Advance concept of nursing I

Unit 1
Nursing process
The nursing process is an organized sequence of problem solving steps used to identify and to manage the health problems of clients .The nursing process is the framework for nursing care in all health care settings.When nursing practice follows the nursing process, clients receive quality care in minimal time with maximal efficiency.
The steps of nursing process
1)Assesment
2)Diagnosis
3)Planning
4)Implementation
5)Evaluation
Assessment
An RN uses a systematic, dynamic way to collect and analyze data about a client, the first step in delivering nursing care. Assessment includes not only physiological data, but also psychological, sociocultural, spiritual, economic, and life-style factors as well. For example, a nurse’s assessment of a hospitalized patient in pain includes not only the physical causes and manifestations of pain, but the patient’s response—an inability to get out of bed, refusal to eat, withdrawal from family members, anger directed at hospital staff, fear, or request for more pain mediation.
Diagnosis
The nursing diagnosis is the nurse’s clinical judgment about the client’s response to actual or potential health conditions or needs. The diagnosis reflects not only that the patient is in pain, but that the pain has caused other problems such as anxiety, poor nutrition, and conflict within the family, or has the potential to cause complications—for example, respiratory infection is a potential hazard to an immobilized patient. The diagnosis is the basis for the nurse’s care plan.
Outcomes / Planning
Based on the assessment and diagnosis, the nurse sets measurable and achievable short- and long-range goals for this patient that might include moving from bed to chair at least three times per day; maintaining adequate nutrition by eating smaller, more frequent meals; resolving conflict through counseling, or managing pain through adequate medication. Assessment data, diagnosis, and goals are written in the patient’s care plan so that nurses as well as other health professionals caring for the patient have access to it.
Implementation
Nursing care is implemented according to the care plan, so continuity of care for the patient during hospitalization and in preparation for discharge needs to be assured. Care is documented in the patient’s record.
Evaluation
Both the patient’s status and the effectiveness of the nursing care must be continuously evaluated, and the care plan modified as needed.

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Nursing care plan

A nursing care plan outlines the nursing care to be provided to an individual/family/community. It is a set of actions the nurse will implement to resolve/support nursing diagnoses identified bynursing assessment. The creation of the plan is an intermediate stage of the nursing process. It guides in the ongoing provision of nursing care and assists in the evaluation of that care.
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[edit]Characteristics 1. Its focus is holistic, and is based on the clinical judgment of the nurse, using assessment data collected from a nursing framework. 2. It is based upon identifiable nursing diagnoses (actual, risk or health promotion) - clinical judgments about individual, family, or community experiences/responses to actual or potential health problems/life processes. 3. It focuses on client-specific nursing outcomes that are realistic for the care recipient 4. It includes nursing interventions which are focused on the etiologic or risk factors of the identified nursing diagnoses. 5. It is a product of a deliberate systematic process. 6. It relates to the future.

Nursing care plan format
Nursing Care Plan Form
Student Name: Date:
Patient Identifier: Patient Medical Diagnosis: Nursing Diagnosis (use PES/PE format):ssessment Data(Include at least three-five subjective and/or objective pieces of data that lead to the nursing diagnosis) | Goals & Outcome(Two statements are required for each nursing diagnosis. Must be Patient and/or family focused; measurable; time-specific; and reasonable.) | Nursing Interventions(List at least three nursing or collaborative interventions with rationale for each goal & outcome.) | Rationale(Provide reason why intervention is indicated/therapeutic; provide references.) | Outcome Evaluation &Replanning(Was goal met? How would you revise the plan of care according the patient’s response to current plan ?) | 1.2.3. | Statement #1Statement #2 | 1.2.3.1.2.3. | 1.2.3.1.2.3. | Outcome #1Outcome #2 |

UNIT ii
Theory
A scientific theory is "a well-substantiated explanation of some aspect of the natural world, based on a body of facts that have been repeatedly confirmed through observation and experiment."[1][2] Scientists create scientific theories from hypothesesthat have been corroborated through the scientific method, then gather evidence to test their accuracy. As with all forms of scientific knowledge, scientific theories are inductive in nature and do not make apodictic propositions; instead, they aim for predictive and explanatory force.[3][4]
CONCEPT
* A general idea derived or inferred from specific instances or occurrences. an idea of something formed by mentally combining all its characteristics or particulars; a construct.a directly conceived or intuited object of thought *
Nursing Theories: An Overview

