MEDICAL SURGICAL NURSING

VIJAYAM'S5

Primitive people had no idea about wh

w
caused illness. They assumed that it
1.1. BRIEF HISTORY OF caused by evil spirits or magic performe
EVOLUTION OF MODERN by an enemy. The 'cure was magic
MEDICINE AND SURGERY cur
drive out the evil spirit or break the e
of enemics spell.
INTRODUCTION Ancient Egyptian Medicine:
on
Medical surgical nursing is the care of adults * In about 3000 BC the curtain rises
in health and illness. It is based on knowledge Egyptian civilisation. In a civilised societ
gfl
derived from the arts and sciences and further some people did specialized jobs. One
enhanced by knowledge from nursing. The focus these was the doctor. The first doctor
of Medical Surgical Nursing is an adult patient's known to history was Sekhmet-eanach
response to actual or potential alternations in who healed the pharaoh's nostrils.
health.
The earliest known medical book is the
Scope of Practice: Medical surgical nursingis Ebers Papyrus, which was written about
one of many specialities in Nursing. Yet its scope 1550 BC. Egyptian doctors used a
huge

is much broader than specialities as range of drugs obtained from herbs and
cardiovascular or orthopedic nursing. In 1991, minerals.
the Academy of Medical Surgical Nurses was
The Egyptians had some knowledge of
created as the first specialty organization for
this group. Medical surgical nurses assume Anatomy from making mummies.
diverse roles and with them, varied Egyptian surgery was limited to such
responsibilities. They may work in any health things as treating wounds and broken|
care setting, but most are employed by acute bones and dealing with boils and|
care facilities. abscesses. The Egyptians used clamps,
The focus of medical surgical nursing is on sutures and cauterisation. They had
adult patients with acute or chronic illness. Such surgical instruments like probes, saws,
patients range from the age of 18 to over age forceps, scalpels and scissors.
100 and their health problems are usually
*They also knew that honey helped to
complex. To care for this wide range ofpatients,
prevent wounds that becoming infected.
medical surgical nurses need a broad knowledge
(It is anatural Antiseptic).
of the biological, psychological and social
sciences Ancient Greek Medicine:
Medical in the ancient world: *The roots of Modern Medicine arein
Primitive People: ancient Greece. On the one hand most
19th Greeks believed in a good of healing called
*In the and early 20th centuriees
Anthropologists studied primitive societies. Asclepius.
Among them, treatment for injury' and *
People who were ill made sacrifices or
sickness was a mixture of common sense offerings to the God. They then slept
and magic. overnight in His temple. They believed

SR1.2
Unit-1 :: Introduction VIJAYAM's
that the god would visit them in their sleep Vedic Period: The period of Vedic medicine
(i.e. in their dreams) and when they woke lasted until about 800 BC. The Vedas are rich in
up, they would be healed. At the same magical practices for the treatment of diseases
time Greek doctors developed a rational and in charms for the expulsion of the demos
theory of disease and sought cures. [e.g. Fever, cough, consumption, diarrhoea,
As early as 500 BC a man named dropsy, abscesses, seizures, tumors and skin
Alcmacon from Croton in Italy said that diseases (including leprosy)]. The herbs
a body was healthy, if it had the right recommended for treatment are numerous. The
balance of hot and cold, wet and dry. experience and concern in health development
Finally Aristotle (384-322 BC) thought the date back to vedic period 3000 BC- 1400 BC.
body was made up of four humours, or Golden period of Indian medicine:
liquids. They were phlegm, blood, *
First medical physician Charaka.
yellow -

bile and black bile. If a person had too

much of one humour they fell ill.
First surgeon -
Sushruta.

