
body parts as well as what to expect in the early and late post-operative
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periods. If the patient needs additional information to make his or her

decision, the nurse notifies the physician about this. It is important that
the consent form be signed before administering pre-medication,
because of the influence of medications that can affect judgment and
decision-making capacity of the patient. Informed consent is necessary
in the following circumstances:
• Invasive procedures, such as a surgical incision, a biopsy, a

cystoscopy, or paracentesis.
• Any procedure, such as an arteriography, that carries some risk to

the patient.
• Procedures involving radiation.
• Major diagnostic procedures, such as a thoracentesis,

bronchoscopy, etc.
The patient personally signs the consent if he or she is of legal age and
is mentally capable. When the patient is a minor or unconscious or
incompetent, permission must be obtained from a responsible family
member (preferably next of kin) or legal guardian. An emancipated
minor (married or independently earning his or her own living) may sign
his or her own consent form. In an emergency, it may be necessary for
the surgeon to operate as a life-saving measure without the patient’s
informed consent... In such a situation, contact can be made by
telephone, telegram, fax, or other electronic means. The consent process
can be enhanced by providing audio visual materials to supplement
discussion, by ensuring that the wording of the consent form is
understandable, and by using other strategies and resources as needed, to
help the patient understand its content.
When the patient has doubts and has not had the opportunity to
investigate alternative treatments, a second opinion may be requested.
No patient should be urged or coerced to sign a consent form. A patient
has a legal right to a surgical procedure. However, such information
must be documented for other arrangements to be made. Where
possible, additional explanations may be provided to the patient and
family, or the surgery may be rescheduled. In an emergency situation,
the surgeon may operate without written permission if the patient is
unable to sign, is a minor, or is incompetent. Every effort is made,
however, to contact a family member or guardian.
3.9 Evaluating the Safety of the Surgical Patient
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Unless adequate precautions are taken, there is a possibility that an

operation may be performed on the wrong patient, or on the wrong side,
limb or digit. The safeguards against such an accident include the
following: Before the patient leaves for surgery, the chart is checked to
ensure that the following are done and charted:
1. Remove dentures if present.

2. Empty the urinary bladder (void).
3. Remove hair pins to prevent accidental scalp injury.
4. Remove all jewelry and store according to agency policy.
5. Remove eyeglasses, contact lenses, hearing aids, and other

prostheses.
6. Skin preparation.
7. Vital signs (temperature, pulse, respiration, blood pressure) chart.
8. Regular medication charted.
9. Weight and height recorded (for use by anesthesiologist).
10. Informed consent signed, witnessed, and attached to chart.
11. All laboratory, radiographic, and ECG reports attached to chart.
12. Is the patient wearing a legible identification band, which has been
checked?
3.10 Transportation to Operating Room
The patient is put on a stretcher and taken to the theatre by a porter.

Before then, the nurse assigned to prepare the patient for surgery checks
his/her record, accompanies the transportation attendant to the patient’s
bedside, checks the identification band, and signs the patient’s
identification form. This form is usually attached to the stretcher.
4.0 CONCLUSION
Surgery is a potential or actual threat to a person’s integrity and thus

may produce both physiologic and psychological stress reactions.
5.0 SUMMARY
• Informed consent is a basic legal consideration for individual

undergoing surgery. This protects the patient from undergoing
unauthorized surgery and the surgeon and hospital against claims of
unauthorized surgery.
• The surgical experience can be classified into three stages: pre-

operative, intra-operative, and post-operative periods
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• Data is collected in the pre-operative period to identify the patient’s

(1) knowledge of events that will occur, (2) psychologic readiness
for surgery, and (3) physiologic status before surgery.
• Special pre-operative tests may be ordered to establish baselines and

detect presence of disease that can affect patient responses in intra-
operative or post-operative phases...
1. Explain the purposes of performing surgery on a patient.

2. Outline some of the psycho-social effect of surgery
3. Describe the phases of pre-operative nursing care.

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UNIT 4 POST OPERATIVE NURSING CARE
CONTENTS
1.0 Introduction
2.0 Objectives
3.0 Main Content
3.1 Operation Bed
3.1.1 Post-operative Nursing Assessment
3.1.2 Process of Healing
3.1.3 Nursing Care during the Intermediate Post-
operative Stage
3.1.4 Nursing Care during the Extended Post-operative
Stage
3.2 Data Analysis and Planning-Post-operative Care
3.3 Expected patient outcomes
3.4 Nursing Intervention
3.4.1 Obstruction of the Airway
3.4.2 Maintaining Fluid and Electrolyte Balance
3.4.3 Maintaining Adequate Nutrition
3.4.4 Maintaining Elimination
3.4.5 Promoting Comfort from Vomiting, Abdominal
Gas Distention
3.4.6 Maintaining Activity
3.4.7 Maintenance of Circulation to Prevent Shock
3.4.8 Hemorrhage
3.5 Other Post-Operative Discomforts
4.0 Conclusion
5.0 Summary
1.0 INTRODUCTION
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This unit is a continuation of the previous unit. In this unit, you will
learn how to give post-operative nursing care. Post-operative
complications will also be discussed after surgery, and the person is
transferred immediately from the Operating Room to the PACU. The
PACU is an area designed for post-anesthesia care. After surgery, the
patient remains in the recovery room until the condition is stable. The
immediate post anesthetic period is critical. The patient must be
observed diligently and must receive intensive physical and
psychological support until the major effects of the anesthetic have worn
off and overall condition has stabilized. The nurse is largely responsible
for the patient at this period.
2.0 OBJECTIVES
• explain the rudiments of post-operative nursing care