INTRODUCTION

* A theory is a group of related concepts that propose action that guide practice. * Theory refers to “a coherent group of general propositions used as principles of explanation” * A nursing theory is a set of concepts, definitions, relationships, and assumptions or propositions derived from nursing models or from other disciplines and project a purposive, systematic view of phenomena by designing specific inter-relationships among concepts for the purposes of describing, explaining, predicting, and /or prescribing. * Kerlinger - theories as a set of interrelated concepts that give a systematic view of a phenomenon (an observable fact or event) that is explanatory and predictive in nature. * Theories are composed of concepts, definitions, models , propositions and are based on assumptions. * They are derived through two principal methods: * Deductive reasoning * Inductive reasoning. * Nursing theorists use both of these methods. * Nursing theories are "attempts to describe or explain the phenomenon (process, occurrence and event) called nursing" - Barnum(1998) * Theories are for professional nursing. * Theory is "a creative and rigorous structuring of ideas that projects a tentative, purposeful, and systematic view of phenomena" * A theory makes it possible to "organize the relationship among the concepts to describe, explain, predict, and control practice"

DEFINITIONS

Concepts * Concepts are basically vehicles of thought that involve images. * Concepts are words that describe objects , properties, or events and are basic components of theory. * Types of Concepts: * Empirical concepts * Inferential concepts * Abstract concepts.

Models * Models are representations of the interaction among and between the concepts showing patterns. * Models allow the concepts in nursing theory to be successfully applied to nursing practice. * They provide an overview of the thinking behind the theory and may demonstrate how theory can be introduced into practice, for example, through specific methods of assessment. * Propositions * Prepositions are statements that explain the relationship between the concepts. * Process * Processes are series of actions, changes or functions intended to bring about a desired result . * During a process one takes systemic and continuous steps to meet a goal and uses both assessments and feedback to direct actions to the goal. * A particular theory or conceptual frame work directs how these actions are carried out . * The delivery of nursing care within the nursing process is directed by the way specific conceptual frameworks and theories define the person (patient), the environment, health and nursing.
IMPORTANCE OF NURSING THEORIES

* Nursing theory aims to describe, predict and explain the phenomenon of nursing (Chinn and Jacobs1978). * It should provide the foundations of nursing practice, help to generate further knowledge and indicate in which direction nursing should develop in the future (Brown 1964). * Theory is important because it helps us to decide what we know and what we need to know (Parsons1949). * It helps to distinguish what should form the basis of practice by explicitly describing nursing. * This can be seen as an attempt by the nursing profession to maintain its professional boundaries.
CHARACTERISTICS OF THEORIES

Theories:

* interrelate concepts in such a way as to create a different way of looking at a particular phenomenon. * are logical in nature. * are generalizable. * are the bases for hypotheses that can be tested. * increase the general body of knowledge within the discipline through the research implemented to validate them. * are used by the practitioners to guide and improve their practice. * are consistent with other validated theories, laws, and principles but will leave open unanswered questions that need to be investigated
BASIC PROCESSES IN THE DEVELOPMENT OF NURSING THEORIES * Nursing theories are often based on and influenced by broadly applicable processes and theories. Following theories are basic to many nursing concepts.
A. General System Theory: * It describes how to break whole things into parts and then to learn how the parts work together in " systems". * These concepts may be applied to different kinds of systems, e.g.. Molecules in chemistry , cultures in sociology, organs in Anatomy and health in Nursing.

B. Adaptation Theory

* It defines adaptation as the adjustment of living matter to other living things and to environmental conditions. * Adaptation is a continuously occurring process that effects change and involves interaction and response. * Human adaptation occurs on three levels: * --- the internal ( self ) * --- the social (others) * --- and the physical ( biochemical reactions ) * C. Developmental Theory * * It outlines the process of growth and development of humans as orderly and predictable, beginning with conception and ending with death. * The progress and behaviors of an individual within each stage are unique. * The growth and development of an individual are influenced by heredity , temperament, emotional, and physical environment, life experiences and health status.
COMMON CONCEPTS IN NURSING THEORIES

* Four concepts common in nursing theory that influence and determine nursing practice are * The person( patient) * The environment * Health * Nursing (goals, roles, functions) * Each of these concepts is usually defined and described by a nursing theorist. Of the four concepts, the most important is that of the person. The focus of nursing is the person.

HISTORY

* Nightingale (1860): To facilitate "the body’s reparative processes" by manipulating client’s environment * Paplau 1952: Nursing is; therapeutic interpersonal process. * Henderson 1955: The needs often called Henderson’s 14 basic needs * Abdellah 1960: This theory focus on delivering nursing care for the whole person to meet the physical, emotional, intellectual, social, and spiritual needs of the client and family. * Orlando 1962: To Ida Orlando (1960), the client is an individual; with a need; that, when met, diminishes distress, increases adequacy, or enhances well-being. * Johnson’s Theory 1968: Dorothy Johnson’s theory of nursing 1968 focuses on how the client adapts to illness and how actual or potential stress can affect the ability to adapt. The goal of nursing to reduce stress so that; the client can move more easily through recovery. * Rogers 1970: to maintain and promote health, prevent illness, and care for and rehabilitate ill and disabled client through "humanistic science of nursing" * Orem1971: This is self-care deficit theory. Nursing care becomes necessary when client is unable to fulfill biological, psychological, developmental, or social needs. * King 1971: To use communication to help client reestablish positive adaptation to environment. * Neuman 1972: Stress reduction is goal of system model of nursing practice. * Roy 1979: This adaptation model is based on the physiological, psychological, sociological and dependence-independence adaptive modes. * Watson’s Theory 1979: Watson’s philosophy of caring 1979 attempts to define the outcome of nursing activity in regard to the; humanistic aspects of life.

