FUNDAMENTALS OF NURSING

By nclexnursing.com

OVERVIEW

I. THEORETICAL FRAMEWORK of NURSING PRACTICE

A. Nursing
B. Concepts of Health and Illness
C. Concepts of Stress
D. Homeostasis
E. Adaptation
F. Adaptation to Stress – Physiological Response (Hans Selye)
G. Physiologic Indicators of Stress

II. COPING STRATGIES (COPING MECHANISMS)

A. 2 Types of Coping Strategies
B. Relaxation Techniques

III. PSYCHOLOGICAL RESPONSE

A. Task – Oriented Behaviors
B. Defense Mechanisms
C. Common Defense Mechanisms

IV. TYPES of NURSING DIAGNOSES

A. Formulating the Nursing Diagnosis
B. Collaborative Problems

V. METHODS USED for ASSESSMENT

A. Collection of Data: Objective and Subjective

VI. DOCUMENTING and REPORTING

A. Guidelines for Good Documentation and Reporting
B. Documentation
C. Documentation Systems
D. Nursing Care Plan (NCP)
E. KARDEX
F. Nursing Discharge / Referral Summaries

VII. PHYSICAL EXAMINATION

A. Purposes
B. Preparation of Examination
C. Order of Examination
D. Skills in Physical Assessment
E. Examples of Adventitious Breath Sounds

VIII. THE COMMUNICATION PROCESS

A. Modes of Communication
B. Verbal Communication
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 C. Nonverbal Communication
D. Factors Influencing the Communication Process
E. Therapeutic Communication Technique
F. Barriers to Communication
G. Phases of the Helping Relationship

PRINCIPLES and PRACTICE of NURSING CARE

IX. PRINCIPLES of ASEPSIS and INFECTION CONTROL

A. Chain of Infection
B. Modes of Transmission
C. Course of Infection
D. Inflammation
E. Immune Response
F. Nosocomial Infection
G. Factors Increasing Susceptibility to Infection
H. Diagnostic Tests Used to Screen for Infection

X. THEORIES OF PAIN
A. Specific Theory
B. Pattern Theory
C. Gate Control Theory
D. Current Developments in Pain Theory

XI. TYPES OF PAIN

A. Acute Pain
B. Chronic Pain

XII. PAIN ASSESSMENT

A. TOOLS/INSTRUMENTS USED
B. A B C D E method of pain assessment
C. P Q R S T assessment for pain perception
D. Pain History

ADMINISTRATION OF MEDICATIONS

XIII. DRUG NOMENCLATURE and FORMS

A. Names
B. Classification
C. Forms
D. Types of Drug Actions
E. Principles in Administering Medications

XIV. BASIC HUMAN NEEDS

A. Abraham Maslow
B. Maslow’s Characteristics of a Self–Actualized Person

XV. MEETING OXYGENATION NEEDS

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 A. Oxygenation
B. Cardiovascular Physiology
C. Structure and Function
D. Steps in the Process of Oxygenation
E.
XVI. MEETING NUTRITIONAL NEEDS
A. Principles of Nutrition
B. Nutrients

XVII. MEETING URINARY ELIMINATION NEEDS

A. Normal Urinary Function
B. Common Assessment Findings

XVIII. URINARY CATHETERIZATION

A. Purposes
B. Necessary Equipment for Catheterization
C. Preparation of the Patient
D. Retention or Indwelling Catheter (Foley)
E. Procedure for Insertion
F. Caring for the Patient with an Indwelling Catheter
G. Removing the Indwelling Catheter and Aftercare of the Patient

XIX. MEETING BOWEL ELIMINATION NEEDS

A. Factors that Influence Bowel Elimination
B. Characteristics of Normal Stool
C. Common Bowel Elimination Problems

XX. TYPES of ENEMAS

A. Cleansing
B. Oil-Retention
C. Carminative
D. Astringent

XXI. NASOGASTRIC and INTESTINAL TUBES

A. Nasogastric Tubes
B. Intestinal Tubes

XXII. LOSS AND GRIEF

A. Loss
B. Grieving Process (Theories of Grief, Dying, and Mourning)
C. Anticipatory Grief
D. Complications of Bereavement
E. Symptoms of Normal Grief
F. Nursing Health Promotion (to facilitate mourning)

1. THEORETICAL FRAMEWORK of NURSING PRACTICE

A. Nursing
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 As by the INTERNATIONAL COUNCIL OF NURSES (ICN, 1973) as written by Virginia
Henderson: The unique function of the nurse is to assist the individual, sick or well, in
the performance of those activities contributing to health. It’s recovery, or to a peaceful
death that the client would perform unaided if he had the necessary strength, will or
knowledge.

Help the client gain independence as rapidly as possible.

1. CONCEPTUAL AND THEORETICAL MODELS OF NURSING PRACTICE

Theorist Description

FLORENCE  Developed the first theory of nursing.

NIGHTINGALE  Focused on changing and manipulating the environment
in order to put the patient in the best possible conditions
for nature to act.

HILDEGARD  Introduced the Interpersonal Model.

PEPLAU  She defined nursing as a therapeutic, interpersonal
process which strives to develop a nurse-patient
relationship in which the nurse serves as a resource
person, counselor and surrogate.

FAYE ABDELLAH  Defined nursing as having a problem-solving approach,

with key nursing problems related to health needs of
people; developed list 21 nursing problem areas

IDA JEAN  Developed the three elements – client behavior, nurse

ORLANDO reaction and nurse action – compose the nursing situation.
She observed that the nurse provide direct assistance to
meet an immediate need for help in order to avoid or to
alleviate distress or helplessness.

MYRA LEVINE  Described the Four Conservation Principles.

1. conservation of energy
2. conservation of structured integrity
3. conservation of personal integrity
4. conservation of social integrity

DOROTHY  Developed the Behavioral System Model.

JOHNSON 1. Patient’s behavior as a system that is a whole with
interacting parts
2. how the client adapts to illness
3. goal of nursing is to reduce so that the client can
move more easily through recovery.

MARTHA ROGERS Conceptualized the Science of Unitary Human Beings.

She asserted that human beings are more than different from

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 the sum of their parts; the distinctive properties of the whole
are significantly different from those of its parts.

DOROTHEA Emphasizes the client’s self care needs; nursing care

OREM becomes necessary when client is unable to fulfill biological,
psychological, developmental or social needs.

IMOGENE KING Nursing process is defined as dynamic interpersonal

process between nurse, client and health care system.

BETTY NEUMAN Stress reduction is a goal of system model of nursing

practice. Nursing actions are in primary, secondary or tertiary
level of prevention

SISTER CALLISTA Presented the Adaptation Model. She viewed each person
ROY as a unified bio-psychosocial system in constant
interaction with a changing environment. The goal of nursing
is to help the person adapt to changes in physiological
needs, self-concept, role function and interdependent
relations during health and illness.

LYDIA HALL Introduced the notion that nursing centers around three
components: person(core), pathologic state and
treatment(cure) and body(care).

JEAN WATSON Conceptualized the Human Caring Model. She emphasized

that nursing is the application of the art and human science
through transpersonal caring transactions to help persons
achieve mind-body-soul harmony, which generates self-
knowledge, self-control, self-care and self-healing.

ROSEMARIE Introduced the Theory of Human Becoming. She

RIZZO PARSE emphasized free choice of personal meaning in relating to
value priorities, co-creating of rhythmical patterns, in
exchange with the environment and contranscending in
many dimensions as possibilities unfold.

MADELEINE Developed the Transcultural Nursing Model. She

LENINGER advocated that nursing is a humanistic and scientific mode of
helping a client through specific cultural caring processes
(cultural values, beliefs and practices) to improve or maintain
a health condition

2. ROLES AND FUNCTION OF A NURSE

a. Caregiver – the caregiver role has traditionally included those activities that
assist the client physically and psychologically while preserving the client’s

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 dignity. Caregiving encompasses the physical, psychosocial, developmental,
cultural and spiritual levels.
b. Communicator – communication is an integral to all nursing roles. Nurses
communicate with the client, support persons, other health professionals, and
people in the community. In the role of communicator, nurses identify client
problems and then communicate these verbally or in writing to other members
of the health team. The quality of a nurse’s communication is an important
factor in nursing care.
c. Teacher – as a teacher, the nurse helps clients learn about their health and
the health care procedures they need to perform to restore or maintain their
health. The nurse assesses the client’s learning needs and readiness to learn,
sets specific learning goals in conjunction with the client, enacts teaching
strategies and measures learning.
d. Client advocate – a client advocate acts to protect the client. In this role the
nurse may represent the client’s needs and wishes to other health
professionals, such as relaying the client’s wishes for information to the
physician. They also assist clients in exercising their rights and help them
speak up for themselves.
e. Counselor – counseling is a process of helping a client to recognize and
cope with stressful psychologic or social problems, to developed improved
interpersonal relationships, and to promote personal growth. It involves
providing emotional, intellectual, and psychologic support.
f. Change agent – the nurse acts as a change agent when assisting others,
that is, clients, to make modifications in their own behavior. Nurses also often
act to make changes in a system such as clinical care, if it is not helping a
client return to health.
g. Leader – a leader influences others to work together to accomplish a specific
goal. The leader role can be employed at different levels; individual client,
family, groups of clients, colleagues, or the community. Effective leadership is
a learned process requiring an understanding of the needs and goals that
motivate people, the knowledge to apply the leadership skills, and the
interpersonal skills to influence others.
h. Manager – the nurse manages the nursing care of individuals, families, and
communities. The nurse-manager also delegates nursing activities to ancillary
workers and other nurses, and supervises and evaluates their performance.
i. Case manager – nurse case managers work with the multidisciplinary health
care team to measure the effectiveness of the case management plan and to
monitor outcomes.
j. Research consumer – nurses often use research to improve client care. In a
clinical area nurses need to:
 Have some awareness of the process and language of research
 Be sensitive to issues related to protecting the rights of human subjects
 Participate in identification of significant researchable problems
 Be a discriminating consumer of research findings