Later Alexander the Great conquered *Their books were named as: Charaka
Samhita and Sushruta Samhita
Egypt. In 332 BC, he founded the city of
Alexandria and a great Medical School Charaka Samhita: The Hindus were
was established there. Doctors in prohibitedby their religion from cutting the dead
Alexandria dissected human bodies and body, their knowledge of anatomy was limited.
they gained a much better knowledge of The Sushruta Samhita recommends that a body
anatomy. be placed in a basket and sunk in a river for
seven days. On its removal, the parts could be.
Roman Medicine: easily separated with-out cutting. As a result of
Later in Roman times Galen (130-200these crudewasmethods, the emphasis in Hindu
AD) became a famous doctor. At firstanatomy given to the bones, muscles,
he worked for treating wounded ligaments andjoints.
Gladiators. The Hindus believed that the body contained
Then, in 169 AD he was made doctor to three elementary substances:
Commodus, the roman emperor's son. Spirit.
Galen was also a writer and he wrote Phlegm.
many books.
*Bile.
IraditionalMedicine and Surgery in India:
The history of medicine in India goes back The first classical exposition of Indian system
throughthe centuries to about 3000 BC. Indian medicine deals with an almost all the branches
|
medicine is an ancient. According to of medicine, anatomy, physiology, aetiology.
Atharvaveda, the system of medicine called prognosis, pathology, treatment procedure and
Ayurveda was received by certain Dhanvantari sequence of medication and an extension
rom Brahma and Dhanvantari was defined as Materia Medica for more than 60 days. This
theGod of Medicine. treatise formed the basis of the Atreya school
of medicine in India in 100 AD.

1.3
 VIJAYAMS MEDICAL SURGICAL NURSING.N

200-300 AD: Sushruta Samhita appears to centuries afterwards towns were ven,
have been revised by algorithm, laid main dirty. Most of the streets were unpaved
emphasis on surgery. This great treatise and seldom cleaned. However, tha
described more than 300 operations, three eastern half of the Roman Empire|
different surgical processes and 121 different continued and later medicine was passel
types of instruments. The Materia Medica is on to the Muslims.
also extensive covering more than 650 drugs of
animals, plant and mineral origin. This treatise a
*In the 9th century, man named Hunain
Tbn Ishaq travelled to Greece collecting
forms the basis of Dhanwantari School (300
AD). Greek books. He then returned to
Baghdad and translated them into Arabie,|
500-600 AD: Vagbhata wrote Astanga Hridaya
(limbs and heart). The eight limbs refer to the
*In the 10th century a persian doctor called
al-Razi was the first to distinguish|
eight traditional branches of ayurvedic
knowledge, i.e., between smallpox and measles.
*At about the same time Abul Qasim
known as Albucasis (936-1013) was a|
Therapeutics great surgeon, who practiced in Spain. He
was the first person to write about
Surgery hemophilia.
ENT * In the late 11th century a school of
medicine was founded in Salerno in italy.
Mental and superstitions diseases
In the 12th century, another was founded|
Infantile diseases and treatment at Montpellier.
*
Toxicology In the 13th
century more were founded at
Bologna, Padua and Paris.
Arresting physical and Mental decay *In the 13th century, a new type of
craftsmen emerged in towns. He (or she||
Rejuvenation or regaining lost veracity
because not all were male) was the|
Potency and procreative ability barber-surgeon. They cut hair, they pulled
teeth and they performed simple
operations such as amputations and
Fig. 1.1 setting of broken bones.
Fortunately leprosy grew less commonin
the 15h century and it died out in Britain
Medicine In the Middle Ages:
in the 16th century.
In the 4th century, the Roman Empire split
Medicine in the 19th Century:
in two. The western half was overrun by
Germanic people and most Greek and
*
In 1816 a man named Rene Laennec
Roman medicine and surgical skill was invented the stethoscope.
lost. The great public health schemes of *
During the 19th century there were
the Romans also feel into disrepair. For several outbreaks of cholera in Britain.