CLASSIFICATION OF NURSING THEORIES

* Depending on the generalisability of their principles * Metatheory: the theory of theory. Identifies specific phenomena through abstract concepts. * Grand theory: provides a conceptual framework under which the key concepts and principles of the discipline can be identified. * Middle range theory: is more precise and only analyses a particular situation with a limited number of variables. * Practice theory: explores one particular situation found in nursing. It identifies explicit goals and details how these goals will be achieved. * School of thoughts in Nursing Theories-1950-1970

Theories can also be categorised as:

* "Needs "theories. * "Interaction" theories. * "Outcome "theories. * "Humanistic theories" * "Needs" theories

* These theories are based around helping individuals to fulfill their physical and mental needs. * Needs theories have been criticized for relying too much on the medical model of health and placing the patient in an overtly dependent position.

"Interaction" theories

* These theories revolve around the relationships nurses form with patients. * Such theories have been criticized for largely ignoring the medical model of health and not attending to basic physical needs.

"Outcome" theories * These portray the nurse as the changing force, who enables individuals to adapt to or cope with ill health (Roy 1980). * Outcome theories have been criticized as too abstract and difficult to implement in practice (Aggleton and Chalmers 1988).

"Humanistic" Theories:

* Humanistic theories developed in response to the psychoanalytic thought that a person’s destiny was determined early in life. * Humanistic theories emphasize a person’s capacity for self actualization . * Humanists believes that the person contains within himself the potential for healthy and creative growth. * Carl Rogers developed a person –centered model of psychotherapy that emphasizes the uniqueness of the individual. * The major contribution that Rogers added to nursing practice is the understanding that each client is a unique individual, so person-centered approach now practice in Nursing.

MODELS OF NURSING * A model, as an abstraction of reality, provides a way to visualize reality to simplify thinking. * A conceptual model shows how various concepts are interrelated and applies theories to predict or evaluate consequences of alternative actions. * A conceptual model "gives direction to the search for relevant questions about the phenomena of central interest to a discipline and suggests solutions to practical problems" * Four concepts are generally considered central to the discipline of nursing: the person who receives nursing care (the patient or client); the environment (society); nursing (goals, roles, functions); and health.

Criticisms of nursing theories

* To understand why nursing theory is generally neglected on the wards. * Anrsing theory should have the characteristics of accessibility and clarity. * It is important that the language used in the development of nursing theory be used consistently. * Many nurses have not had the training or experience to deal with the abstract concepts presented by nursing theory. * Majority of nurses fail to understand and apply theory to practice (Miller 1985).

CONCLUSION

* Theory and practice are related * To develop nursing as a profession the concept of theory must be addressed. * If nursing theory does not drive the development of nursing, it will continue to develop in the footsteps of other disciplines such as medicine.

Unit III
Gordon's Functional Health Patterns

Marjorie Gordon (1987) proposed functional health patterns as a guide for establishing a comprehensive nursing data base. These 11 categories make possible a systematic and standardized approach to data collection, and enable the nurse to determine the following aspects of health and human function:

Health Perception and Health Management. Data collection is focused on the person's perceived level of health and well-being, and on practices for maintaining health. Habits that may be detrimental to health are also evaluated, including smoking and alcohol or drug use. Actual or potential problems related to safety and health management may be identified as well as needs for modifications in the home or needs for continued care in the home.

Nutrition and Metabolism
Assessment is focused on the pattern of food and fluid consumption relative to metabolic need. The adequacy of local nutrient supplies is evaluated. Actual or potential problems related to fluid balance, tissue integrity, and host defenses may be identified as well as problems with the gastrointestinal system.

Elimination.
Data collection is focused on excretory patterns (bowel, bladder, skin). Excretory problems such as incontinence, constipation, diarrhea, and urinary retention may be identified.
Activity and Exercise
Assessment is focused on the activities of daily living requiring energy expenditure, including self-care activities, exercise, and leisure activities. The status of major body systems involved with activity and exercise is evaluated, including the respiratory, cardiovascular, and musculoskeletal systems.
Cognition and Perception.
Assessment is focused on the ability to comprehend and use information and on the sensory functions. Data pertaining to neurologic functions are collected to aid this process. Sensory experiences such as pain and altered sensory input may be identified and further evaluated.

Sleep and Rest.
Assessment is focused on the person's sleep, rest, and relaxation practices. Dysfunctional sleep patterns, fatigue, and responses to sleep deprivation may be identified.

Self-Perception and Self-Concept
. Assessment isfocused on the person's attitudes toward self, including identity, body image, and sense of self-worth. The person's level of self-esteem and response to threats to his or her self-concept may be identified.