B. Concepts of Health and Illness

I. Health – As defined by the World Health Organization (WHO): state of

complete physical, mental and social well-being, not merely the absence of
disease or infirmity.
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a. Characteristics
i. A concern for the individual as a total system
ii. A view of health that identifies internal and external environment
iii. An acknowledgment of the importance of an individual’s role in life

A dynamic state in which the individual adapts to

changes in internal and external environment to maintain a state of well being

b. Models of Health and Illness

i. Health-Illness Continuum (Neuman) – Degree of client wellness that exist

at any point in time, ranging from an optimal wellness condition, with
available energy at its maximum, to death which represents total energy
depletion.
ii. High – Level Wellness Model (Halbert Dunn) – It is oriented toward
maximizing the health potential of an individual. This model requires the
individual to maintain a continuum of balance and purposeful direction
within the environment.
iii. Agent – Host – environment Model (Leavell) – The level of health of an
individual or group depends on the dynamic relationship of the agent, host
and environment
 Agent – any internal or external factor that disease or illness.
 Host – the person or persons who may be susceptible to a
particular illness or disease
 Environment – consists of all factors outside of the host
iv. Health – Belief Model – Addresses the relationship between a person’s
belief and behaviors. It provides a way of understanding and predicting
how clients will behave in relation to their health and how they will comply
with health care therapies.

Four Components
 The individual is perception of susceptibility to an illness
 The individual’s perception of the seriousness of the illness
 The perceived threat of a disease
 The perceived benefits of taking the necessary preventive
measures

v. Evolutionary – Based Model – Illness and death serves as a evolutionary

function. Evolutionary viability reflects the extent to which individual’s
function to promote survival and well-being. The model interrelates the
following elements:
 Life events
 Life style determinants
 Evolutionary viability within the social context
 Control perceptions
 Viability emotions
 Health outcomes

vi. Health Promotion Model – A “complimentary counterpart models of health

protection”. Directed at increasing a client’s level of well being. Explain the
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 reason for client’s participation health-promotion behaviors. The model
focuses on three functions:
 It identifies factors (demographic and socially) enhance or
decrease the participation in health promotion
 It organizes cues into pattern to explain likelihood of a client’s
participation health-promotion behaviors
 It explains the reasons that individuals engage in health
activities

II. Illness – State in which a person’s physical, emotional, intellectual, social

developmental or spiritual functioning is diminished or impaired. It is a condition
characterized by a deviation from a normal, healthy state.

a. 3 Stages of Illness
i. Stage of Denial – Refusal to acknowledge illness; anxiety, fear,
irritability and aggressiveness.
ii. Stage of Acceptance – Turns to professional help for assistance
iii. Stage of Recovery (Rehabilitation or Convalescence) – The patient
goes through of resolving loss or impairment of function

b. Rehabilitation
i. A dynamic, health oriented process that assists individual who is ill
or disabled to achieve his greatest possible level of physical,
mental, spiritual, social and economical functioning.
ii. Abilities not disabilities, are emphasized.
iii. Begins during initial contact with the patient
iv. Emphasis is on restoring the patient to independence or regain his
pre-illness/predisability level of function as short a time as possible
v. Patient must be an active participant in the rehabilitation goal
setting an din rehabilitation process.

c. Focuses of Rehabilitation
i. Coping pattern
ii. Functional ability – focuses on self-care: activities of daily living
(ADL); feeding, bathing/hygiene, dressing/grooming, toileting and
mobility
iii. Mobility
iv. Integrity of skin
v. Control of bowel and bladder function

C. Concepts of Stress
I. Stress (Theory by Hans Selye)
a. Non specific response of the body to nay demand made upon it
b. Any situation in which a non specific demand requires an individual to
respond or take action

II. Characteristics of Stress

a. Stress is not nervous energy. Emotional reactions are common stressors

b. Stress is not always the result of damage to the body

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 c. Stress does not always result in feelings of distress (harmful or unpleasant
stress)

d. Stress is a necessary part of life and is essential for normal growth and
development

e. Stress involves the entire body acting as a whole and is an integrated manner

f. Stress response is natural, productive and adaptive

III. Stressors – Factor or agent producing stress, maybe: physiological,

psychological, social, environmental, developmental, spiritual or cultural and
represent an unmet needs

a. Classification of Stressors
i. Internal Stressors – originate from within the body. E.g. fever,
pregnancy, menopause, emotion such as guilt

ii. External Stressors – originate outside a person. E.g. change in

family or social role, peer pressure, marked change in
environmental temperature

b. Factors influencing response to stressors

i. Physiological functioning
ii. Personality
iii. Behavioral characteristics
iv. Nature of the stressor: integrity, scope, duration, number, and
nature of other stressors

D. Homeostasis – Process of maintaining uniformity, stability and constancy with in the

living organisms. (from Greek word homotos – like, and stasis – position)

E. Adaptation – Body’s adjustment to different circumstances and conditions. Process by

the physiological or psychological dimensions change in response to stress; attempt to
maintain optimal functioning

F. Adaptation to Stress-Physiological Response (Hans Selye)

I. Local Adaptation Syndrome (LAS) – Response of a body tissue, organ or part
to the stress of trauma, illness or other physiological change
a. Characteristics
i. The response is localized, it does not involve entire body systems
ii. The response is adaptive, meaning that a stressor is necessary to
stimulate it
iii. The response is short term. It does not persist indefinitely
iv. The response is restorative, meaning that the LAS assists in restoring
homeostasis to the body region or part

b. Two Localized Responses

i. Reflex Pain Response – is a localized response of the central
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 nervous system to pain. It is an adaptive response and protects tissue
from further damage. The response involves a sensory receptor, a
sensory nerve from the spinal cord, and an effector muscle. An example
would be the unconscious, reflex removal of the hand from a hot surface.

ii. Inflammatory Response – is stimulated by trauma or infection. This

response localizes the inflammation, thus revenging its spread and
promotes healing. The inflammatory response may produce localized
pain, swelling, heat, redness and changes in functioning.

c. Three Phases of Inflammatory Response

i. First Phase – Narrowing of blood vessels occurs at the injury to control
bleeding. Then histamine is released at the injury, increasing the number of
white blood cells to combat infection.

ii. Second Phase – It is characterized by release of exudates from the wound

iii. Third Phase – The last phase is repair of tissue by regeneration or scar
formation. Regeneration replaces damaged cells with identical or similar
cells.

II. General Adaptation Syndrome (GAS) or Stress Syndrome – characterized

by a chain or pattern of physiologic events.
a. 3 Stages
i. Alarm Reaction – initial reaction of the body which alerts the
body’s defenses. SELYE divided this stage into 2 parts:
 The SHOCK PHASE
 The COUNTERSHOCK PHASE
ii. Stage of Resistance – occurs when the body’s adaptation takes
place; the body attempts to adjust with the stressor and to limit
the stressor to the smallest area of the body that can deal with
it.
iii. Stage of Exhaustion – the adaptation that the body made during
the second stage cannot be maintained; the ways used to cope
with the stressors have been exhausted
on, the stage of resistance and the stage of exhaustion.

Stressor

Shock Phase

Epinephrine
Tachycardia Norepinephrine Cotisone
↑ Myocardial contractility ↓ Blood to kidney Protein catablism
↑ Blood clotting ↑ Renin Gluconeogenesis
↑ Metabolism

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Stage of Resistance
 Adaptation Stage of Exhaustion

↓ ↓
Rest Death

b.
c.
d.
e.
f.
g.
h.
i.
j. STRESSORS stimulate the sympathetic nervous system, which in turn
stimulates the hypothalamus. The HYPOTHALAMUS releases
corticotrophin releasing hormone (CRH). During times of stress, the
ADRENAL MEDULLA secretes EPINEPHRINE & NOREPINEPHRINE in
response to sympathetic stimulation. Significant body responses to
epinephrine include the following:
i. Increased myocardial contractility, which increases cardiac
output & blood flow to active muscles
ii. Bronchial dilation, which allows increased oxygen intake
iii. Increased blood clotting
iv. Increased cellular metabolism
v. Increased fat mobilization to make energy available & to
synthesize other compounds needed by the body.

G. Physiologic Indicators of Stress

a. Pupils dilate to increase visual perception when serious threats to the body arise.

b. Sweat production (diaphoresis) increases to control elevated body heat due to

increased metabolism.

c. The heart rate & cardiac output increase to transport nutrients and by-products of
metabolism more efficiently.

d. Skin is pallid because of constriction of peripheral vessels, an effect of

norepinephrine.

e. Sodium & water retention increase due to release of mineralocorticoids, which

results in increased blood volume.

f. The rate & depth of respirations increase because of dilation of the bronchioles,
promoting hyperventilation.

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 g. Urinary output may increase or decreases.

h. The mouth may be dry.

i. Peristalsis of the intestines decreases, resulting in possible constipation and

flatus.

j. For serious threats, mental alertness improves.

k. Muscle tension increases to prepare for rapid motor activity or defense.

l. Blood sugar increases because of release of glucocorticoids & gluconeogenesis.

H. Psychologic Indicators – psychologic manifestations of stress include anxiety, fear,

anger, depression & unconscious ego defense mechanisms.

a. Anxiety – a common reaction to stress. It is a state of mental uneasiness,

apprehension, dread, or foreboding or a feeling of helplessness related to an
impending or anticipated unidentified threat to self or significant relationships.
It can be experienced, subcutaneous or unconscious level. Can be
manifested on 4 LEVELS:
b. Fear – an emotion or feeling of apprehension aroused by impending or seeming
danger, or other perceived threat. The object of fear may or may not be based
in reality.
c. Anger – an emotional state consisting of a subjective feeling of animosity or strong
displeasure. People may feel guilty when they feel anger because they have
been taught that to feel angry is wrong.
d. Depression – common reaction to events that seem overwhelming or negative. It is
an extreme feeling of sadness, despair, dejection, lack of worth or emptiness.