• identify post-operative complications in a surgical patient
• identify some clinical manifestations of post-operative complication.
3.0 MAIN CONTENT
3.1 Operation Beds
As soon as the patient has gone, her bed is made ready for her return. It
should be made with clean linen, unless the operation is very minor, to
provide clean surroundings for the operation site. Pillows are not usually
allowed until consciousness is regained, but one flat one may be
permitted, especially after neck or head operations, when it should have
a jaconet cover. A mackintosh and towel at the head of the bed is
necessary for some cases (e.g. tonsillectomy), and may be liked by the
ward sister for all patients. Blocks may be ready for the foot of the bed,
either to help in the treatment of shock in the recovery phase, or to help
prevent the patient slipping down the bed later.
On the locker are the following:
(a) Vomit bowl and towel, or paper handkerchiefs

(b) Thermometer
(c) Mouth wash and receiver. If the patient is to take no fluids by
mouth, a mouth tray is substituted
(d) Treatment board
(e) Suction machine
3.1.1 Post operative Assessment
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This includes systematic assessment of:
a. Respiratory function: Ensuring patient airway, preventing

respiratory distress, promoting adequate oxygen exchange.
b. Cardiovascular function: Preventing hypotension, shock and

cardiac arrest and promoting adequate cardiac functioning.
c. Neurological and sensory function: Assessing level of

consciousness, reorienting the person as he or she regains
consciousness.
d. Water and electrolyte balance: Monitoring intake and output of

fluids, restoring water and electrolyte balance.
e. Safe, comfortable physical and psychological environment:

Maintaining body temperature, relieving discomfort, and
promoting relaxation, providing support and reassurance.
f. Ability to move all four extremities
g. Consciousness: Ability of patients to answer simple questions

and follow verbal commands.
h. Colour: Assess colour to make sure it is normal.
3.1.2 The Process of healing
The aim of the inflammatory process is to return the damaged tissue to

its normal structure and function. This is accomplished through the
process of healing or repair which begins early in the inflammatory
process. Wound heals by multiplication of connective tissue and
formation of a fibrous tissue over which epidermis grows. Wound may
heal by first intention or by second intention, but the process is similar.
The difference is merely the quantity of new tissue required to heal the
wound. Healing by first intention occurs in incised wounds where the
skin edges are in close contact, therefore only a thin-line of new tissue is
required to bring about healing. In gaping wounds, there is loss of tissue
causing a wide gap between the edges. A mass of new tissue is required
to fill this gap. This is healing by second intention.
Repair proceeds in stages. In the early days, the wound is filled with a
variable amount of tissue fluid and blood which quickly clots. New
blood capillaries begin to form from the endothelium of blood vessels in
the injured area. Almost simultaneously, fibroblasts formed from nearby
loose connective tissue and enter the clotted exudates. These fibroblasts
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cannot multiply if the plasma protein level is low, hence, the need for
adequate intake of protein for efficient wound healing. After the removal
of cellular debris, collagen fibers are laid arranging themselves in layers.
This fibrillar collagen becomes strengthened, consistent and durable in
the presence of Vitamin C. The collagen at this point is referred to as
scar. Gradually, the fibrous tissue contracts. The scar changes over the
months from pink to white and becomes less noticeable in case of
incised wounds. Wounds heal efficiently and more rapidly in the
presence of good blood supply
3.1.3 Nursing Care during the Intermediate Post-operative

Stage
The intermediate post-operative stage begins when the person is

discharged from the PACU and generally ends 48-72 hours later. During
this period, the person remains at risk for post-operative complications,
including respiratory, circulatory, or gastric dysfunction. The person
returns to the surgical unit after stabilization in the recovery room.
Constant monitoring is required at this stage.
3.1.4 Nursing Care during the Extended Post-operative Stage
A person enters the extended post-operative stage two to three days after
surgery. Recovery progresses and the individual approaches discharge.
Continue to intervene to meet the needs of the person. Support him to
promote self care, and to prepare him for discharge.
Level of Consciousness
Level of consciousness should be ascertained. Variation in

consciousness level from alertness to drowsiness will be observed. A
decrease in consciousness level may indicate shock (from jarring
motions during the transfer) and should be documented and reported
along with any other pertinent data.
Positioning
Until protective reflexes have returned, the best position for the majority
of patients is a side-lying or semi-prone position with the head tilted
back and the jaw supported forward. It is to prevent aspiration.
Maintenance of Respiration
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An orpharyngeal or nasopharyngeal airway is often left in place after