Roles and Relationships. Assessment is focused on the person's roles in the world and relationships with others. Satisfaction with roles, role strain, or dysfunctional relationships may be further evaluated.

Sexuality and Reproduction. Assessment is focused on the person's satisfaction or dissatisfaction with sexuality patterns and reproductive functions. Concerns with sexuality may he identified.

Coping and Stress Tolerance. Assessment is focused on the person's perception of stress and on his or her coping strategies Support systems are evaluated, and symptoms of stress are noted. The effectiveness of a person's coping strategies in terms of stress tolerance may be further evaluated.

Values and Belief. Assessment is focused on the person's values and beliefs (including spiritual beliefs), or on the goals that guide his or her choices or decisions.

Unit iv

Objectives
At the end of this session learners will be able to: * Define Health, wellness & Illness * Identify key determinants of health. * Describe perception of health. * Discuss the need of perception of health. * Know about wellness continuum.

Objectives * Explain Health Belief Model. * Enumerate components of Health Belief Model. Explore the implication of Health Belief Model. * Determine the health promoting behavior. * Enlist barriers to behavior change. * Discuss nursing measures for promoting healthy lifestyles. * Develop some nursing diagnosis associated with health pattern. * Conclude health perception pattern
Health perception and health management pattern
It focused on the person’s perceived level of health and well-being and on practices for maintaining health. Also evaluated habits including smoking and alcohol or drug use. The nurses perception of the clients health status and the clients perception of their own health are not identical. For example, the client may have been born with a major disability but regard this as normal for them. Consequently some clients seek nursing attention far more or less readily than health professionals might expect.
Health management refers to the clients behavior in relation to their own health. Some clients will seek nursing attention at the slightest excuse because they view health issues with great concern. Other clients at the other end of the extreme will avoid nursing attention at all cost (e.g. clients with paranoid tendencies will regard health assessment as invasive). The bulk of nursing contacts will be in between these extremes, but clients health-seeking behavior needs to be respected throughout the nursing relationship.
The first contact between nurse and client is often during the initial interview when the nurse will obtain a history from the client and collateral data from other sources such as relatives, existing records and allied agencies. The following questions could be asked by the nurse to provide an overview of the individuals subjective health history and health practices that are used to reach the current level of health or wellness. Generally well? Regular exercise?Any absences from work/school?Important things to keep healthy? Use drugs (eg Caffeine, nicotine) Perform self exams at intervals i.e. Breast/testicular self-examination? Accidents? What do you think caused current illness? Why have you asked for an assessment? What actions have you taken since symptoms started? Does anything alleviate the symptom or make it worse?
A client with optimal health seeking behavior will take steps to maintain their own health status, such as safe sex practices, personal protective equipment, retire early to bed and so on. A more specific health assessment is used to pinpoint the nature and extent of the clients complaint once an initial impression has been formed. Then the nurse can ask more probing questions and collect objective data relevant to the disturbed functional health pattern.

Health it is the general condition of a person's mind and body, usually meaning to be free from illness, injury or pain (as in "good health" or "healthy")
"a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.
Determinants of health
Generally, the context in which an individual lives is of great importance for his health status and quality of life. It is increasingly recognized that health is maintained and improved not only through the advancement and application of health science, but also through the efforts and intelligent lifestyle choices of the individual and society. According to the World Health Organization, the main determinants of health include the social and economic environment, the physical environment, and the person's individual characteristics and behaviors.[6]
More specifically, key factors that have been found to influence whether people are healthy or unhealthy include:[ * Income and social status * Social support networks * Education and literacy * Employment working conditions * Social environments * Physical environments * Personal health practices and coping skills
The determinants of health
Introduction
Many factors combine together to affect the health of individuals and communities. Whether people are healthy or not, is determined by their circumstances and environment. To a large extent, factors such as where we live, the state of our environment, genetics, our income and education level, and our relationships with friends and family all have considerable impacts on health, whereas the more commonly considered factors such as access and use of health care services often have less of an impact.
The determinants of health include: * the social and economic environment, * the physical environment, and * the person’s individual characteristics and behaviours.
The context of people’s lives determine their health, and so blaming individuals for having poor health or crediting them for good health is inappropriate. Individuals are unlikely to be able to directly control many of the determinants of health. These determinants—or things that make people healthy or not—include the above factors, and many others: * Income and social status - higher income and social status are linked to better health. The greater the gap between the richest and poorest people, the greater the differences in health. * Education – low education levels are linked with poor health, more stress and lower self-confidence. * Physical environment – safe water and clean air, healthy workplaces, safe houses, communities and roads all contribute to good health. Employment and working conditions – people in employment are healthier, particularly those who have more control over their working conditions * Social support networks – greater support from families, friends and communities is linked to better health. Culture - customs and traditions, and the beliefs of the family and community all affect health. * Genetics - inheritance plays a part in determining lifespan, healthiness and the likelihood of developing certain illnesses. Personal behaviour and coping skills – balanced eating, keeping active, smoking, drinking, and how we deal with life’s stresses and challenges all affect health. * Health services - access and use of services that prevent and treat disease influences health * Gender - Men and women suffer from different types of diseases at different ages.