Emotional symptoms can include: Feelings of tiredness, sadness, emptiness, or

numbness

Behavioral signs include: Irritability, inability to concentrate, difficulty making decisions,

loss of sexual desire, crying, sleep disturbance and social withdrawal.

Physical signs include: Loss of appetite, weight loss, constipation, headache and
dizziness

I. Cognitive Indicators – are thinking responses that include problem-solving,

structuring,
Self-control or self-discipline, suppression and fantasy

a. Problem solving – involves thinking through the threatening situation,

using a specific steps to arrive at a solution

b. Structuring – arrangement or manipulation of a situation so that

threatening events do not occur.

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 c. Self-Control (discipline) – assuming a manner of facial expression that
convey a sense of being in control or in change.

d. Suppression – consciously and willfully putting a thought or feeling out of

mind

e. Fantasy – (daydreaming) – likened to make believe. Unfulfilled wishes &

desires are imagined as fulfilled, or a threatening experience is reworked
or replayed so that it ends differently from reality.

2. COPING STRATEGIES (COPING MECHANISMS)

Coping – dealing with problems & situations or contending with them successfully.

Coping Strategy – innate or acquired way of responding to a changing environment or

specific problem or situation.

According to Folk man and Lazarus, coping is “the cognitive & behavioral effort to manage
specific external and/ or internal demands that are appraised as taxing or exceeding the
resources of the person”.

A. Coping Strategies: 2 Types

I. Problem-focused coping – efforts to improve a situation by making changes or
taking some action
II. Emotion-focused coping – does not improve the situation, but the person often
feels better.

Coping strategies are also viewed as:

a. Long-term coping strategies – can be constructive & realistic
b. Short-term coping strategies – can reduce stress to a tolerable limit
temporarily but are in the end of ineffective ways to deal with reality.
Coping can be adaptive or maladaptive:
B. Adaptive Coping – helps the person to deal effectively with stressful
events & minimizes distress associated with them.
C. Maladaptive Coping – can result in unnecessary distress for the person &
others associated with the person or stressful event.

*Effective coping results in adaptation; ineffective coping results in

maladaptation. The effectiveness of an
Individual’s coping is influenced by a number of factors:
 The number, duration & intensity of the stressors
 Past experiences of the individual
 Support systems available to the individual
 Personal qualities of the person

*If the duration of the stressors is extended beyond the coping powers of the
individual, that person becomes exhausted and may develop increased
susceptibility to health problems.

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 *Reaction to long term stress is seen in family members who undertake the
care of a person in the home for a long period. This stress is called caregiver
burden & produces responses such as chronic fatigue, sleeping difficulties &
high BP.

*Prolonged stress can also result in mental illness.

D. Relaxation Techniques – used to quiet the mind, release tension & counteract the fight
or flight responses of General Adaptation Syndrome (GAS).
I. Breathing Exercises
II. Massage
III. Progressive Relaxation
IV. Imagery
V. Biofeedback
VI. Yoga
VII. Meditation
VIII. Therapeutic Touch
IX. Music Therapy
X. Humor & Laughter

3. PSYCHOLOGICAL RESPONSE

Exposure to a stressor results in psychological and physiological and physiological

adaptive responses. As people are exposed a stressors, their ability to meet their basic
needs is threatened. This threat whether actual or perceived, produces frustration, anxiety
and tension. Psychological adaptive behaviors assist the person’s ability to cope with
stressors. These behaviors are directed at stress management and are acquired through
learning and experience as a person identifies acceptable and successful behaviors.

Psychological adaptive behaviors are also related to as COPING MECHANISMS. It

involves:

A. Task – Oriented Behaviors – Involve using cognitive abilities to reduce stress, solve
problems, resolve conflicts and gratify needs. It enables a person to cope realistically
with the demands of a stressor.

Three General Types

I. Attack Behavior – Is acting to remove or overcome a stressor or to satisfy a
need
II. Withdrawal Behavior – Is removing the self physically or emotionally from the
stressor
III. Compromise Behavior – Is changing the usual method of operating, substituting
goals or omitting the satisfaction of needs to meet other needs or to avoid
stress.

B. Defense Mechanisms – Unconscious behaviors that offer psychological protection

from a stressful event. They are used by everyone and help protect against feelings of
worthlessness and anxiety. Frequently activated by short-term stressors and usually do
not result in psychiatric disorders.

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 4. TYPES OF NURSING DIAGNOSES

A. Formulating the Nursing Diagnosis

I. Actual
a. Clients demonstrates defining characteristics of a problem
b. Nurse intervenes to resolve or help client cope with the problem

II. High-risk
a. A problem is likely to develop based on assessment of risk factors
b. Nurse intervenes to reduce risk factors or increase protective factors
c. Example: encourage smoking cessation

III. Wellness
a. Client is presently healthy but wishes to achieve a higher level of function
b. Nurse intervenes to promote growth or maintenance of the healthy
response

B. Collaborative Problems
I. Definition: a potential problem the nurse manages using both independent and
interdependent interventions

II. Example: potential complication of head injury: loss of consciousness, epidural

or subdural hematoma, seizures

III. Usually occurs when a disease is present or a treatment is prescribed

IV. Clients with similar disease or treatment will have the same potential for
complications, which must be managed collaboratively; however, their
responses to the condition will vary, so a broad range of nursing diagnoses will
apply.
a. Example: a client with asthma will always be at risk for lowered oxygen
saturation; however, the client’s response to this condition will be unique
based on his/her developmental level, past experiences and family
configuration

b. Refer to Table for examples of collaborative problems

Example:
Disease/Situation Complication Related to Etiology
Potential Hemorrhage Related to 1.Uterine atony
complication of 2. Retained
childbirth placental fragment
3. Bladder
distention

Potential Dysrhythmia Related to Low serum

complication of potassium
diuretic therapy

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 5. METHODS USED for ASSESSMENT

A. Collaboration of Data: Objective & Subjective

I. Review of clinical record

a. Client records contain information collected by many members of the
healthcare team, such as demographics, past medical history, diagnostic
test results and consultations

b. Reviewing the client’s record before beginning an assessment prevents

the nurse from repeating questions that the client has already been asked
and identifies information that needs clarification.

II. Interview
a. The purpose of an interview is to gather and provide information, identify
problems of concerns, and provide teaching and support.
b. The goals of an interview are to develop a rapport with the client and to
collect data
c. An interview has 3 major stages
i. Opening: purpose is to establish rapport by creating goodwill
and trust; this is often achieved through a self – introduction,
nonverbal gestures (a handshake), and small talk about the
weather, local sports team, or recent current event; the purpose
of the interview is also explained to the client at this time.
ii. Body: during this phase, the client responds to open and closed-
ended questions asked by the nurse.
iii. Closing: either the client or the nurse may terminate the
interview, it is important fro the nurse to try to maintain the
rapport and trust that was developed thus far during the
interview process.

d. Types of questions
i. Closed questions used in directive interview
 Re____ short factual answers; e.g. “Do you have pain?”
 Answers usually reveal limited amounts of information
 Useful with clients who are highly stressed and/or have
difficulty communicating

ii. Open-ended questions used in nondirective interview

 Encourage clients to express and clarify their thoughts and
feelings; e.g. “How have you been sleeping lately?’
 Specify the broad area to be discussed and invite longer
answers
 Useful at the start of an interview or to change the subject

iii. Leading questions

 Direct the client’s answer; e.g. “You don’t have any questions
about your medications, do you?”
 Suggests what answer is expected

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  Can result in client giving inaccurate data to please the
nurse
 Can limit client choice of topic for discussion

III. Nursing History

a. Collection of information about the effect of the client’s illness on daily
functioning and ability to cope with the stressor (the human response)

b. Subjective data
i. May be called “covert data”
ii. Not measurable or observable
iii. Obtained from client (primary source), significant others, or
health professionals (secondary sources).
iv. For example, the client states, “I have a headache”

c. Objective data
i. May be called “overt data”
ii. Can be detected by someone other than the client
iii. Includes measurable and observable client behavior
iv. For example, a blood pressure reading of 190/110 mmHg.

IV. Physical assessment

a. Systematic collection of information about the body systems through the
use of observation, inspection, auscultation, palpation and percussion
b. A body system format for physical assessment is found below:

 General assessment
 Integumentary system
 Head, ears, eyes, nose, throat
 Breast and axillae
 Thorax and lungs
 Cardiovascular system
 Nervous system
 Abdomen and gastrointestinal system
 Anus and rectum
 Genitourinary system
 Reproductive system
 Musculoskeletal system

V. Psychosocial assessment
a. Helpful framework for organizing data
b. A suggested format for psychosocial assessment is found below:
 Vocation/education/financial
 Home and Family
 Social, leisure, spiritual and cultural
 Sexual
 Activities of daily living
 Health Habits
 Psychological
17
 c. The developmental of Erickson, Freud, Havighurst, Kohlberg and Piaget
may also be helpful for guiding data collection

VI. Consultation
a. The nurse collects data from multiple sources: primary (client) and
secondary (family members, support persons, healthcare professionals
and records)
b. Consultation with individuals who can contribute to the client’s database is
helpful in achieving the most complete and accurate information about a
client
c. Supplemental information from secondary sources (any source other then
the client) can help verify information, provide information for a client who
cannot do so, and convey information about the client’s status prior to
admission

VII. Review of literature

a. A professional nurse engages in continued education to maintain
knowledge of current information related to health care
b. Reviewing professional journals and textbooks can help provide additional
data to support or help analyze the client database