administration of a general anesthetic to keep the passage open and the
tongue forward until pharyngeal reflexes have returned. These artificial
airways are made of rubber, plastic, or metal. They are removed as soon
as the patient begins to awaken and have regained cough and
swallowing reflexes.
No one should be left alone until the cough reflex has returned one to
this level of consciousness. And at this level the patient is safe if the
nurse is within reach in case of vomiting or restlessness. During the
dangerous period before the cough reflex returns, asphyxia may occur
for one of these reasons.
Removal of Secretions
If the patient cannot cough up an expectorate secretions, it must be

suctioning. Pharyngeal suctioning is usually all that is necessary,
although intratracheal suctioning may be indicated.
Adequate Ventilation
Post-operative hypoventilation can result from drugs (anesthetics,

narcotics, tranquilizers, and sedatives), incisional pain, chronic lung
disease, or pressure on the diaphragm. Oxygenation and ventilation can
be enhanced by oxygen therapy and breathing exercises. Oxygen is
administered by nasal cannula or catheter, disposable face mask or
shield or endotracheal or tracheostomy tube if one is in place.
Breathing Exercise
Deep-breathing exercises are started as soon as the patient is conscious

and able to follow directions.
Maintaining Circulation
The blood pressure, pulse, and respirations are usually taken every 15
minutes until they are stable, then every half hour for two hours, and
then every four hours until ordered otherwise. The rate, volume, and
rhythm of the pulse are carefully observed and the character and rate of
respiration is noted the patient must be observed for shock.
Restlessness is an early sign of shock.
After surgery of the extremities, local circulation is assessed by the

presence and strength of peripheral pulses distal to the operative site or
plaster cast. If the dressing is too tight, it should be loosened.
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Possible Causes of Post-operative Shock
Moving patient from operating table to bed

Jarring patient (bed) during transport
Reactions to drugs and anesthesia
Loss of blood and other body fluids
Cardiac arrhythmias
Cardiac failure
Inadequate ventilation
Pain
Residual sympathectomy from conductive anesthesia
Preventing Injury
After anesthesia, side rails on the stretcher or bed are generally raised
and are left so until patient is fully awake. The patient is turned
frequently and placed in good body alignment to prevent nerve damage
from pressure and muscle and joint strain from lying in one position for
a long time.
Comfort
The patient is asked for symptoms of discomfort after having been

transferred to the bed and positioned in supportive body alignment. This
gives the nurse a quick indication of the level of alertness as well as
symptoms of discomfort. An indirect question such as, “How do you
feel?” will elicit data concerning nausea or pain without focusing on a
specific area where may be no discomfort.
Dressing
The entire dressing is inspected for haemorrhage. Excess drainage is

reported immediately.
Whenever it is anticipated that fluid may collect in a body area post-

operatively, leading to delay in healing, the surgeon usually inserts a
tube or drain to permit escape of the fluid. One end of the tube or drain
is placed in or near the organ or cavity to be drained, and the other end
is passed through the body wall, either through a separate “stab wound”
or through the incision.
After most types of surgery, usually the surgeon changes the dressing
for the first time. if these additional dressings become wet, they are
removed and replaced soaked with new dressings, leaving the original
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dressing intact. Dressings that can be changed by the nurse as often as

necessary to prevent infection and to promote patient’s comfort.
Safety
Bed side rails are kept raised until the patient is fully awake and
responding or to prevent the heavily medicated patient from falling.
3.2 Data Analysis and Planning-Post-operative Care
In planning the patient’s care the nurse uses previously collected data,
present data, knowledge of factors related to specific types of surgery
and specific post-operative needs and possible post-operative
complications.
3.3 Expected Patient Outcomes
1. No injury occurs during hospitalization.
2. The incision heals normally without infection.
3. No avoidable complications (atelectasis, pneumonia,

thrombophlebitis) occur.
4. Elimination patterns are re-established.
5. The person carries out activities of daily living at an optimal level,

although fatigue may still be present.
6. The person has an opportunity to explore individual concerns.
7. At discharge the person or significant other can explain:
a. Treatments to be carried out at home, if any.

b. Medications to be taken at home (name, dosage, frequency, side
effects).
c. Any dietary changes required by the surgery.
d. Activity limits incurred by the surgery and any exercise programmes
to be carried out at home.
e. When and where to go for follow-up care by the surgeon.
3.4 Nursing Intervention
3.4.1 Obstruction of the Airway
The airway can be obstructed by vomittus or reflux of stomach contents

or mucus which may be secreted by the respiratory tract in response to
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anesthesia and instrumentation. Spasm of the Glottis can also block the
airway. This is more likely to occur during induction of anesthesia than
after operation. The artificial airway should not be removed until the
patient is making movements of the tongue and lips to reject it. If the air
way is out, and the patient lying on the back, the relaxed tongue may
obstruct the glottis. This can be prevented by keeping the patient on her
side, or at least keeping the head turned to one side.
3.4.2 Maintaining Fluid and Electrolyte Balance
Fluid is lost during surgery through blood loss and increased insensible
fluid loss through the lungs and skin. During the surgical procedure, the
blood loss is estimated and fluids are replaced intravenously.
Intravenous administration of fluids is monitored carefully so that fluids
are given evenly over the entire 24 hours. Peristalsis is present and can
tolerate drinking fluids, the physician discontinues fluids are started
orally as soon as sips of water are offered first to see if fluids can be
tolerated.
3.4.3 Maintaining Adequate Nutrition
Two food substances of special importance in wound healing are protein