Wellness
Wellness is generally used to mean a healthy balance of mind ,body and spirit that results in an overall feeling of wellbeing.
The condition of good physical,mental and emotional health,especially when maintained by an appropriate diet ,exercise and other lifestyle modification.

DISEASE
A disease is an abnormal condition that affects the body of an organism. It is often construed as a medical condition associated with specific symptoms and signs.[1] It may be caused by factors originally from an external source, such as infectious disease, or it may be caused by internal dysfunctions, such as autoimmune diseases. In humans, "disease" is often used more broadly to refer to any condition that causes pain, dysfunction, distress, social problems, or death to the person afflicted, or similar problems for those in contact with the person. In this broader sense, it sometimes includes injuries, disabilities, disorders, syndromes, infections, isolated symptoms, deviant behaviors, and atypical variations of structure and function, while in other contexts and for other purposes these may be considered distinguishable categories. Diseases usually affect people not only physically, but also emotionally, as contracting and living with many diseases can alter one's perspective on life, and their personality.

HEALTH BELIEF MODEL
The health belief model describes the health behavior of people in relation to what they believe about themselves,health and decision making process is seeking healthcare services.

History and Orientation
The Health Belief Model (HBM) is a psychological model that attempts to explain and predict health behaviors. This is done by focusing on the attitudes and beliefs of individuals. The HBM was first developed in the 1950s by social psychologists Hochbaum, Rosenstock and Kegels working in the U.S. Public Health Services. The model was developed in response to the failure of a free tuberculosis (TB) health screening program. Since then, the HBM has been adapted to explore a variety of long- and short-term health behaviors, including sexual risk behaviors and the transmission of HIV/AIDS.

The Health Belief Model helps explain why individual patients may accept or reject preventative health services or adopt healthy behaviors. Social psychologists originally developed the Health Belief Model to predict the likelihood of a person taking recommended preventative health action and to understand a person’s motivation and decision-making about seeking health services. The Health Belief Model proposes that people will respond best to messages about health promotion or disease prevention when the following four conditions for change exist:
The person believes that he or she is at risk of developing a specific condition.The person believes that the risk is serious and the consequences of developing the condition are undesirable.The person believes that the risk will be reduced by a specific behavior change.The person believes that barriers to the behavior change can be overcome and managed.The first condition in the Health Belief Model is perceived threat. If the person does not see a health care behavior as risky or threatening, there is no stimulus to act. For example, a 59 year old woman who sunbathes every day who doesn’t believe that she is at risk of skin cancer will continue to sun bathe. There are two types of perceived threats: perceived susceptibility and perceived severity. Susceptibility refers to how much risk a person perceives he or she has; severity refers to how serious the consequences might be. To effectively change health behaviors, the individual must usually believe in both susceptibility and severity. This is one reason that many people “get religion” after they have been diagnosed with cancer, heart disease, or diabetes. Because both susceptibly and severity are a clear and present danger, people who have previously resisted or put off behavior change finally give up smoking, stop drinking, lose weight, or start an exercise program. Individuals must also have the expectation that the new behavior will be beneficial; they must feel that barriers to change do not outweigh the benefits and that they can realistically accomplish the needed changes in behavior. Unfortunately, for many desirable health behaviors, the barriers are immediate and the benefits are long-range. For example, it’s difficult to pass up eating a piece of chocolate cake with the hope that you will not have heart disease or cancer in the future. From this perspective, it is not hard to see why it is so difficult to get patients to change behaviors.Knowing what aspect of the Health Belief Model patients accept or reject can help you design appropriate interventions. For example, if a patient is unaware of his or her risk factors for one or more diseases, you can direct teaching toward informing the patient about personal risk factors. If the patient is aware of the risk, but feels that the behavior change is overwhelming or unachievable, you can focus your teaching efforts on helping the patient overcome the perceived barriers.