6. DOCUMENTING and REPORTING

A. Guidelines for Good Documentation and Reporting

I. Fact – information about clients and their care must be factual. A record should
contain descriptive, objective information about what a nurse sees, hears, feels
and smells
II. Accuracy – information must be accurate so that health team members have
confidence in it
III. Completeness – the information within a record or a report should be complete,
containing concise and thorough information about a client’s care. Concise data
are easy to understand
IV. Correctness – ongoing decisions about care must be based on currently reported
information. At the time of occurrence include the following:
a. Vital signs
b. Administration of medications and treatments
c. Preparation of diagnostic tests or surgery
d. Change in status
e. Admission, transfer, discharge or death of a client
f. Treatment fro a sudden change in status
V. Organization – the nurse communicate in a logical format or order
VI. Confidentiality – a confidential communication is information given by one person
to another with trust and confidence that such information will not be disclosed

18
B. Documentation – anything written or printed that is relied on as a record of proof fro
authorized persons.

Purposes of Records:
I. Communication
II. Planning Client Care
III. Auditing Health Agencies
IV. Research
V. Education
VI. Reimbursement
VII. Legal Documentation
VIII. Health Care Analysis

C. Documentation Systems
I. Source – Oriented Record
a. The traditional client record
b. Each person or department makes notations in a separate section or
sections of the client’s chart
c. It is convenient because care providers from each discipline can easily
locate the forms on which to record data and it is easy to trace the
information
d. Example: the admissions department has an admission sheet; the
physician has a physician’s order sheet, a physician’s history sheet &
progress notes
e. NARRATIVE CHARTING is a traditional part of the source-oriented record

II. Problem – Oriented Medical Record (POMR)

a. Established by Lawrence Weed
b. The data are arranged according to the problems the client has rather
than the source of the information.

The four (4) basic components:

i. Database – consists of all information known about the client
when the client first enters the health care agency. It includes
the nursing assessment, the physician’s history, social & family
data
ii. Problem List – derived from the database. Usually kept at the
front of the chart & serves as an index to the numbered entries
in the progress notes. Problems are listed in the order in which
they are identified & the list is continually updated as new
problems are identified & others resolved
iii. Plan of Care – care plans are generated by the person who lists
the problems. Physician’s write physician’s orders or medical
care plans; nurses write nursing orders or nursing care plans
iv. Progress Notes – chart entry made by all health professionals
involved in a client’s care; they all use the same type of sheet
for notes. Numbered to correspond to the problems on the
problem list and may be lettered for the type of data

Example: SOAP Format Or SOAPIE and SOAPIER

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 S – Subjective data
O – Objective data
A – Assessment
P – Plan
I – Intervention
E – Evaluation
R- Revision
Advantages of POMR:
 It encourages collaboration
 Problem list in the front of the chart alerts caregivers to the
client’s needs & makes it easier to track the status of each
problem.

Disadvantages of POMR:
 Caregivers differ in their ability to use the required charting
format
 Takes constant vigilance to maintain an up-to-date problem
list
 Somewhat inefficient because assessments & interventions
that apply to more than one problem must be repeated.

III. PIE (Problems, Interventions, and Evaluation)

a. Groups information in to three (3) categories
b. This system consists of a client care assessment floe sheet & progress
notes
c. FLOW SHEET – uses specific assessment criteria in a particular format,
such as human needs or functional health patterns
d. Eliminate the traditional care plan & incorporate an ongoing care plan into
the progress notes

IV. Focus Charting

a. Intended to make the client & client concerns & strengths the focus of care
b. Three (3) columns for recording are usually used: date & time, focus &
progress notes

V. Charting by Exception
a. Documentation system in which only abnormal or significant findings or
exceptions to norms are recorded
b. Incorporates three (3) key elements:
i. Flow sheets
ii. Standards of nursing care
iii. Bedside access to chart forms

VI. Computerized Documentation

a. Developed as a way to manage the huge volume of information required
in contemporary health care
b. Nurses use computers to store the client’s database, add new data, create
& revise care plans & document client progress.
20
 VII. Case Management
a. Emphasizes quality, cost-effective care delivered within an established
length of stay
b. Uses a multidisciplinary approach to planning & documenting client care,
using critical pathways.

D. Nursing Care Plan (NCP)

Two Types:
I. Traditional Care Plan – written fro each client; it has 3 columns: nursing
diagnoses, expected outcomes & nursing interventions.
II. Standardized Care Plan – based on an institution’s standards of practice;
thereby helping to provide a high quality of nursing care

E. KARDEX widely used, concise method of organizing & recording data about a client,
making information quickly accessible to all health professionals. Consists of a series of
cards kept in a portable index file or on computer generated forms. Information may be
organized into sections:
I. Pertinent information about the client
II. List of medications
III. List of IVF
IV. List of daily treatments & procedures
V. List of Diagnostic procedures
VI. Allergies
VII. Specific data on how the client’s physical needs are to be met
VIII. A problem list, stated goals & list of nursing approaches to meet the goals

F. Nursing Discharge / Referral Summaries – completed when the client is being

discharged & transferred to another institution or to a home setting where a visit by a
community health nurse is required. Regardless of format, it include some or all of the
following:
I. Description of client’s physical, mental & emotional state
II. Resolved health problems
III. Unresolved continuing health problems
IV. Treatments that can be continued (e.g. wound care, oxygen therapy)
V. Current medications
VI. Restrictions that relate to activity, diet & bathing
VII. Functional/self-care abilities
VIII. Comfort level
IX. Support networks
X. Client education provided in relation to disease process
XI. Discharge destination
XII. Referral Services (e.g. social worker, home health nurse)

7. PHYSICAL EXAMINATION
A. Purposes

The nurse uses physical assessment for the following reasons:

I. To gather baseline data about the client’s health
II. To supplement, confirm or refute data obtained in the nursing history
21
 III. To confirm and identify nursing diagnoses
IV. To make clinical judgments about a client’s changing health status and
management

B. Preparation of Examination
I. Environment – A physical examination requires privacy. An examination room
that is well equipped for all necessary procedures is preferable
II. Equipment – Hand washing is done before equipment preparation and the
examination. Hand washing reduces the transmission of microorganisms
III. Client
a. Psychological Preparation – clients are easily embarrassed when forced
to answer sensitive questions about bodily functions or when body parts
are exposed and examined. The possibility that the examination will find
something abnormal also creates anxiety so reduction of this anxiety may
be the nurse’s highest priority before the examination
b. Physical Preparation – the client’s physical comfort is vital to the success
of the examination. Before starting, the nurse asks if the client needs to
use the toilet.
c. Positioning – during the examination, the nurse asks the clients to assume
proper positions so that body parts are accessible and clients stay
comfortable. Client’s abilities to assume positions will depend on their
physical strength and degree of wellness.

C. Order of Examination
I. General Survey – includes observation of general appearance and behavior,
vital signs, height and weight measurement
II. Review of systems
III. Head to toe examination

D. Skills in Physical Examination

I. Inspection – to detect normal characteristics or significant physical signs. To
inspect body parts accurately the nurse observes the following principles:
a. Make sure good lighting is available
b. Position and expose body parts so that all surface can be viewed
c. Inspect each areas for size, shape, color, symmetry, position and
abnormalities
d. If possible, compare each area inspected with the same area of the
opposite side of the body
e. Use additional light (for example, a penlight) to inspect body cavities

II. Palpation – the hands can make delicate and sensitive measurements of
specific physical signs, so palpation is used to examine all accessible parts of
the body. The nurse uses different parts of the hand to detect characteristics
such as texture, temperature and the perception of movement.

III. Percussion – examination by striking the body’s surface with a finger, vibration
and sound are produced. This vibration is transmitted through the body tissues
and the character of the sound depends on the density of the underlying tissue

22
 IV. Auscultation – is listening to sound created in body organs to detect variations
from normal. Some sounds can be heard with the unassisted ear, although
most sounds can be heard only through a stethoscope.
a. Bowel sounds
b. Breath sounds
i. Vesicular
ii. Bronchovesicular
iii. Bronchial
E. Examples of Adventitious Breath Sounds
I. Crackles (previously called rales)
II. Rhonchi
III. Wheeze
IV. Friction rub

Therapeutic Communication Techniques

1. Using silence
2. Providing general leads
3. Being specific & tentative
4. Using open-ended questions
5. Using touch
6. Restating to paraphrasing
7. Seeking clarification
8. Perception checking or seeking consensual validation
9. Offering self
10. Giving information
11. Acknowledging
12. Clarifying time or sequence
13. Presenting reality
14. Focusing
15. Reflecting
16. Summarizing & planning
B. Barriers to Communication
1. Stereotyping
2. Agreeing & disagreeing
3. Being defensive
4. Challenging
5. Probing
6. Testing
7. Rejecting
8. Changing topics & subjects
9. Unwarranted reassurance
10. Passing judgment
11. Giving common advice

Phases of the Helping Relationship

12. Pre-interaction Phase

13. Introductory Phase
a. Opening the relationship
b. Clarifying the problem
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 c. Structuring & formulating the contract

14. Working Phase

a. Exploring & understanding thoughts or feelings
b. Facilitating & taking action

15. Termination Phase

8. PRINCIPLES of ASEPSIS and INFECTION CONTROL

A. Chain of Infection
I. The chain of infection refers to those elements that must be present to cause
an infection from a microorganism

II. Basic to the principle of infection is to interrupt this chain so that an infection
from a microorganism does not occur in clients

III. Infectious agent; microorganisms capable of causing infections are referred to

as an infectious agent or pathogen.

IV. Modes of transmission: the microorganism must have a means of

transmission to get from one location to another, called direct and indirect

V. Susceptible host describes a host (human or animal) not possessing enough

resistance against a particular pathogen to prevent disease or infection from
occurring when exposed to the pathogen; in humans this may occur if the
person’s resistance is low because of poor nutrition, lack of exercise of a
coexisting illness that weakens the host.