and vitamin C. protein intake is necessary to restore nitrogen balance
and to provide the necessary amino acids for anabolism. During
catabolism in the early post-operative period, a negative nitrogen
balance occurs. Nitrogen is an essential constituent of amino acids, the
building blocks of proteins. Vitamin C is stored only in small amounts
in the tissues, so must be supplied daily from an external source. The
weight of the patient may be taken daily to encourage and teach post-
operative patients to eat foods high in protein and vitamin C. Discuss
with underweight persons their plans for obtaining the desired nutrients
after discharge.
3.4.4 Maintaining elimination
Urine Elimination
A patient who is well hydrated usually voids within six to eight hours
after surgery. Urinary retention, or the inability to void, may occur in the
early post-operative period for several reasons.
Causes of Post-operative Urinary Retention
Recumbent position
Nervous tension
Anesthetic: decreased bladder sensation and ability to void
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Narcotic: decreased bladder sensation

Pelvic surgery: interference with innervations of bladder muscles, and
local edema
Urinary tract infections may occur in patients who must have prolonged
bed rest after surgery, have a history of urinary tract indwelling
catheters. Monitor urinary output equals fluid intake. Fluids are then
encouraged up to 3000 ml, unless contraindicated, to prevent urinary
stasis.
Bowel Elimination
Peristalsis will be decreased for at least 24 hours after abdominal or

pelvic surgery and for several days after surgery of the gastrointestinal
tract. Constipation occurs frequently after major surgery for several
reasons.
Causes of Post-operative Constipation
Neuroendocrine response to stress (decreased gastrointestinal motility)

Anesthetic agents
Narcotics
Inactivity
Decreased intake of high-fiber foods
Monitor daily for bowel movement. If absent, ask if patient is passing

flatus. Encourage maximal activity within prescribed limits. Encourage
intake of foods high in fiber, if permissible.
3.4.5 Promoting Comfort from Vomiting, Abdominal Gas

Distention
The major discomforts after surgery are nausea and vomiting, abdominal
distention and gas pains, and incisional pain.
Nausea and vomiting may be related to a number of factors.
(a) Causes of Post-operative Vomiting
Anesthetic agent
Narcotic
Abdominal distention (fluid, gas)
Pain
Electrolyte imbalances
Drug idiosyncrasies
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Interventions for the person who is experiencing nausea and vomiting

include:
1. Side-lying position to prevent aspiration

2. No food or fluids until vomiting subsides
3. Sips of fluid (hot tea) or (crackers) after vomiting subsides
4. Frequent oral care
5. Prescribed antiemetics may be given.
(b) Abdominal Distention and Gas Pains
Post-operative distention results from accumulation of nonabsorbable

gas in the intestines caused by a reaction to the handling of the bowel
during surgery, or by swallowing of air during recovery from anesthesia
or attempts to overcome nausea, and by passing of gases from the
bloodstream to the atonic portion of the bowel. Distention will persist
until the tone of the bowel returns to normal and peristalsis resumes.
(c) Pain
Pain is common after nearly all types of surgical procedures. It may

result from stimulation of nerve endings by chemical substances
released at the time of surgery or from tissue ischemia caused by
interference of blood supply to the part, such as by pressure, muscle
spasm, or edema, infections, distention, muscle spasms surrounding the
incisional area, and tight dressings or casts. Post-operative pain usually
lasts 24 to 48 hours but may continue longer depending on the extent of
the surgery, the pain threshold of the patient, and response to pain.
Nursing Intervention for Pain
It is often impossible to prevent post-operative pain, but it can be

minimized so that the patient is relatively comfortable. -Patients who
have had adequate pre-operative instructions and who have confidence
in the surgeon, in the nurse, and in the outcome of the surgery usually
have less post-operative pain than apprehensive patients because they
have less tension:
- Measures to reduce anxiety and apprehension will also help

reduce pain. Relief of pain may encourage the patient to move
and breathe more deeply, thus preventing post-operative
complications, which cause more pain.
- Find out the cause of pain.
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- If the cause of pain is determined to be other than incisional,

measures are taken to relieve the cause. Emptying a full bladder
can relieve what was though to be pain from a lower abdominal
incision. Elevation of a part may relieve venous stasis. Loosenig
of a tight bandage, if permissible, will relieve ischemic pain.
Other measure includes:
1. Encourage patient to move in bed or to ambulate, to decrease

pain from muscle tension and increase circulation to the part.
2. Move the injured part as a whole; for example, move trunk as one
unit.
3. Support an injured limb during a move (a pillow is a useful

support).
4. Give pain medications as ordered according to the guidelines for

acute pain.
a. Narcotics are usually required on a regular basis for 12 to 48

hours after major surgery.
3.4.6 Maintaining Activity
Early ambulation is a significant factor in hastening post-operative

recovery and preventing post-operative complications. Numerous
benefits are derived from the exercise of getting in and out of bed and
walking during the early post-operative period. Ambulation is usually
contraindicated when there is a severe infection or thombophlebitis.
Effects of early post-operative ambulation are:
1. Increased rate and depth of breathing