COMPONENTS OF HEALTH BELIEF MODEL
Perceived Susceptibility
People will not change their health behaviors unless they believe that they are at risk.Those who does not think that they are at risk of acquiring HIV from unprotected intercourse are unlikely to use a condom.
Perceived Severity
The probability that a person will change his/her health behaviors to avoid a consequence depends on how serious he or she considers the consequence to be.
If you are young and in love, you are unlikely to avoid kissing your sweetheart on the mouth just because he has the sniffles, and you might get his cold. On the other hand, you probably would stop kissing if it might give you Ebola.
Perceived Benefits
It's difficult to convince people to change a behavior if there isn't something in it for them.
Your father probably won't stop smoking if he doesn't think that doing so will improve his life in some way.
Perceived Barriers
One of the major reasons people don't change their health behaviors is that they think that doing so is going to be hard. Sometimes it's not just a matter of physical difficulty, but social difficulty as well. Changing your health behaviors can cost effort, money, and time.
If everyone from your office goes out drinking on Fridays, it may be very difficult to cut down on your alcohol intake.
The Health Belief Model, however, is realistic. It recognizes the fact that sometimes wanting to change a health behavior isn't enough to actually make someone do it, and incorporates two more elements into its estimations about what it actually takes to get an individual to make the leap. These two elements are cues to action and self efficacy. Agent, Host and Environmental model of causation
Agent host environment model was originally developed by leavell and clark (1965) to describe health in a community, but it is also usefull in when examining the cause of the disease in an individual.Accordingly the level of health and illness of an individual or group depends on the dynamic relationship of the agent,host and the environment .
The agent is an internal
This triangular model was developed for infectious disease. Disease spread requires a susceptible host, an infective agent and a supportive environment

Unit v
Nutrition metabolic pattern
It’s focused on the pattern of food and fluid consumption relative to metabolic need. Is evaluated the adequacy of local nutrient supplies. Actual or potential problems related to fluid balance, tissue integrity, and host defenses may be identified as well as problems with the gastrointestinal system.

Nutrients
Nutrient are biochemical substance derived from food and fluids that are used in biosynthesisenergy production and require for growth.A nutrient is a chemical that an organism needs to live and grow or a substance used in an organism's metabolism which must be taken in from its environment.[1] They are used to build and repair tissues, regulate body processes and are converted to and used as energy. Methods for nutrient intake vary, with animals and protists consuming foods that are digested by an internal digestive system, but most plants ingest nutrients directly from the soil through their roots or from the atmosphere.
Nutrition Nutrition (also called nourishment or aliment) is the provision, to cells and organisms, of the materials necessary (in the form of food) to support life. Many common health problems can be prevented or alleviated with a healthy diet.
Nutrition, nourishment, or aliment, is the supply of materials - food - required by organisms and cells to stay alive. In science and human medicine, nutrition is the science or practice of consuming and utilizing foods.
In hospitals, nutrition may refer to the food requirements of patients, including nutritional solutions delivered via an IV (intravenous) or IG (intragastric) tube.
Nutritional science studies how the body breaks food down (catabolism) and repairs and creates cells and tissue (anabolism) - catabolism and anabolism = metabolism. Nutritional science also examines how the body responds to food. In other words, "nutritional science investigates the metabolic and physiological responses of the body to diet".
As molecular biology, biochemistry and genetics advance, nutrition has become more focused on the steps of biochemical sequences through which substances inside us and other living organisms are transformed from one form to another - metabolism and metabolic pathways.

Macronutrients is defined in several different ways.The chemical elements humans consume in the largest quantities are carbon, hydrogen, nitrogen, oxygen, phosphorus, and sulfur.
The classes of chemical compounds humans consume in the largest quantities and which provide bulk energy are carbohydrates, proteins, and fats. Water and atmospheric oxygen also must be consumed in large quantities, but are not always considered "food" or "nutrients".
Calcium, salt (sodium and chloride), magnesium, and potassium (along with phosphorus and sulfur) are sometimes added to the list of macronutrients because they are required in large quantities compared to other vitamins and minerals. They are sometimes referred to as the macrominerals.
Micronutrient
Micronutrients are nutrients required by humans and other organisms throughout life in small quantities to orchestrate a range of physiological functions. [1] For people, they include dietary trace minerals in amounts generally less than 100 milligrams/day[citation needed] - as opposed to macrominerals which are required in larger quantities. The microminerals or trace elements include at least iron, cobalt, chromium, copper,[2] iodine, manganese, selenium, zinc and molybdenum. Micronutrients also include vitamins, which are organic compounds required as nutrients in tiny amounts by an organism.

Carbohydrates carbohydrates are one of the main types of nutrients .They are the most important source of energy for your body .Your digestive system changes carbohydrates in glucose (blood sugar).Your body uses this sugar for energy for your cells, tissues and organs.It stores any extra sugar in your liver and muscles for when it is needed.
Carbohydrates are called simple or complex, depending on their chemical structure. Simple carbohydrates include sugars found naturally in foods such as fruits, vegetables, milk, and milk products. They also include sugars added during food processing and refining. Complex carbohydrates include whole grain breads and cereals, starchy vegetables and legumes. Many of the complex carbohydrates are good sources of fiber.
Functions of Carbohydrates
Carbohydrates have six major functions within the body: * Providing energy and regulation of blood glucose * Sparing the use of proteins for energy * Breakdown of fatty acids and preventing ketosis * Biological recognition processes * Flavor and Sweeteners * Dietary fiber
Providing energy and regulating blood glucose
Glucose is the only sugar used by the body to provide energy for its tissues. Therefore, all digestible polysaccharides, disaccharides, and monosaccharides must eventually be converted into glucose or a metabolite of glucose by various liver enzymes. Because of its significant importance to proper cellular function, blood glucose levels must be kept relatively constant.