VI. Portal of entry: the means of a pathogen entering a host: the means of entry
can be the same as one that is the portal of exit (gastrointestinal, respiratory,
genitourinary tract).

VII. Reservoir: the environment in which the microorganism lives to ensure

survival; it can be a person, animal, arthropod, plant, oil or a combination of
these things; reservoirs that support organism that are pathogenic to humans
are inanimate objects food and water, and other humans.

VIII. Portal of exit: the means in which the pathogen escapes from the
reservoir and can cause disease; there is usually a common escape route for
each type of microorganism; on humans, common escape routes are the
gastrointestinal, respiratory and the genitourinary tract.

Modes of Transmission
1. Direct contact: describes the way in which microorganisms are
transferred from person to person through biting, touching, kissing, or
sexual intercourse; droplet spread is also a form of direct contact but
can occur only if the source and the host are within 3 feet from each
other; transmission by droplet can occur when a person coughs,
sneezes, spits, or talks.
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 2. Indirect contact: can occur through fomites (inanimate objects or
materials) or through vectors (animal or insect, flying or crawling); the
fomites or vectors act as vehicle for transmission
3. Air: airborne transmission involves droplets or dust; droplet nuclei can
remain in the air for long periods and dust particles containing
infectious agents can become airborne infecting a susceptible host
generally through the respiratory tract

B. Course of Infection

I. Incubation: the time between initial contact with an infectious agent until the
first
Signs of symptoms - - > the incubation period varies from different
Pathogens; microorganisms are growing and multiplying during this
stage

II. Prodromal Stage: the time period from the onset of nonspecific symptoms
to the
Appearance of specific symptoms related to the causative pathogen
- - > symptoms range from being fatigued to having a low-grade fever
with
Malaise; during this phase it is still possible to transmit the pathogen to
Another host

III. Full Stage: manifestations of specific signs & symptoms of infectious agent;
referred to as the acute stage; during this stage, it may be possible to
transmit the infectious agent to another, depending on the virulence of the
infectious agent

IV. Convalescence: time period that the host takes to return to the pre-illness
stage; also called the recovery period; - - >the host defense mechanisms
have responded to the infectious agent and the signs and symptoms of the
disease disappear; the host, however, is more vulnerable to other pathogens at
this time; an appropriate nursing diagnostic label related to this process would
be Risk for Infection

C. Inflammation – The protective response of the tissues of the body to injury or infection;
the physiological reaction to injury or infection is the inflammatory response; it may be
acute or chronic

Body’s response
I. The “inflammatory response” begins with vasoconstriction that is followed by a
brief increase in vascular permeability; the blood vessels dilate allowing plasma
to escape into the injured tissue

II. WBCs (neutrophils, monocytes, and macrophages) migrate to the area of injury
and attack and ingest the invaders (phagocytosis); this process is responsible
for the signs of inflammation
III. Redness occurs when blood accumulates in the dilated capillaries; warmth
occurs as a result of the heat from the increased blood in the area, swelling
25
 occurs from fluid accumulation; the pain occurs from pressure or injury to the
local nerves.

D. Immune Response
I. The immune response involves specific reactions in the body to antigens or
foreign material

II. This specific response is the body’s attempt to protect itself, the body protects
itself by activating 2 types of lymphocytes, the T-lymphocytes and B-
lymphocytes

III. Cell mediated immunity: T-lymphocytes are responsible for cellular immunity
a. When fungi , protozoa, bacteria and some viruses activate T-lymphocytes,
they enter the circulation from lymph tissue and seek out the antigen
b. Once the antigen is found they produce proteins (lymphocytes) that
increase the migration of phagocytes to the area and keep them there to
kill the antigen
c. After the antigen is gone, the lymphocytes disappear
d. Some T-lymphocytes remain and keep a memory of the antigen and are
reactivated if the antigen appears again.

IV. Humoral response: the ability of the body to develop a specific antibody to a
specific antigen (antigen-antibody response)
a. B-lymphocytes provide humoral immunity by producing antibodies that
convey specific resistance to many bacterial and viral infections

b. Active immunity is produced when the immune system is activated either

naturally or artificially.
i. Natural immunity involves acquisition of immunity through
developing the disease
ii. Active immunity can also be produced through vaccination by
introducing into the body a weakened or killed antigen
(artificially acquired immunity)
iii. Passive immunity does not require a host to develop antibodies,
rather it is transferred to the individual, passive immunity occurs
when a mother passes antibodies to a newborn or when a
person is given antibodies from an animal or person who has
had the disease in the form of immune globulins; this type of
immunity only offers temporary protection from the antigen.

E. Nosocomial Infection
I. Nosocomial Infections: are those that are acquired as a result of a healthcare
delivery system

II. Iatrogenic infection: these nosocomial infections are directly related to the
client’s treatment or diagnostic procedures; an example of an iatrogenic
infection would be a bacterial infection that results from an intravascular line or
Pseudomonas aeruginosa pneumonia as a result of respiratory suctioning

26
 III. Exogenous Infection: are a result of the healthcare facility environment or
personnel; an example would be an upper respiratory infection resulting from
contact with a caregiver who has an upper respiratory infection

IV. Endogenous Infection: can occur from clients themselves or as a reactivation of

a previous dormant organism such as tuberculosis; an example of endogenous
infection would be a yeast infection arising in a woman receiving antibiotic
therapy; the yeast organisms are always present in the vagina, but with the
elimination of the normal bacterial flora, the yeast flourish.

F. Factors Increasing Susceptibility to Infection

I. Age: young infants & older adults are at greater risk of infection because of
reduced defense mechanisms
a. Young infants have reduced defenses related to immature immune
systems
b. In elderly people, physiological changes occur in the body that make them
more susceptible to infectious disease; some of these changes are:
i. Altered immune function (specifically, decreased phagocytosis
by the neutrophils and by the macrophages)
ii. Decreased bladder muscle tone resulting in urinary retention
iii. Diminished cough reflex, loss of elastic recoil by the lungs
leading to inability to evacuate normal secretions
iv. Gastrointestinal changes resulting in decreased swallowing
ability and delayed gastric emptying.

II. Heredity: some people have a genetic predisposition or susceptibility to some

infectious diseases

III. Cultural practices: healthcare beliefs and practices, as well as nutritional and
hygiene practices, can influence a person’s susceptibility to infectious diseases

IV. Nutrition: inadequate nutrition can make a person more susceptible to

infectious diseases; nutritional practices that do not supply the body with the
basic components necessary to synthesized proteins affect the way the body’s
immune system can respond to pathogens

V. Stress: stressors, both physical and emotional, affect the body’s ability to
protect against invading pathogens; stressors affect the body by elevating
blood cortisone levels; if elevation of serum cortisone is prolonged, it decreases
the anti-inflammatory response and depletes energy stores, thus increasing the
risk of infection

VI. Rest, exercise and personal health habits: altered rest and exercise patterns
decrease the body’s protective, mechanisms and may cause physical stress to
the body resulting in an increased risk of infection; personal health habits such
as poor nutrition and unhealthy lifestyle habits increase the risk of infectious
over time by altering the body’s response to pathogens

VII. Inadequate defenses: any physiological abnormality or lifestyle habit can

influence normal defense mechanisms in the body, making the client more
27
 susceptible to infection; the immune system functions throughout the body and
depends on the following:
a. Intact skin and mucous membranes
b. Adequate blood cell production and differentiation
c. A functional lymphatic system and spleen
d. An ability to differentiate foreign tissue and pathogens from normal body
tissue and flora; in autoimmune disease, the body has a problem with
recognizing it’s own tissue and cells; people with autoimmune disease are
at increased risk of infection related to their immune system deficiencies.

VIII. Environmental: an environment that exposes individuals to an increased

number of toxins or pathogens also increases the risk of infection; pathogens
grow well in warm moist areas with oxygen (aerobic) or without oxygen
(anaerobic) depending on the microorganism, an environment that increases
exposure to toxic substances also increases risk

IX. Immunization history: inadequately immunized people have an increased risk of

infection specifically for those diseases for which vaccines have been
developed.

X. Medications and medical therapies: examples of therapies and medications that

increase clients risk for infection includes radiation treatment, anti-neo-plastic
drugs, anti-inflammatory drugs and surgery

G. Diagnostic Tests Used to Screen for Infection

I. Signs and symptoms related to infections are associated with the area infected;
for instance, symptoms of a local infection on the skin or mucous membranes
are localized swelling, redness, pain and warmth

II. Symptoms related to systemic infections include fever, increased pulse &
respirations, lethargy, anorexia, and enlarged lymph nodes

III. Certain diagnostic tests are ordered to confirm the presence of an infection.

9. THEORIES OF PAIN
A. Specific Theory
I. Proposes that body’s neurons & pathways for pain transmission are specific,
similar to other senses like taste

II. Free nerve endings in the skin act as pain receptors, accept input & transmit
impulses along highly specific nerve fibers

III. Does not account for differences in pain perception or psychologic variables
among individuals.

B. Pattern Theory
I. Identifies 2 major types of pain fibers; rapidly & slowly conducting

II. Stimulation of these fibers forms a pattern; impulses ascend to the brain to be
interpreted as painful
28
 III. Does not account for differences in pain perception or psychologic variables
among individuals.

C. Gate Control Theory

I. Pain impulses can be modulated by a transmission blocking action within the
CNS.
II. Large-diameter cutaneous pain fibers can be stimulated (e.g. rubbing or
scratching an area) and may inhibit smaller diameter fibers to prevent
transmission of the impulse (“close the gate”).