1.4
 VIJAYAM'S
Unit-1: Introduction
During the year 1854 John Snow Medicine In the 201th Century:
(1813-1858) showed that cholera was
Medicine made huge advances in the 20
transmitted as epidemic by water. century. In 1900 different blood types
Louis Pasteur (1822-1895) proved were identified. That made safe blood
Later transfusions possible. The first successful
that microscopic organisms were caused
the discase. blood transfusion was made in 1914.
Insulin was first used to treat a patient in
*In 1880 Pasteur and a team of co-
1922.
workers searched for to cure the chicken
cholera. *The EEG machine was first used in 1929.
Pasteur: nd his team went on to create a
* In 1910 the Salvarsan, a drug used to
vaccine for anthrax by keeping anthrax treat syphilis was discovered.
germs heated to 42-43 degrees centigrade *In 1935 prontosil was used to treat blood
for 8 days. poisoning and later it was discovered that
the active ingredient of the dye was a
Meanwhile in 1875 Robert Koch (1843-
chemical called sulphonamide, which was
1910) isolated the germ that causes
derived from coal tar.
anthrax.
Another antibiotic, streptomycin was
Meanwhile the organism that causes isolated in 1944.
leprosy was discovered in 1879.
Iron lung was invented in 1928 and in
The germ that causes diptheria was 1943 Willem Kolffbuilt the first artificial
discovered in 1882 by Edwin Klebs. kidney machine.
Immunisation against diphtheria was The first pacemaker was made in 1958.
invented in 1890. * Thefirst heart transplant was performed
vaccine for typhoid was invented in in 1967.
*A
1897. * The first artificial heart was installed in
1982
In 1865 Joseph Lister (1828-1912)
discovered antiseptic surgery. *The first heart and lung transplant was
performed in 1987
In 1851 Herman von Helmholtz invented
the ophthalmoscope. The laser was invented in 1960..
*Develoment of endoscopes in the 1960s.
In 1895 X-rays were discovered by
Wilhelm Roentgen. The first test tube baby was born in 1978.

*Florence Nightingale (1820-1910) and *1980 the World Health Organization

Mary Seacole (1805-1881), who both announced that smallpox had been.
nursed soldiers during the Crimean War eradicated.
1854-56.

1.5
VIJAYAM'S MEDICAL SURGICAL NURSING

*In 1981 a terrible new disease called *Many institutions now a day, placin
AIDS was isolated. computers at client bedside to decrease
In 1983 Magnetic Resonance Imaging or the time required for documentation,
MRI was introduced.
5. Expansion of Knowledge:
*Synthetic skin was developed in 1986 and
gene therapy was introduced in 1990. *As medical surgical nurses assume
diverse roles and with them varied
Current Trends: responsibilities.
1. Population Changes:
So, they must have special skills to look
*
Over the last decade, the demographic after the special needs of the client.
profile of requiring nursing care has
changed dramatically Due to their skills, she acquires
understanding of the behavioural pattem
These factors impact greatly on nursing and an ability to promote problem solving
care, which leads to changing role of skills for individual, families and groups.
nurse in different, specially as
cardiovascular or orthopedic nursing 6. Evidence Based Practice: It is a concept
used to improve care to achieve client
2. Advanced Nursing Practice:
outcome and also it uses for research findings
*Advance practice role requires expert that are grounded in science along with client
skills in interviewing, observation, physical characteristics to guide clinical practice,
assessment and examination and latest thereby preventing practice being directed
clinical technique. by tradition.
So, now nurse must be skilled in decision 7. Consumer Orientation: Main goal of
making, evaluating outcome of care, medical surgical nurse is for promotion of
implementing measures to promote cost health, prevention of illness, restoration of
containment and reduction. health when illness will occur. During care
3. Health Care Reform: Over the years, health given to client, she is oriented to clients,
care has become increasingly expensive, physical, emotional, spiritual and
insurance premiums have climbed and psychological nature.
business have been less inclined to offer
8. Ethical Concern: It is an important trend
health benefits to all through government
which is growing among patients and nurses.
programs.
Ethical issues sprout when question arises
4. Computerisation: as to who is right and who is right to prevail.
Institutions using computer in many ways Nurses apply ethics during care for terminaly
such as ordering supplies and services, ill care for dying arises. She should aware of
storing and providing immediate access right of the patients and different ethics.
to diagnostic test results, documenting
nursing access and care and developing
individualised plans of care.