Among the enormous metabolic activities the liver performs, it also includes regulating the level of blood glucose. During periods of food consumption, pancreatic beta cells sense the rise in blood glucose and begin to secrete the hormone insulin. Insulin binds to many cells in the body having appropriate receptors for the peptide hormone and causes a general uptake in cellular glucose. In the liver, insulin causes the uptake of glucose as well as the synthesis of glycogen, a glucose storage polymer. In this way, the liveris able to remove excessive levels of blood glucose through the action of insulin.
Sparing Protein and Preventing Ketosis
So why are carbohydrates important if the body can use other carbon compounds such as fatty acids and ketones as energy? First of all, maintaining a regular intake of carbohydrates will prevent protein from being used as an energy source. Gluconeogenesis will slow down and amino acids will be freed for the biosyntheses of enzymes, antibodies, receptors and other important proteins. Furthermore, an adequate amount of carbohydrates will prevent the degradation of skeletal muscle and other tissues such as the heart, liver, and kidneys. Most importantly, ketosis will be prevented. Although the brain will adapt to using ketones as a fuel, it preferentially uses carbohydrates andand requires a minimum level of glucose circulating in the blood in order to function properly. Before the adaptation process occurs, lower blood glucose levels may cause headaches in some individuals. To prevent these ketotic symptoms, it is recommended that the average person consume at least 50 to 100g of carbohydrates per day.
Although the processes of protein degradation and ketosis can create problems of their own during prolonged fasting, they are adaptive mechanisms during glucose shortages. In summary, the first priority of metabolism during a prolonged fast is to provide enough glucose for the brain and other organs that dependent upon it for energy in order to spare proteins for other cellular functions. The next priority of the body is to shift the use of fuel from glucose to fatty acids and ketone bodies. From then on, ketones become more and more important as a source of fuel while fatty acids and glucose become less important.

Flavor and Sweeteners
A less important function of carbohydrates is to provide sweetness to foods. Receptors located at the tip of the tongue bind to tiny bits of carbohydrates and send what humans perceive as a "sweet" signal to the brain. However, different sugars vary in sweetness. For example, fructose is almost twice as sweet as sucrose and sucrose is approximately 30% sweeter than glucose.
Sweeteners can be classified as either nutritive or alternative. Nutritive sweeteners have all been mentioned before and include sucrose, glucose, fructose, high fructose corn syrup, and lactose. These types of sweeteners not only impart flavor to the food, but can also be metabolized for energy. In contrast, alternative sweeteners provide no food energy and include saccharin, cyclamate, aspartame, and acesulfame. Controversy over saccharin and cyclamate as artificial sweeteners still exists but aspartame and acesulfame are used extensively in many foods in the United States. Aspartame and acesulfame are both hundreds of times sweeter than sucrose but only acesulfameis able to be used in baked goods since it is much more stable than aspartame when heated.

Dietary Fiber
Dietary fibers such as cellulose, hemicellulose, pectin, gum and mucilage are important carbohydrates for several reasons. Soluble dietary fibers like pectin, gum and mucilage pass undigested through the small intestine and are degraded into fatty acids and gases by the large intestine. The fatty acids produced in this way can either be used as a fuel for the large intestine or be absorbed into the bloodstream. Therefore, dietary fiber is essential for proper intestinal health.
In general, the consumption of soluble and insoluble fiber makes the elimination of waste much easier. Since dietary fiber is both indigestible and an attractant of water, stools become large and soft. As a result, feces can be expelled with less pressure. However, not enough fiber consumption will change the constitution of the stool and increase the amount of force required during defecation. Excessive pressure during the elimination of waste can force places in the large intestine wall out from between bands of smooth muscle to produce small pouches called diverticula. Hemorrhoids may also result from unnecessary strain during defecation.
The disease of having many diverticula in the large intestine is known as diverticulosis. Although diverticula is often asymptomatic, food particles become trapped in their folds and bacteria begin to metabolize the particles into acids and gases. Eventually, the diverticula may become inflamed, a condition known as diverticulitis. To combat the disease, antibiotics are administered to the patient to destroy the bacteria while the intake of fiber in the diet is decreased until the inflammation has subsided. Once the inflammation has been reduced, a high fiber diet is begun to prevent a relapse.