D. Current Developments in Pain Theory – Indicate that pain mechanisms & responses are
far more complex than believed to be in the past.
I. Pain may modulated at different points in the nervous system.
a. First-order neurons at the tissue level
b. Second-order neurons in the spinal cord that process nociceptor
information
c. Third-order tracts & pathways in the spinal cord & brain that relay/process
this information

II. The role of the pain experience in the development of new nociceptors and/or
reducing the threshold of current nociceptor is also being investigate

10. TYPES OF PAIN

A. Acute Pain
I. Usually temporary, sudden in onset, localized, lasts for 6 months; results from
tissue injury associated with trauma, surgery, or inflammation.

Types of Acute Pain

a. Somatic: arises from nerve receptors in the skin or close to body’s
surface; may be sharp & well-localized or dull & diffuse; often
accompanied by nausea & vomiting

b. Visceral: arises from body’s organs; dull & poorly localized because of
minimal nociceptors; accompanied by nausea & vomiting, hypotension &
restlessness

c. Referred pain: pain that is perceived in an area distant from the site of
stimuli (e.g. pain in a shoulder following abdominal laparoscopic
procedure).

II. Acute pain initiates the “fight-or-flight” response of the Autonomic Nervous
System and is characterized by the following symptoms:
a. Tachycardia
b. Rapid, shallow respirations
c. Increased BP
d. Sweating
e. Pallor
f. Dilated pupils
g. Fear & Anxiety
29
B. Chronic Pain
I. Prolonged, lasting longer than 6 months, often not attributed to a definite cause,
often unresponsive to medical treatment.

Types of Chronic Pain

a. Neuropathic: painful condition that results from damage to peripheral
nerves caused by infection or disease; post-therapeutic neuralgia
(shingles) is an example

b. Phantom: pain syndrome that occurs following surgical or traumatic

amputation of a limb.
i. The client is aware that the body part is missing
ii. Pain may result of stimulation of severed nerves at the site of
amputation
iii. Sensation may be experienced as an itching, pressure, or as
stabbing or burning in nature
iv. It can be triggered by stressors (fatigue, illness, emotions,
weather)
v. This experience is limited for most clients because the brain
adapts to amputated limb; however, some clients experience
abnormal sensation or pain over longer periods
vi. This type of pain requires treatment just as any other type of
pain does.

c. Psychogenic: pain that is experienced in the absence of a diagnosed

physiologic cause or event; the client’s emotional needs may prompt pain
sensation.

II. Depression is a common associated symptom for the client experiencing

chronic pain; feelings of despair & hopelessness along with fatigue are
expected findings.

11. PAIN ASSESSMENT

A. TOOLS/INTRUMENTS USED
I. A VERBAL REPORT using an intensity scale is a fast, easy & reliable method
allowing the client to state pain intensity & in turn, promotes consisted
communication among the nurse, client & other healthcare professionals about
the client’s pain status; the 2 most common scales used are “0 to 5” or “0 to
10”. With 0 specifying no pain & the highest number specifying the worst pain

II. A VISUAL ANALOG SCALE is a horizontal pain-intensity scale with word

modifiers at both ends of the scale, such as “no pain” at one end and “worst
pain” at the other, clients are asked to point or mark along the line to convey the
degree of pain being experienced

30
 III. A GRAPHIC RATING SCALE is similar to the visual analog scale but adds a
numerical scale with the word modifiers, usually the numbers “0 to 10” are
added to the scale.

IV. FACES PAIN SCALE children, clients who do not speak English & clients with
communication impairments may have difficulty using a numerical pain intensity
scale; the FACES pain scale may be used for children as young as 3 years old;
this scale provides facial expressions (happy face reflects no pain, crying face
represents worst pain)

V. PHYSIOLOGIC INDICATORS OF PAIN may be the only means a nurse can

use to assess pain for a non-communicating client, facial & vocal expression
may be the initial manifestations of pain; expressions may include rapid eye
blinking, biting of the lip, moaning, crying, screaming, either closed or clenched
eyes, or stiff unmoving body position

B. A B C D E method of pain assessment

I. This acronym was developed for cancer pain; however, it is very appropriate for
clients with any type of pain, regardless of the underlying disease.
II. A = Ask about pain
III. B = Believe the client & family reports pain
IV. C = Choose pain control options appropriate for the client
V. D = Deliver interventions in a timely, logical &coordinated fashion
VI. E = Empower clients & families

C. P Q R S T assessment for pain reception

I. This method is especially helpful when approaching a new pain problem
II. P = what precipitated the pain?
III. Q = what are the quality & quantity of the pain?
IV. R = what is the region of the pain?
V. S = what is the severity of the pain?
VI. T = what is the timing of the pain?
D. Pain History
I. Location – when clients report “pain all over”, this generally refers to total pain
or existential distress (unless there is an underlying physiologic reason for pain
all over the body, such as myalgias); assess the client’s emotional state for
depression, fear, anxiety or hopelessness.

II. Intensity – It is important to quantify pain using a standard pain intensity scale.
When clients cannot conceptualize pain using a number, simple word
categorizes can be useful (e.g. no pain, mild, moderate, severe).

III. Quality
a. Nociceptive pain are usually related to damage to bones, soft tissues, or
internal organs; nociceptive pain includes somatic & visceral pains.
i. Somatic pain is aching, throbbing pain; example arthritis
ii. Visceral pain is squeezing, cramping pain; example: pain
associated with ulcerative colitis

31
 IV. Pattern – pain may be always present for a client; this is often termed baseline
pain. Additional pain may occur intermittently that is of rapid onset & greater
intensity than the baseline pain; known as breakthrough pain. People at end-of-
life often have both types of pain. Cultural beliefs regarding the meaning of pain
should be examined

ADMINISTRATION OF MEDICATIONS

12. DRUG NOMENCLATURE and FORMS

A. Names
I. Chemical Name – provides an exact description of the drug’s composition. An
example of chemical name acetylsalicylic known common as Aspirin

II. Generic Name – is given by the manufacturer who first develops the drug
before it receives official approval. Protected by law, the generic name is given
before a drug receives official publications.

III. Official Name – is the name under which drug is listed in official publication

IV. Trade, Brand or Propriety Name – is the name under which a manufacturer
markets.

B. Classification – Nurses categorized medications with similar characteristics by their

class. Drug classification indicates the effects on a body system, the symptoms relieved
or the desired effect. Each class contains drugs prescribed for similar types of health
problems. The physical and chemical composition of drugs within a class is not
necessarily the same. A drug may also belong to more than one class. For example,
aspirin is an analgesic and antipyretic and an anti-inflammatory drug.

C. Forms – Drugs are available in a variety of forms preparations. The form of the drug
determines its route o administration. For example, a capsule is taken orally and a
solution may be given intravenously. The composition drug is designed to enhance its
absorption and metabolism within the body. Many drugs are available in several forms
such as tablets, capsules, elixirs and suppositories. When administering a medication,
the nurse must be certain to give the metabolism in the proper form.

D. Principles in Administering Medications

I. Observe the 7 RIGHTS of Drug Administration:
a. Right Drug
b. Right Dose
c. Right Time
d. Right Route
e. Right Patient
f. Right Recording
g. Right Approach

II. Practice asepsis

III. Nurses who administer medications are responsible for their own actions.
Question any order that you can consider incorrect.
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 IV. Be knowledgeable about medications that you administer

V. Keep narcotics & barbiturates in locked place

VI. Use only medications that are in clearly labeled containers

VII. Return liquid that are cloudy or have changed in color to the pharmacy

VIII. Before administering a medication, identify the client correctly

IX. Do not leave the medication at the bedside

X. If the client vomits after taking an oral medication, report this to the nurse in
charge and/or physician

XI. Preoperative medications are usually discontinued during the post-operative

period unless ordered to be continued

XII. When a medication is omitted for any reason, record the fact together
with the reason

XIII. When a medication error is made, report immediately to the nurse in

charge and/or physician

13. BASIC HUMAN NEEDS

A. Abraham Maslow – developed the five (5) levels of human needs:

I. Physiologic Needs – needs such as air, food, water, shelter, rest, sleep, activity
and temperature maintenance are crucial for survival
II. Safety and Security Needs – the need for safety has both physical and
physiologic aspects
III. Love and Belonging Needs – the third level of needs includes giving and
receiving affection, attaining a place in a group and maintaining the feeling of
belonging
IV. Self-Esteem Needs – the individual needs both self-esteem and esteem from
others
V. Self-Actualization – when the need for self-esteem is satisfied, the individual
strives for self-actualization, the innate need to develop one’s maximum
potential and realize one’s abilities and qualities

B. Maslow’s Characteristics of a Self-Actualized Person

I. Is realistic, sees life clearly and is objective about his or her observations
II. Judges people correctly
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 III. Has superior perception, is more decisive
IV. Has a clear notion of right or wrong
V. Is usually accurate in predicting future events
VI. Understands art, music, politics and philosophy
VII. Possesses humility, listens to others carefully
VIII. Is dedicated to some work, task, duty or vocation
IX. Is highly creative, flexible, spontaneous, courageous,
and willing to make mistakes
X. Is open to new ideas
XI. Is self-confident and has self-respect
XII. Has low degree of self-conflict; personality is integrated
XIII. Respect self, does not need fame, possesses a feeling of self-
control
XIV. Is highly independent, desires privacy
XV. Can appear remote or detached
XVI. is friendly, loving and governed more by inner directives than by society
XVII. Can make decisions contrary to popular opinion
XVIII. Is problem centered rather than self-centered
XIX. Accepts the world for what it is

14. MEETING OXYGENATION NEEDS

A. Oxygenation – a basic human need & is required to sustain life.

B. Cardiovascular Physiology – the function of the cardiac system is to

deliver oxygen, nutrients, & other substances to the tissues and to remove the waste
products of cellular metabolism

C. Structure and Function – the heart pumps blood through the pulmonary circulation by
way of the right ventricle and to the systemic circulation by way of the left ventricle
I. Myocardial Pump – the “pumping action” of the heart is essential to maintain
oxygen delivery
II. Myocardial Blood Flow – to maintain adequate blood flow to the pulmonary and
systemic circulations, myocardial blood flow must sufficiently supply oxygen
and nutrients to the myocardium itself
III. Coronary Artery Circulation – blood flow to the atria and ventricles does not
supply oxygen and nutrients to the myocardium itself. It is the branch of the
systemic circulation that supplies oxygen and nutrients and removal of waste
from the myocardium
IV. Systemic Circulation – the arteries and veins of the systemic circulation deliver
nutrients and oxygen and remove wastes from the tissues. Oxygenated blood
flows from the left ventricle by way of of the aorta and into the large systemic
arteries
V. Regulation of Blood Flow – the amount of blood ejected from the left ventricle
each minute is the cardiac output. The circulating volume of blood changes
according to the oxygen and metabolic needs of the body. For example, during
exercise, pregnancy and fever, the cardiac output increases but during sleep,
the cardiac output decreases.