1.6
 VIJAYAM'SJ
Unit-1:: Introduction
specific micro-organims within the body.
ILLNESS AND ITS It remains a guiding theory that underlies
14/THEORIES OF
CAUSATION contemporary biomedicine.
The concept oftheory cause of embodied
in the germ theory ofdiscase is generally
ILLNESS rcferred to as a one-to-one relationship
ness is a highly personal state in which between the causal agent and disease.
the person's physical, emotional intellectual, *As disecasc-spreading conditions-rotting
SOcial, developmentalorspiritualfunctioningis meat, open sewage, and such things was
Rhought to bediminished often highly odorous, the smell and
disease were associated.
It is not synonymous with disease and may
or may not be related to discase. An individual
could have a disease, for example, a growth in Disease
Man Disease
agent
the stomach, and not fell ill. Similarly, a person
can feel ill, that is, feel uncomfortable, yet have
no disceible disease. Fig. 1.2 Causation of Disease.

llness is highly subjective. Only the

individual person can say he or she is ill. 2. Epidemiological Triad: A broader concept
Concept of Disease Causation: The causation of disease causation that synthesized the
ofdisease is called its etiology. Up to the time basic factors of agent, host and environment.
of Louis Pasteur (1895-1922) various concepts
of disease causation were in vogue such as: Environment

The super natural theory of disease.

The theory of humors.
The concept of contagion.
Agent Host
Miasmatic theoryof disease.
The theory of spontaneous generation and Fig. 1.3 Epidemiological Triad.
so on. Discoveries in microbiology
marked a turning point in our aetiological
concepts. *Agent Factors: The first link inthe chain
of disease transmission is a disease agent.
1. Germ Theory of Disease: (19th and early The disease "agent" is defined as a
20hcentury). substance, living or non-living, or a force
In 1873 Louis Pasteur advancedthe germ tangible or non-tangible, the excessive
theory of disease and the emphasis presence or relative lack of which may
causes bad air in the diseases. Germ initiate to perpetuate a disease process.
theory states that many diseases are
caused by the presence and actions of

RREEOMOEE1.7
VIJAYAM'SS MEDICAL SURGICAL NURSING -

*Host Factors: Host factors may include: a. Prepathogenesis phase: This refers to
age, sex, ethnic group, nutritional status, the period of preliminary to the onset
of
socioeconomic status. disease in man. The disease agent has
Personal behaviours: Smoking, diet, not yet entered man, but the factors
drinking, sexual practices, exercise which favour its interaction with the
immunization status: Vaccinated or human host already exist in the
unvaccinated. Physiologic states: environment. This situation is frequently
Pregnancy, puberty, fatigue, immuno- referred to as "man in the midst of
compromised and pre-existing discase. disease" or man exposed to the risk of
disease.
Environment Factors: "All that which
is extemal to the individual human host, b. Pathogenesis Phase: The pathogenesis
iving and non-living and with which he is phase begins with the entry of the disease
constant interaction" this includes-air, agent in the susceptible agent and also in
water, food, housing etc. the susceptible human host.

3. Multifactorial Causation: (Pettenkofer of *The disease agent multiplies and induces

Munich (1819-1901). tissue and physiological changes in the
disease progresses through a period of
It was an early proponent of this concept.
incubation and later through early and late
But, the germ theory of disease or 'single
pathogenesis.
cause idea' in the late 19th century
overshadowed the multiple cause theory. *
The final outcome of the disease may be
recovery, disability and death. The
*The purpose of knowing the multiple
pathogenesis phase may be modified by
factory disease is to quantify and arrange
them in prioritization for modification or
intervention measures such as
immunization and chemotherapy.
amelioration to prevent or control disease.
The multifactorial concept offers multiple
approaches for the prevention or control
of disease.
4. Natural History of Disease:
*
1.3. ILLNESS AS HUMAN
The natural history of a disease is the EXPERIENCE
course of a disease that takes as it
progresses.
Illness behaviour is a coping mechanism,
*Disease results from a complex involves ways individuals
interaction between men, an agent describe, monitor and
the environment.
andinterpret their symptoms, take remedial actions
and use the health care system. How people
The nature of the history of disease is behave when they are ill is highly individualized
consisting of twophases It is affected by many variables such as age,
sex, occupation, socioeconomic status, religion,
personality, education and modes of coping.