2. Increased circulation
3. Increased micturition
4. Increased metabolism
5. Increased peristalsis
3.4.7 Maintenance of Circulation to Prevent Shock
Shock is a condition of which the underlying pathology is a fall in the

blood pressure.
Signs and Symptoms
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- The blood pressure is low (i.e. he systolic pressure is less than

100 mm. Hg.).
- The pulse is feeble, tending to be slow at the onset and becoming
quicker in rate and thinner in volume as the condition progresses.
- The temperature is subnormal and the skin cold and moist.
- The colour is “livid” i.e. pale with a tinge of cyanosis.
- Vomiting is common
- Thirst if the patient is conscious.
The characteristics mood is apathetic
Shock is caused by trauma, especially crushing injuries, fractures,

painful injuries like burns, major operations involving resection of
tissue, or traction on the mesentery or lung roots. It is made worse by
fluid loss, as from hemorrhage, vomiting, diarrhoea or profuse sweating,
or leakage from raw areas; by pain; by fear. Until recently, exposure to
cold would have been added to this list, but recent work makes this
doubtful.
The classical treatment for shock include:
Rest
The patient must be moved as little as possible. The foot of the bed is
elevated to allow the blood to reach the heart and brain where it is most
needed.
Relief of Pain
Fractures must be temporarily splinted, and burns covered. Morphine

has enjoyed a high reputation, and for patients with internal bleeding,
pain or fear is excellent. Its chief danger is that when given to a patient
with circulation impaired by shock, it may remain in the tissues and only
be released as the condition improves.
Fluids
If shock is not severe, fluids by mouth can be freely given. If these are
contra-indicated, tap water of N/5 saline per rectum is useful. If the
condition is more than moderate, intravenous fluids will be needed.
Blood is incomparably the best, but plasma or dextrin may be life-
saving. Saline can only effect a temporary improvement. Large amounts
of fluid are sometimes needed, and watch must be kept on the pulse,
respiration and superficial veins lest right heart failure threaten from
dilation of the right side of the heart by the incoming fluid.
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Oxygen
Poor circulation results in lack of oxygen in the tissues, and for severe
shock oxygen at eight litres per minute are valuable.
3.4.8 Hemorrhage
Hemorrhage may be internal when it takes place into the peritoneal or

some other body cavity, or external when it is manifest on the surface. It
can be classified to the vessel from which it is taken place:
Arterial
The blood is bright red and appears in spurts corresponding to the heart
beats. It may be seen (briefly) in the theatre when small arteries are
severed, before artery clamps are applied.
Venous
The blood is darker in colour, and wells out. Such loss may be very
severe. If a large vein near the heart (e.g. internal jugular) is cut, the
negative pressure in the vein may allow air to be sucked in and carried
to the heart.
Capillary
The blood oozes capillary bleeding cut if is taking place from a large
raw area, it can be troublesome, especially if it is maintained by a failure
to clot, as in jaundiced patients, or those in whom the intestine has been
sterilized by antibiotics; both are short of Vitamin K, and therefore have
a low prothrombin level.
A classification of bleeding useful to the nurse depends on the time

at which it occurs
Primary Hemorrhage occurs at the time of injury. In surgical practice,

it takes place in the theatre and the surgeon sees that it is checked before
the patient leaves.
Reactionary Hemorrhage occurs as the blood pressures rises following

shock and vessels begin to bleed that were unnoticed at operation. It,
therefore, takes place within a few hours of operation. Patients who are
suffering from shock must be watched closely for bleeding as their
condition improves. No patient is immune, but the operations most
commonly followed by bleeding are prostatectomy, transillectomy, and
operations on the rectum, vagina and blood vessels.
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Secondary Hemorrhage is always due to sepsis, and therefore, a few

days normally elapse before it occurs. The classical day is the clot that is
sealing the severed vessels, and arterial bleeding is possible.
The signs of internal hemorrhage are as follows: low temperature and

blood pressure, a pulse rising in rate and falling in volume (“thready”),
pallor and sweating, sighing respiration, yawning (especially with
bleeding into the stomach), fainting, and anxiety. If patient is
unconscious, this picture will, of course, be somewhat modified, and a
nurse may be undecided if her patient is suffering from shock or
concealed bleeding. She should make regular observation of the
temperature, pulse, respiration and blood pressure and watch the colour.
A progressive deterioration in these, however small, will make her
suspect hemorrhage and inform the surgeon, since shock should become
less when the operation is over and adequate anti-shock treatment
instituted.
3.5 Other Post-Operative Discomforts
Pain
Wound pain is normal, but can be effectively relieved. Morphine or one