D. Steps in the Process of Oxygenation

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 I. Ventilation – process by which gases are moved into and out of the lungs.
Adequate ventilation requires coordination of the muscular and elastic
properties of the lung and thorax and intact innervation. The major inspiratory
muscle is the “diaphragm” which is innervated by the “phrenic nerve”.

II. Perfusion – the primary function of pulmonary circulation is to move blood to

and from the alveolar-capillary membrane so that gas exchange can occur

III. Exchange of Respiratory Gases – respiratory gases are exchanged in the

alveoli of the lungs and the capillaries of the body tissues
a. Diffusion – movement of molecules from an area of higher concentration
to an area of lower concentration
b. Oxygen Transport – delivery depends on the amount of oxygen entering
the lungs (ventilation), blood flow to the lungs & tissues (perfusion),
adequacy of diffusion & capacity of the blood to carry oxygen.
c. Carbon Dioxide Transport – carbon dioxide diffuses into RBCs and I
rapidly hydrated into carbonic acid because of the presence of carbonic
hydras

15. MEETING NUTRITIONAL NEEDS

A. Principles of Nutrition
I. Digestion – process by which food substances are changed into forms that can
be absorbed through cell membranes

II. Absorption – the taking in of substance by cells or membranes

III. Metabolism – sum of all physical and chemical processes by which a living
organism is formed and maintained and by which energy is made available

IV. Storage – some nutrients are stored when not used to provide energy; e.g.
carbohydrates are stored either as glycogen or as fat
V. Elimination – process of discarding unnecessary substances through
evaporation, excretion

B. Nutrients
I. Carbohydrates – the primary sources are plant foods
Types of Carbohydrates
a. Simple (sugars) such as glucose, galactose, and fructose
b. Complex such as starches (which are polysaccharides) and fibers
(supplies bulk or roughage to the diet)

II. Proteins – organic substances made up of amino acids

III. Lipids – organic substances that are insoluble in water but soluble in alcohol
and ether.
a. Fatty acids – the basic structural units of all lipids and are either saturated
(all the carbon atoms are filled with hydrogen) or unsaturated (could
accommodate more hydrogen than it presently contains)
b. Food sources of lipids are animal products (milk, egg yolks and meat) and
plants and plant products (seeds, nuts, oils)
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 IV. Vitamins – organic compounds not manufactured in the body and needed in
small quantities to catalyze metabolic processes
a. Water-soluble vitamins include C and B-complex vitamins
b. Fat-soluble vitamins include A, D, E, and K and these can be stored in
limited amounts in the body

V. Minerals – compounds that work with other nutrients in maintaining structure

and function of the body
a. Macronutrients – calcium, phosphate, sodium, potassium, chloride,
magnesium and sulfur
b. Micronutrients (trace elements) – iron, iodine, copper, zinc, manganese
and fluoride
The best sources are vegetables, legumes, milk and some meats

VI. Water – the body’s most basic nutrient need; it serves as a medium for
metabolic reactions within cells and a transporter fro nutrients, waste products
and other substances

16. MEETING URINARY ELIMINATION NEEDS

A. Normal Urinary Function
I. Normal urine output is 60mL/hr or 1500mL/day; should remain 30 mL/hr to
ensure continued normal kidney function
II. Urine normally consists of 96% water
III. Solutes found in urine include:
a. Organic solutes: urea, ammonia, uric acid and creatinine
b. Inorganic solutes: sodium, potassium, chloride, sulfate, magnesium &
phosphorus

B. Common Assessment Findings

I. Urgency – strong desire to void my be caused by inflammations or infections in
the bladder or urethra
II. Dysuria – painful or difficult voiding
III. Frequency – voiding that occurs more than usual when compared with the
person’s regular pattern or the generally accepted norm of voiding once every 3
to 6 hours
IV. Hesitancy – undue delay and difficulty in initiating voiding
V. Polyuria – a large volume of urine or output voided at any given time
VI. Oliguria – a small volume of urine or output between 100 to 500 mL/24 hr
VII. Nocturnal – excessive urination at night interrupting sleep
VIII. Hematuria – RBCs in the urine

17. URINARY CATHETERIZATION

 Is the introduction of a catheter through the urethra into the bladder for the
purpose of withdrawing urine?

A. Purposes
I. To relieve urinary retention
II. To obtain a sterile urine specimen from a woman
III. To measure the amount of residual urine in the bladder
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 IV. To obtain a urine specimen when a specimen cannot secure satisfactory by
other means
V. To empty bladder before and during surgery and before certain diagnostic
examinations
***Several BASIC FACTS about the lower urinary tract system should be borne in mind
when considering catheterization.

B. Necessary Equipment for Catheterization

 Catheters are graded on the French scale according to the size of the lumen.
For the female adult, No. 14 and No. 16 French catheters are usually used. Small
catheters are generally not necessary and the size of the lumen is also so small
that it increases the length of time necessary for emptying the bladder. Larger
catheter distends the urethra and tends to increase the discomfort of the
procedure. For male adult, No.18 and No. 20 French catheters usually used, but
if this appears to be too large, smaller catheter should be used. No. 8 and No. 10
French catheters are commonly used for children.

C. Preparation of the Patient

I. Adequate exploration
II. Position – dorsal recumbent for the female and supine for the male using a firm
mattress or treatment table, Sim’s or lateral position can be an alternate for the
female patient
III. Provision for privacy

D. Retention or Indwelling Catheter (Foley) – A catheter to remain in place for the

following purposes:
I. The gradual decompression of an over distended bladder
II. For intermittent bladder drainage
III. For continuous bladder drainage

An indwelling catheter has a balloon which is inflated after the catheter is inserted
into the bladder. Because the inflated balloon is larger than the opening to the urethra,
the catheter is retained in the bladder.

E. Procedure for Insertion

I. Inflate the balloon with the prefilled syringe before inserting the catheter to
check for balloon patency. Aspirate the fluid back into the syringe when it is
determined that the balloon is patent.
II. Hold the catheter with one hand and inflate the balloon according to the
manufacturer’s instructions, as soon as the catheter is in the bladder and urine
has begun to drain from the bladder. Usually 5 ml to 10 ml of sterile water is
used
III. If the patient complains of pain after the balloon is inflated, allow it to empty and
replace the catheter with another one. The balloon is probably located in the
urethra and is causing discomfort owing to distention of the urethra
IV. Exert slight tension on the catheter after the balloon is inflated to assure its
proper placement in the bladder
V. Connect the catheter to the drainage tubing and drainage bag if not already
connected

37
 VI. Tape the catheter along the interior aspect of the thigh fro a female patient. Be
sure there is no tension on the catheter when it is taped to the patient
VII. Hang the drainage bag on the frame of the bed below the level of the
bladder

F. Caring for the Patient with an Indwelling Catheter

I. Be sure to wash hands before and after caring for a patient with an indwelling
catheter
II. Clean the perineal area thoroughly, especially around the meatus, twice a day
and after each bowel movement. This helps prevent organisms for entering the
bladder
III. Use soap or detergent and water to clean the perineal area and rinse the area
well
IV. Make sure that the patient maintains a generous fluid intake. This helps prevent
infection and irrigates the catheter naturally by increasing urinary output
V. Encourage the patient to be up and about as ordered
VI. Record the patient’s intake and output
VII. Note the volume and character of urine and record observations carefully
VIII. Teach the patient the importance of personal hygiene, especially the
importance of careful cleaning after having bowel movement and thorough
washing of hands frequently
IX. Report any signs of infection promptly. These include a burning sensation and
irritation at the meatus, cloudy urine, a strong odor to the urine, an elevated
temperature and chills
X. Plan to change indwelling catheters only as necessary. The usual length of time
between catheter changes varies and can be anywhere from 5 days to 2
weeks. The less often a catheter is changed, the less the likelihood than an
infection will develop

G. Removing the Indwelling Catheter and Aftercare of the Patient

I. Be sure the balloon is deflated before attempting to remove the catheter. This
may be done by inserting a syringe into the balloon valve or by cutting the
balloon valve
II. Have the patient take several deep breaths to help him relax while gently
removing the catheter. Wrap the catheter in a towel or disposable, waterproof
drape
III. Clean the area at the meatus thoroughly with antiseptic swabs after the
catheter is removed
IV. See to it that the patient’s fluid intake is generous and record the patient’s
intake and output. Instruct the patient to void into the bedpan or urinal
V. Observe the urine carefully for any signs of abnormality
VI. Record and report any usual signs such as discomfort, a burning sensation
when voiding, bleeding and changes in vital signs, especially the patient’s
temperature. Be alert to any signs of infection and report them promptly

18. MEETING BOWEL ELIMINATION NEEDS

A. Factors that influence Bowel Elimination
I. Age
II. Diet
III. Position
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 IV. Pregnancy
V. Fluid Intake
VI. Activity
VII. Psychological
VIII. Personal Habits
IX. Pain
X. Medications
XI. Surgery/Anesthesia

B. Characteristics of Normal Stool

I. Color – varies from light to dark brown foods & medications may affect color
II. Odor – aromatic, affected by ingested food and person’s bacterial flora
III. Consistency – formed, soft, semi-solid; moist
IV. Frequency – varies with diet (about 100 to 400 g/day)
V. Constituents – small amount of undigested roughage, sloughed dead bacteria
and epithelial cells, fat, protein, dried constituents of digestive juices (bile
pigments); inorganic matter (calcium, phosphates)

C. Common Bowel Elimination Problems

I. Constipation – abnormal frequency of defecation and abnormal hardening of
stools
II. Impaction – accumulated mass of dry feces that cannot be expelled
III. Diarrhea – increased frequency of bowel movements (more than 3 times a day)
as well as liquid consistency and increased amount; accompanied by urgency,
discomfort and possibly incontinence
IV. Incontinence – involuntary elimination of feces
V. Flatulence – expulsion of gas from the rectum
VI. Hemorrhoids – dilated portions of veins in the anal canal causing itching and
pain and bright red bleeding upon defecation.