2SEENK 1.8 SRta

 Introduction VIJAYAM'S
Unit-1::
llness: Illness is the result of a disease (cither | of illness persist or increase, the person is
physiological or psychological) or injury that motivated to seck proféssional help.
affects functioning, and occurs when there is
inability to meet one's needs. Stage 1ll: Medical Care Contact: Sick people
scek the advice of a health professional by their
Disease: Disease literally means without case. own or by the motivationi of others. When people
Any deviation from normal function or state of scek professional advice, they are really asking
complete physical or mental well being since, for three types of information.
health and disease are mutually exclusive. A Validation of real illness.
disease is any disturbance or anomaly in the
nommal functioning ofthe body that probably has
*Explanation of the symptoms in
a specific cause and identifiable symptoms. understandable terms.

Suchman (1979) describes five stages of *Reassurance that they will be all right or
illness: prediction of what the outcome will be.
Not all clients progress through each stage. *The client may accept or deny the
e.g. The client who experiences a sudden heart diagnosis.
attack, after the emergency care enters the
stages 3 and 4. Stage-IV: Dependent Client Role: After
accepting the illness and seeking treatment, the
Stage-I:Symptom Experiences: At this stage client becomes dependent on the professional
the person believes that something is wrong. It for help. Role obligations such as those of wage
has three aspects. If self-management is earner, father, mother, student, base ball team
ineffective, the individual enters the next stage.
member or chair member complicate the
decision to give up independence. For some
The physical experience of symptoms. clients illness may meet dependence needs that
(eg. Pain, rash, cough, fever or bleeding).
have never been met and thus provide
cognitive aspect. satisfaction.
The
Stage-V; Reeovery or Rehabilitation: During
(eg. Interpretation of the symptoms). this stage, the client is expected to relinquish
the dependent role and resume formal roles and
The emotional response.
responsibilites. People who have long-term
(eg. Fear or anxiety). illnesses and must adjust their lifestyles may find
recovery more difficult. For clients with a
Stage-Il: Assumption of the Sick Role: The Ppermanent disability, this final stage may require
individual now accepts the sick role and seeks therapy to leam howto make major adjustments
confirmation from family and friends. During in functioning.
this stage people may be excused from normal
duties and role expectations. When symptoms

ets1.9
VIJAYAMw'S MEDICAL SURGICAL NURSING

Steps in Nursing Process:

REVIEW OF NURSING
PROCES AND NURSING
CARE PLAN
Evaluation Assessment

Nursing process is a framework Nursing

problem solving continued with
of scientific
critical thinking Process
skills. It is a series of planned Nursing
actions (or) Implementation Diagnosis
operations directed towards a particular
or result
goal.
Planning
Definition: It is a systematic, rational method
ofplanning and providing individualized nursing
care. Its goal is to identify a Fig. 1.4 Steps of Nursing Process.
client's health care
status and actual or potential
health problems,
to establish plans to meet the identified
needs 1. Assessment: Gather information about the
and to deliver specific nursing interventions to
address those needs. patient.
2. Diagnosis: Identify the patient problems.
Purposes:
3. Planning: Set goals of care and desired
To identify a client's health status. outcome and identify appropriate nursing
To identify actual or potential health care action.
problems or needs. 4. Implementation: Perform (or) intervene
the nursing actions identified planning.
To establish plans to meet the identified
problems or needs. 5. Evaluation: Determine, if the goals are met
and outcome is achieved.
*To deliver specific nursing interventionto
meet client needs.
Components of Nursing Process: Nursing 1. ASSESSMENT
process is a scientific, systematic, client-
Nursing assessment focuses on gathering
oriented, goal-oriented, continuous and dynamic,
data about a client's state of wellness,
which consists ofthe following components and functional ability, physical
they are series of planned actions to meet the status. Strengths
and responses to actual and potential health
goal. problems.
-Gorden, 1994.
Purposes:
*Gather data about the client (individual,
family or community).