of its allies (e.g. omnopon) is necessary after major operations, and
usually is repeated once or twice. It is used very cautiously after chest or
head operations because of its depressing effects on the respiratory
centre. Pethidine by mouth or intramuscular injection is less depressing
and very effective for gynecological and thoracic patients. Once the first
day or so is over one or two compound codeine or any strong analgesic
tablets are effective. Aspirin is excellent for sore throats, as after
tonsillectomy of thyroidectomy. Pain may be associated with many of
the complications described below and their effective treatment will
relieve it.
Vomiting
This is a side effect of anesthetics, but it may once or twice as

consciousness is regained. A clean bowl should be given each time a
patient vomits, and the mouth rinsed out. An anti-emetic drug like
perphenazine (“Fentazin”) is often prescribed.
If vomiting continues for more than twelve hours, it may be due to

nervous tension and anxiety abdominal complication. A Ryle’s tube can
be passed transnasally into the stomach and retained to prevent
vomiting. The character of the fluid and its amount is noted. Fluid may
be given intravenously to replace fluid.
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Flatulence after abdominal operations is due to wind collecting in the

inactive gut. This is common on the second and third days. The
distention stretches the wound painfully and impedes the movement of
the diaphragm. Early mobilization will help to prevent it. Drinking of
peppermint water may help. A flatus tube may be passed. The tube is
lubricated at the eye end, and the other is attached to a glass connection
and a piece of rubber tubing which lies under a bowl of water. About 6
in. is passed into the rectum, and left for 10 minutes, or longer. Its relief
is experienced. Heat (e.g. an electric pad) to the abdomen is comforting.
An enema or glycerin suppository may be given on the third day if there
are no contradictions. Once the bowels are open no further trouble is
experienced.
Urinary Complications
Retention of urine is the inability to pass urine although the bladder is

full. It is common in the patient who must have lied in an unusual
position, or after operations on the rectum or vagina. It may be
prevented sometimes by introducing the patient to the use of urinal or
bedpan before the operation, and by seeing that the patient is
comfortably settled in privacy when the first attempt is made to empty
the bladder. A note should always be made as to when the patient first
passes urine, and the amount recorded.
To allow a patient to sit on a commode is usually effective in curing

nervous retention, and many who would once have been thought too ill
may now be permitted to do so. No perturbation should be shown if
difficulty is experienced, and simple methods of suggestion such as a
sharp drink like lemonade, or the sound of a running tap may help. A
woman may have a pint of warm water poured over the vulva while
sitting on a bedpan. An injection of carbachol helps to increase the tone
of the bladder and is often effective. Catheterization must not be delayed
until the bladder is unduly distended, and urine measurements must be
continued until the bladder is being satisfactorily emptied. If very small
amounts of urine are being passed at frequent intervals, it usually
indicates that retention with overflow has been reached, and the use of
an indwelling catheter is discussed more fully in connection with
gynecology (P. 292).
Suppression of urine or anuria means that no urine is being secreted and

the bladder remains empty. It is a serious condition, since if secretion is
not re-established, it must be fatal. Treatment depends on the cause.
Cystitis or inflammation of the bladder is signalized by frequent painful
micturition and may occur if the operation causes trauma to the bladder
or retention is allowed to go untreated. Its incidence can be reduced by
good operative methods, aseptic catherization. A high fluid intake of
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about 5 pints, or 3000 mls a day is aimed at, to dilute the infection
within the urinary system.
Respiratory Complications:
Broncho-pneumonia
This is quite common after abdominal and thoracic operations, and may
follow any type of anesthetic. Contributory causes are:
1. Poor movement of the chest and abdomen allowing accumulation

of bronchial secretion. Since men depend more on abdominal
movement than women, they are more liable to Broncho
pneumonia.
2. Immobility in bed permitting congestion of the lung bases.
3. Pre-existing bronchitis.
4. Heavy smoking. On this count, too, men outnumber women.
5. Irritating anesthetics.
6. Heavy sedation with drugs depressing to the respiratory centre,
e.g. Morphine.
Signs and Symptoms
About twenty-four hours after operation, there is a light cough and is

heard rattling in the bronchi. The temperature, pulse and respiration rate
all rise slightly (e.g. 99.6°F. (37.5°C.); p. 90; R. 22). If not promptly and
effectively treated, the temperature will fluctuate irregularly up to 101°
or 102° F. (38.3° or 38.9°C.), and the pulse and respiration rate are
correspondingly elevated. An undue rise in the strain and beginning to
fail. The course of bronchopneumonia is indeterminate with remissions
and relapses as the infection spreads in one part of the lungs and clears
in another.
Treatment
Prevention is better than cure. Before operation, any bronchitis should

be treated effectively, smoking should be cut or forbidden, breathing
exercises should be taught; nurses should see that all these are observed.
After operation, deep breathing and coughing are encouraged;
supporting the wound may be a great help, and percussion over the chest
by the physiotherapist will help to loosen secretions .post-operative
drugs should be judiciously prescribed and given to susceptible patients.
When pneumonia is first susceptible, all these efforts at improving the

chest movement should be redoubled. Steam inhalations are helpful if
the sputum is tenacious, and fluids are freely given. A course of a broad-
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spectrum antibiotic, such as ampicillin, is begun. If improvement is not