19. TYPES OF ENEMAS

A. Cleansing Enemas: Stimulate peristalsis through irrigation of colon and rectum and by
distention
I. Soap Suds: Mild soap solutions stimulate and irritate intestinal mucosa. Dilute 5
ml of castile soap in 1000 ml of water
II. Tap water: Give caution o infants or to adults with altered cardiac and renal
reserve
III. Saline: For normal saline enemas, use smaller volume of solution
IV. Prepackaged disposable enema (Fleet): Approximately 125 cc, tip is pre-
lubricate and does not require further preparation

B. Oil-Retention Enemas: Lubricates the rectum and colon; the feces absorb the oil and
become softer and easier to pass

C. Carminative Enema: Provides relief from gaseous distention

D. Astringent Enema: Contracts tissue to control bleeding

Key Points: Administering Enema
I. Fill water container with 750 to 1000 cc of lukewarm solution, (500 cc or less for
children, 250 cc or less fro an infant), 99 degrees F to 102 degrees F. Solutions
39
 that are too hot or too cold, or solutions that are instilled too quickly, can cause
cramping and damage to rectal tissues
II. Allow solution to run through the tubing so that air is removed
III. Place client on left side in Sim’s position
IV. Lubricate the tip of the tubing with water-soluble lubricant
V. Gently insert tubing into client’s rectum (3 to 4 inches for adult, 1 inch for
infants, 2 to 3 inches for children), past the external and internal sphincters
VI. Raise the water container no more than 12 to 18 inches above the client
VII. Allow solution to flow slowly. If the flow is slow, the client will experience
fewer cramps. The client will also be able to tolerate and retain a greater
volume of solution
VIII. After you have instilled the solution, instruct client to hold solution for
about 10 to 15 minutes
IX. Oil retention: enemas should be retained at least 1 hour. Cleansing enemas are
retained 10 to 15 minutes.

20. NASOGASTRIC and INTESTINAL TUBES

A. Nasogastric Tubes

I. Levin Tube – single lumen

a. Suctioning gastric contents
b. Administering tube feedings

II. Salem Sump Tube – double lumen (smaller blue lumen vents the tube & prevents
suction on the gastric mucosa, maintains intermittent suction regardless of suction
source)
a. Suctioning gastric contents
b. Maintaining gastric decompression

Key Points:
a. Prior to insertion, position the client in High-Fowler’s position if
possible.
b. Use a water-soluble lubricant to facilitate insertion
c. Measure the tube from the tip of the client’s nose to the earlobe and
from the nose to the xiphoid process to determine the approximate
amount of tube to insert to reach the stomach
d. Flex the client’s head slightly forward; this will decrease the chance of
entry into the trachea
e. Insert the tube through the nose into the nasopharyngeal area; ask the
client to swallow, and as the swallow occurs, progress the tube past
the area of the trachea and into the esophagus and stomach. Withdraw
tube immediately if client experiences respiratory distress
f. Secure the tube to the nose; do not allow the tube to exert pressure on
the upper inner portion of the nares
g. Validating placement of tube.
 Aspirate gastric contents via a syringe to the end of the tube
 Measure ph of aspirate fluid

40
  Place the stethoscope over the gastric area and inject a small
amount of air through the NGT. A characteristic sound of air
entering the stomach from the tube should be heard

h. Characteristics of nasogastric drainage:

 Normally is greenish-yellowish, with strands of mucous
 Coffee-ground drainage – old blood that has been broken
down in the stomach
 Bright red blood – bleeding from the esophagus, the stomach
or swallowed from the lungs
 Foul-smelling (fecal odor) – occurs with reverse peristalsis in
bowel obstruction; increase in amount of drainage with
obstruction

B. Intestinal Tubes – provide intestinal decompression proximal to a bowel obstruction.

Prevent/decrease intestinal distention. Placement of a tube containing a mercury weight
and allowing normal peristalsis to propel tube through the stomach into the intestine to
the point of obstruction where decompression will occur

I. Types of Intestinal Tubes

a. Cantor and Harris Tubes
i. Approximately 6-10 feet long
ii. Single lumen
iii. Mercury placed in rubber bag prior to tube insertion

b. Miller-Abbot Tubes
i. Approximately 10 feet long
ii. Double lumen
iii. One lumen utilized for aspiration of intestinal contents
iv. Second lumen utilized to instill mercury into the rubber bag after
the tube has been inserted into the stomach

II. Nursing Implications

a. Maintain client on strict NPO
b. Initial insertion usually done by physician and progression of the tube may
be monitored via an X-ray
c. After the tube has been placed in the stomach, position client on the right
side to facilitate passage through the pyloric valve
d. Advance the tube 2 to 4 inches at regular intervals as indicated by the
physician
e. Encourage activity, to facilitate movement of the tube through the intestine
f. Evaluate the type of gastric secretions being aspirated
g. Do not tape or secure the tube until it has reached the desired position
h. Tubes may attached to suction and left in place for several days
i. Offer the client frequent oral hygiene, if possible offer hard candy or gum
to reduce thirst
j. Removal of the tube depends on the relief of the intestinal obstruction
i. May be removed by gradual pulling back (4-6 inches per hour)
and eventual removal via the nose or mouth
41
 ii. May be allowed to progress through the intestines and expelled
via the rectum.

21. LOSS AND GRIEF

A. Loss – absence of an object, person, body part, emotion, idea

Or function that was valued
I. Actual loss is identified and verified by others
II. Perceived Loss cannot be verified by others
III. Maturational Loss occurs in normal development
IV. Situational Loss occurs without expectations
V. Ultimate Loss (Death) results in a lost for a dying person
As well as for those left behind, can be viewed as a time of growth for all who
Experienced it

B. Grieving Process (Theories of Grief, Dying and Mourning)

I. 3 Phases of Grief
a. Protest: lack of acceptance, concerning the loss, characterized by anger,
ambivalence and crying
b. Despair: denial and acceptance occurs simultaneously causing
disorganized behavior, characterized by crying and sadness
c. Detachment: loss is realized; characterized by hopelessness, accurately
defining the relationship with the lost individual and energy to move
forward in life.

II. Kubler-5 Stages of Grieving

a. Denial – characterized by shock and disbelief, serves as a buffer to
mobilize defense mechanism
b. Anger: resistance of the loss occurs, anger is typically directed toward
others
c. Bargaining = deals are sought with God or other higher power in an effort
to postpone the loss
d. Depression: loss is realized; may talk openly or withdraw.
e. Acceptance: recognition of the loss occurs, disinterest may occur; future
thinking may occur.

III. Worden’s 4 Tasks of Mourning

a. Accept the reality of the loss, the loss is accepted
b. Experience the pain of grief, healthy behaviors are accomplished to assist
in the grieving process.
c. Adjust to the environment without the deceased, task are accomplished to
reorient the environment, i.e. removing the clothes of the deceased from
the closet.
d. Emotionally relocate the deceased and move forward with life, correctly
align the past, the present & look towards the future

C. Anticipatory Grief – expression of the symptoms of grief prior to the actual loss, grief
period following the lost may be shortened and the intensity lessened because of the

42
 previous of grief; for example, a child told that a family move is expected may grieve
about losing friends prior to actually living

D. Complications of Bereavement
I. Chronic Grief – symptoms of grief occur beyond the expected time frame and
the severity of symptoms is greater; depression may result.

II. Delayed Grief – when symptoms of grief are not expressed and are
suppressed, a delayed reaction of grief occurs, the nurse should discuss the
normal process of grieving with the client and give permission to express these
symptoms

E. Symptoms of Normal Grief

I. Feelings include sadness, exhaustion, numbness, helplessness, loneliness,
and disorganization, preoccupation with the lost object or person, anxiety,
depression.
II. Thought patterns include fear, guilt, denial, ambivalence, anger
III. Physical sensations include nausea, vomiting, anorexia, weight loss or gain,
constipation or diarrhea, Diminished hearing or sight, chest pain, shortness of
breath, tachycardia
IV. Behaviors include crying, difficulty carrying out activities of daily living and
insomia

F. Nursing Health Promotion (to facilitate mourning)

1. Help client accept that the loss is real by providing sensitive, factual information
concerning the loss

2. Encourage the expression of feelings to support people; this build relationships

and enhances the grief process

3. Support efforts to live without the diseased person or in the face of disability; this
promotes a client’s sense of control as well as a healthy vision of the future

4. Encourage establishment with new relationships to facilitate healing.

5. Allow time to grief, the work of grief may take longer for some; observe for a
healthy progression of symptoms.

6. Interpret “normal” behavior by teaching thoughts, feelings, and behaviors that

can be expected in the grief process

7. Provide continuing support in the form of the presence for therapeutic

communication and resource information.

8. Be alert for signs of ineffective coping such as inability to carry out activities of
daily living, signs of depression, or lack of expression of grief.

43