1.10
Unit-1:: Introduction VIJAYAM's

Use the data for diagnosing, identifying Nurse's Role:

the outcomes, planning and implementing
care. During the assessment, the nurse does the
following
Collection of Data: Data collection is a
process of gathering information about *Identify assessment priorities determined
client's health status. It includes the nursing by the purpose of the assessment and the
health history, physical' assessment, client's condition.
physician's history and results of diagnostic * Prioritize types of data to be collected
tests. Data should include past history as
well systematically.
as present complaints. While collecting
data,
nurse should keep in mind the following *Establish the data base.
points: * Documentation ofhistory findings.

Data collection must be systematic and *Physical examination.

continuous to prevent the omission of Nursing examination.
significant data.
*Review of the client rècord and nursing
Data collected should be relevant to actual literature.
or potential health problems. Consultation with the client's support
persons and helath care professionals.
Data collected should be descriptive,
concise, complete and accurate.. *
Continuously update the data base.

Organizing Data / Formulating Nursing

*
Validate data.
Judgement: In order to obtain data Communicate data.
systematically, a professional nurse uses
organized assessment frame-work or written an2. NURSING DIAGNOSIS
format.
Nursing diagnosis is the second step of
Data Interpretation: In simple words nursing process followed by nursing
validation meanš cross checking the
-
assessment. In this phase analysis of the
collected information to be [Link] the collected data is done to identify the nursing
collected information is factual or true. It is diagnosis and problems that will be the basis
the process of confirming the accuracy of ofnursing care.
assessment data collected, while collecting NANDA diagnosis is a list of Diagnosis made
data, nurse gets many cues and inferences. by North American Nursing Association.
Recording the Data: Recording of the Purposes:
collected data should be done systematically.
It can be done either on the assessment *To analyze collected data.
record or computerized assessment record,
depending upon hospital policies.
*To identify client's normal functional level
statement.

1.11
 MEDICAL SURGICAL NURSING
VIJAYAM'S
* "Risk for impaired skin integrity related
*To identify the client's strengths and
weaknesses. to surgery. Presently client does not
have pressure ulcer, but if remains bed
* To formulate diagnostic weaknesses. ridden for a long time, without
changing position, he is at high risk to
To identify factors that cause health
develop pressure ulcer.
problems.
"High-risk for infection related to
Types of Nursing Diagnosis:
hospitalization immunosuppressed
medication".

Actual diagnosis. ii. Wellness Diagnosis: "It is a clinical

Wellness diagnosis.
judgement about an individual family
Types of Nursing community in transition from specific level
Diagnosis Syndrome diagnosis.
of wellness to a higher level of wellness".
High-risk diagnosis. [Link] of newborn twins.

Fig. 1.5 Types of Nursing Diagnosis. Wellness Nursing Diagnosis: Potential

for growth related to an unexpected birth
of twins.
i. Actual Diagnosis: Represents a
[Link] Diagnosis: Cluster of actual
problem, which has many defining or high-risk nursing diagnosis that are
characteristics. It is a judgement about a
predicted to be present because of certain
client's response to a health problem that
event or situation. (Carpenito 1993).
is present at the time of nursing
[Link] Trauma Syndrome.
assessment.
Nursing Diagnosis Statement: It consists
e.g. 1. Ineffective breathing pattern
of three parts:
related to respiratory disease.

2. Anxiety related to hospitalization.|

3. Pain related to surgery. Problem

ii. High-risk Diagnosis: Describes a

potential problem. It means client is prone
ofdevelopaproblem than other problem,
ifleft in similarcondition. Defining
Etiology
Characteristics
e.g. An obese client is undergone for hip
replacement surgery. As patient is
immobile /bed ridden, nurse may follow
Fig. 1.6 Statement of Nursing Diagnosis.
nursing diagnosis frame.