obvious in twelve hours, a specimen of sputum is sent to the
bacteriologist to find the antibiotic to which the infecting organism is
sensitive. Although broncho-pneumonia is painful and prolongs
convalescence, it is not as dangerous as before.
Lobar Collapse
If a bronchus is plugged with mucus, so that air entry is stopped, the air
remaining in the lobe is absorbed and that portion becomes solid. The
onset is more dramatic than that of bronco-pneumonia, with a sudden
and marked rise in temperature, pulse and respiration rate (e.g. T.
102.4°F. (39.1°C); P.120; R. 32) and the patient looks ill and anxious on
exanimation, the chest is dull over the collapsed lobe.
It is vital that the mucus be coughed up at once to allow the lung to re-
expands. The patient may be laid on the good side with the head low and
vigorous clapping over the affected lobe and coughing undertaken. If the
mucus is too thick to be expectorated, resort will have to be made to
bronchoscopy. A good fluid intake (intravenous if necessary) must be
kept up to make the bronchial secretions more fluid.
Pulmonary Embolism
A pulmonary embolus begins as a blood clot, usually in a vein and the

measures described in the next section on how to avoid such clothing
will also help to prevent embolism.
Minor cases of embolism are treated by encouraging activity and giving

anticoagulant drugs by mouth. In more severe cases, intravenous heparin
is given extension of the clot. Some surgeons, once the initial stage of
shock is over, perform arteriography by intracardiac. Catherterization, to
see how much of the lung is affected, and if it is large, give intravenous
streptonase to attempt to dissolve the clot and restore function to the
lung. Patients with a large embolus who might be expected otherwise to
make a good recovery may be taken to the theatre, and have the clot
removed after opening the pulmonary artery. This is a severe operation
for a dangerously ill person, but is sometimes successful.
Intravascular Thrombosis
Clotting within blood vessels occurs in two different ways, and the
cause, prognosis and treatment is quite distinct. (A) Thrombophlebitis
often seen at the site of an intravenous infusion. Pain is invariably
present, and the vein is tender and can be felt as solid with clot; the
temperature rises, usually to 90°-100° F. (37.2-37.8° C.), but sometimes
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higher. The clot is firmly adherent to the inflamed vein, and its
detachment to form an embolus is unlikely. Warmth by kaolin poultices
will relieve the pain, and the patient’s progress is not delayed long.
Intravenous dextrose is especially liable to cause thromobophebitis, and
infusions should be continued longer than is strictly necessary. (B)
Clotting within the deep veins of the calf appears to be caused by a
combination of some of these factors:
1. Pressure on the calves on the theatre table or in bed.

2. A prolonged subnormal blood pressure, as in shock.
3. Anemia.
4. Pelvic operations.
The vein wall is normal, the clot does not usually fill the lumen, and is
only loosely adherent, so that the danger of pulmonary embolism is very
great, and is what this condition so important. There is very great, and is
what makes this condition so important. There may be a little fever,
cramp or tenderness may be felt in the calves, and if the clothing
becomes extensive, there may be edema of the leg.
This phlebothrombosis should be prevented. Pressure on the calves on

the table can be relieved by a sandbag under the Achilles tendons. Shock
should be adequately treated and anemia relieved. Deep breathing
exercises will improve the return of blood to the heart, and early rising
after operations and mobility in bed are important. Nurses should feel
the calves while giving a bed bath after abdominal or pelvic operations,
and report tenderness at once.
If clotting occurs, an intravenous course of heparin (e.g. 10, 000 units

six-hourly on the first day) followed by dindevan (e.g. 50-100 mg. twice
a day) is usual, to lower the clotting powers of the blood, unless
hemorrhage is feared. Surgeons’ practices vary according to whether
they believe mobilization will bring the risk of embolism nearer, or if
they think confinement to bed encourages the growth of the clot. Most
would probably keep the patient in bed if there was any fever, but
encourage mobility as soon as it disappeared. The prothrombin time is
estimated daily as long as dindevan is being given, and not allowed to
fall below 20% lest bleeding occur.
The importance of breathing exercises and of activity is apparent in

several of the above sections. Good diaphragmatic movement lessens
the risk of pneumonia, of thrombosis in the legs, and of pulmonary
infarct and lobar collapse. It must not be thought, however, that post-
operative patients need little care other than of their own wounds. It is
true that many of them benefit from performing their own toilet, but
unless they are encouraged and helped with it in the early days, they
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may quite understandably do it with as little disturbance to themselves

as possible, and not very efficiently. Activity should be planned; to hope
that it will result from leaving the patient to fend for himself, shows lack
of nursing insight.
Infection
Infection has always been a problem in surgical wards and still is. We
rarely see the gas-gangrene that used to be common in the eighteenth
century, and streptococcal infections can be speedily and successfully
treated. It is the staphylococcus, strains of which have acquired
resistance to many antibiotics that is still a major problem.
Staphylococci infect human tissues to produce boils, styesmyelitis,

pneumonia or pyelitis. But staphylococci may also be present on the
skin and in the anterior part of the nose of people who are quite healthy,
and who merely carry the organism. Patients, nurses, doctors and
domestic or lay staff who work in surgical wards may thus be sources of
infection to others. This is termed cross-infection.
In addition, staphylococci from such sources may be transferred to