1.12
Unit-1:: Introduction VIJAYAM'S

Problem: It describes client's response for 3. PLANNING

which nursing care is given. Nurse states the
Planning is the important third step of
area clearly and concisely in which the
nursing process. It is a purposeful activity,
problem occurs, e.g. Knowledge deficit,
which involves critical thinking. It is the
Acute, Chronic, Ineffective, Altered,
determination of what is to be done, when is
Decreased etc. e.g. Knowledge deficit in
to be done, and who will do and also how to
diet.
evaluate the results.
Etiology: Etiology is a component of Definition: "Planning is a deliberative
diagnosis, identifies one or more causes of systematic phase of the nursing process that
health problem. Etiology should give direction
involves decision-making and problem-
in planning of nursing interventions. It helps solving". - Kozier (1975)
the nurse to give individualized patient care,
because two patients may have same Purposes of Planning
problem but, different etiologic factors. *Direct client care activities.
e.g. [Link] related to hospitalization. *Establish continuity of care.
2. Anxiety related to diagnostic test. *Focus on proper documentation.
Defining Characteristics: These are major. *Encourage delegation of care activities.
and minor clinical cues that validate the Planning is the establishment of client
presence of an actual nursing diagnosis. goals by the nurse working with the client
These are the signs and symptoms of that prevent, reduce, or resolve problems
problem, which help in validating the nursing identified in the nursing diagnoses, and the
diagnosis. It includes subjective or objective determination ofrelated nursing interventions
data. most likely to assist the client in achieving
1.
these goals.
eg. Fluid volume deficit related to
decrease oral intake manifested by dry .

Nurse's Role: Planning ofcare involves:

skin and mucus membrane. a. Setting Priorities: Obviously, life-
2. Risk for impaired skin integrity related threatening problems must be dealt
to immobility manifested by redness immediately. The identified and prioritized
on sacral region. nursing care problems are recorded on
the care plan. In general nursing care,
Nurse's Role: problems are to be listed from highest to
During the diagnosis step of the. nursing lowest in priority.
process, the nurse does the following: b. Determining Expected Patient
Interpret and analyze client data. Outcomes: The expected goal or outcome
*
of providing nursing care is manifested
Identify client's strengths and problems. as a change, resolution, improvement or
Formulate and validate nursing diagnosis. deterioration in patient's problem.
e.g. Patient has developed dry, cracked
*Develop a prioritized list of nursing mucous membranes of the mouth and lips.
diagnosis.

1.13
VIJAYAM'S MEDICAL SURGICAL NURSING

e.g. Diagnosis: Altered oral mucous Purposes:

membrane related to NPO states.
*To provide technical nursing care.
Intervention: To promote fluid intake
adequate, To prevent dehydration. To provide therapeutic nursingcare.

c. Identifying Nursing Intervention: * To help the client to achieve optimum

Writing nursing interventions becomes level of health.
casy once the goal is established.
Nurse's Role:
Planned interventions:
During the implementating step of the
Provide 100-200 ml ofliquids H,O. nursing process, the nurse does the following:

*Maintain I/Ochart. *Carries out the plan of nursing care.

d. Writing Nursing Care Plans: In most Continues data collection and modifies the
health care facilities a nursing care plan plan of care as needed.
is written for each patient.
*Documents care.
Purpose: To document patient's needs,
results of nursing interventions and
outcomes of care. It serves as legal proof.5. EVALUATION

Evaluating is the measuring of the extent

to which the client's goals have been met
4. IMPLEMENTATION
The nurse and the client together measure
Implementing simply means, the carrying how well the client has achieved goals
aut the plan of care. The planned activities specified in the plan of care, and nurse and
are that the nurse performs to accomplish client identify factors that either positively
the implementation are called nursing or negatively influenced goal achievement.
interventions. It includes all actions Client response to the plan of care
performed by nurses to promote wellness, determines, whether nursing care should be
prevent disease or illness, restore health, and continued as it is, modified or terminated.
facilitate coping with altered functioning.
Nurse's Role:
Definition: "Anursing intervention is a single
During the evaluation step of nursing process,
nursing action treatment, procedure or
the nurse does the following:
activity-designed to achieve an outcome to
a diagnosis nursing or medical for which
-
*Measure how well the client has achieved
the nurse is accountable." desired goals/outcomes.
Campbell (1990). *Identify the factors contributing to the
client's success or failure.
Modify the plan of care, if indicated.

1.14
 VIJAYAM'S
Unit-1 Introduction
Table: Example for Writing Nursing Care Plan.

ititi

RSEERERE1.15
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