objects in the ward by direct contact or through the air, and bed clothes,
curtains, dust bath, screens and all kinds of ward equipment. These act
as depots in which organisms can survive for long periods, and
eventually may be transferred to patients. Staphylococcal infections may
endanger life, and at least will prolong the patient’s stay in hospital.
The measures that will reduce the incidence of infection include these:
1. Ward premises should be clean and beds well spaced. Surfaces

that can be easily cleaned are desirable.
2. Nursing staff should maintain a high standard of hygiene in their

work.
3. Techniques for dressing should be aseptic, and carried out

conscientiously.
4. Wound and other infections must be recognized early;

precautions to prevent spread are taken, and the patient isolated.
5. Contamination of the articles in the ward must be avoided.

Wounds are kept covered, discarded dressings are disposed of
quickly. Hands must be washed after touching infected surfaces.
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6. Possible depots of infection must be removed. Ward cleaning

must be effective, and methods that disperse dust into the air are
dangerous. Bedding, curtains and screen covers are changed
regularly.
7. Method of sterilization must be effective.
8. Susceptible people must be protected, small babies are an

obviously example.
9. The guidance of a bacteriologist on acceptable techniques of

ward hygiene should be available.
4.0 CONCLUSION
1. The Post Operative period is divided into two phases; the

intermediate post-operative stage and the extended post-operative
stage. The intermediate post-operative stage begins when the
person is discharged from the PACU and generally ends 48 - 72
hours later. A person enters the extended post-operative stage
two to three days after surgery.
2. During these periods, the person remains at risk for post-

operative complications, including respiratory, circulatory, or
gastric dysfunction.
3. Constant monitoring is required at this stage.
5.0 SUMMARY
• The post-operative period is critical and the nurse is largely

responsible for the patient at this period
• The patient must be observed diligently until the major effects of the
anesthetic have worn off and overall condition stabilized.
1. Explain the rudiments of post-operative nursing care.

2. Mention some likely post-operative complications noticeable in a
surgical

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NATIONAL OPEN UNIVERSITY OF NIGERIA

SCHOOL OF SCIENCE AND TECHNOLOGY

COURSE CODE:NSS 321

COURSE CODE TITLE:MEDICO-SURGICAL NURSING I

Course Team Dr. Clara Agbedia (Developer/Writer) - DELSU

NATIONAL OPEN UNIVERSITY OF NIGERIA

National Open University of Nigeria

First Printed 2009

All Rights Reserved

Nursing is a profession that serves the needs of society in the area of

The rapid changes in health, technological advances, knowledge

The course you are about to study is Medico-Surgical Nursing, and is

Medical-Surgical III, is designed in such a way that you will continue to

Medico-Surgical Nursing I is divided into three modules.

Module 1 lays the foundation for Medico-Surgical Nursing practices

Module 2 deals with nursing history and physical examination of

Module 3 deals with the challenges of surgical nursing. The unit on

The goal of this course (Medico-Surgical Nursing) is to provide you

surgical nursing and the therapeutic skills needed for effective

This course is set to assist you achieve the following objectives:

1. Understand the basic concept and terminologies in Medical Surgical

Working through the Course

This course requires extensive reading. The contents of this material

The Course Material

You will be provided with the following materials:

Module 1 General Introduction to the Course

Unit 1 Framework of Nursing Practice

Module 2 Medical-Surgical Conditions

Unit 1 Fluid and Electrolyte Distribution

Unit 2 Fluid and Electrolyte Imbalances

Module 3 Diagnostics and Investigations of Medical–Surgical

Unit 1 Diagnostic and Laboratory Investigation in Medical-

In addition, the course comes with a list of recommended textbooks,

Barbara Kozier, Glenora Erb. [No date]. Fundamentals of Nursing.

Brunner & Suddarth. Medical Surgical Nursing. (10th ed) Lippincott

Schultz, A. Predicting and Preventing Pressure Ulcers in Surgical

The TMA is the continuous assessment component of your course. It

Final Examination and Grading

This examination concludes the assessment for the course. It constitutes

Course Code NSS 321

Course Team Dr. Clara Agbedia (Developer/Writer) - DELSU

NATIONAL OPEN UNIVERSITY OF NIGERIA

National Open University of Nigeria

First Printed 2009

All Rights Reserved

Module 1 General Introduction to the Course……….…….. 1

Unit 1 Framework of Nursing Practice…………….………. 1

Module 2 Medical - Surgical Conditions………………….…. 56

Unit 1 Fluid and Electrolyte Distribution………………….. 56

Module 3 Diagnostics and Investigations of Medical –

Unit 1 Diagnostic and Laboratory Investigation in Medical-

MODULE 1 GENERAL INTRODUCTION TO THE

Unit 1 Framework of Nursing Practice

UNIT 1 FRAMEWORK OF NURSING PRACTICE

frameworks and models reflect a synthesis of the first two approaches.

At the end of this unit, you should be able to:

• differentiate between a concept, theory, conceptual framework,

3.0 MAIN CONTENT

A concept is a building block of theory. It is an idea or word that