Besides the prevention of intestinal disease, diets high in fiber have other health benefits. High fiber intake reduces the risk of developing obesity by increasing the bulk of a meal without yielding much energy. An expanded stomach leads to satisfaction despite the fact that the caloric intake has decreased.
Beyond dieters, diabetics can also benefit from consuming a regular amount of dietary fiber. Once in the intestine, it slows the absorption of glucose to prevent a sudden increase in blood glucose levels. A relatively high intake of fiber will also decrease the absorption of cholesterol, a compound that is thought to contribute to atherosclerosis or scarring of the arteries. Serum cholesterol may be further reduced by a reduction in the release of insulin after meals. Since insulin is known to promote cholesterol synthesis in the liver, a reduction in the absorption of glucose after meals through the consumption of fiber can help to control serum cholesterol levels. Furthermore, dietary fiber intake may help prevent colon cancer by diluting potential carcinogens through increased water retention, binding carcinogens to the fiber itself and speeding the passage of food through the intestinal tract so that cancer-causing agents have less time to act.

Biological Recognition Processes
Carbohydrates not only serve nutritional functions, but are also thought to play important roles in cellular recognition processes. For example, many immunoglobulins (antibodies) and peptide hormones contain glycoprotein sequences. These sequences are composed of amino acids linked to carbohydrates. During the course of many hours or days, the carbohydrate polymer linked to the rest of the protein may be cleaved by circulating enzymes or be degraded spontaneously. The liver can recognize differences in length and may internalize the protein in order to begin its own degradation. In this way, carbohydrates may mark the passage of time for proteins.

FIBER
Dietary fiber, dietary fibre, or sometimes roughage and ruffageis the indigestible portion of plant foods having two main components:
Soluble fiber dissolves in water. It is readily fermented in the colon into gases and physiologically active byproducts, and can be prebiotic and/or viscous. Soluble fibers tend to slow the movement of food through the system.
Insoluble fiber does not dissolve in water. It can be metabolically inert and provide bulking or prebiotic, metabolically fermenting in the large intestine. Bulking fibers absorb water as they move through the digestive system, easing defecation.[1] Fermentable insoluble fibers mildly promote stool regularity, although not to the extent that bulking fibers do, but they can be readily fermented in the colon into gases and physiologically active byproducts. Insoluble fibers tend to accelerate the movement of food through the system.
Dietary fibers can act by changing the nature of the contents of the gastrointestinal tract and by changing how other nutrients and chemicals are absorbed.[2] Some types of soluble fiber absorb water to become a gelatinous, viscous substance and is fermented by bacteria in the digestive tract. Some types of insoluble fiber have bulking action and are not fermented.[3] Lignin, a major dietary insoluble fiber source, may alter the rate and metabolism of soluble fibers.[1] Other types of insoluble fiber, notably resistant starch, are fully fermented.[4]
Chemically, dietary fiber consists of non-starch polysaccharides such as arabinoxylans, cellulose, and many other plant components such as resistant starch, resistant dextrins, inulin, lignin, waxes, chitins, pectins, beta-glucans, and oligosaccharides.Food sources of dietary fiber are often divided according to whether they provide (predominantly) soluble or insoluble fiber. Plant foods contain both types of fiber in varying degrees, according to the plant's characteristics.
Advantages of consuming fiber are the production of healthful compounds during the fermentation of soluble fiber, and insoluble fiber's ability (via its passive hygroscopic properties) to increase bulk, soften stool, and shorten transit time through the intestinal tract.
Disadvantages of a diet high in fiber is the potential for significant intestinal gas production and bloating. Constipation can occur if insufficient fluid is consumed with a high-fiber diet.
Functions of Fiber
Prevents Hunger
When hunger strikes, your natural response is to provide your body with food. Unfortunately, eating the wrong types of foods can leave you hungry again within a few hours.

Fiber doesn't digest completely within your stomach, and your body processes fiber-rich foods more slowly than many other types of food, such as simple carbohydrates. Fiber keeps you satisfied--preventing hunger between meals. This, in turn, prevents you from overeating. Thus, fiber-rich foods help ward off obesity and the health problems that accompany it.

Prevents Constipation
According to the Harvard School of Public Health, constipation is the most common gastrointestinal ailment in the United States. Consuming adequate amounts of fiber, however, can alleviate this condition and prevent it from recurring.

Soluble fiber maintains a gel-like consistency. After passing out of the stomach, it adheres to the lining of the intestines--making it easier and more comfortable for the body to eliminate waste material. Insoluble fiber, by contrast, simultaneously softens and adds weight to stool. The added weight and softer consistency of the stool help it pass through the intestines quicker and more comfortably.
Regulates Blood Sugar
Fiber causes the body to absorb sugar from the foods that you eat more slowly. Because sugar enters the bloodstream at a controlled pace, your blood sugar levels don't increase to the level that they would had your meal not contained fiber.

Stable blood sugar levels don't only benefit diabetics--they benefit everyone. The Ohio State University Extension notes that, over time, high blood sugar can cause red blood cells to move more slowly. This reduces your circulation and can result in nerve damage.
Regulates LDL Cholesterol
Soluble fibers regulate the level of LDL or "bad" cholesterol in your bloodstream that could otherwise lead to heart disease. Fiber directly interferes with the speed at which your body absorbs bile acid--a component of digestion. In response to this interference, the liver extracts LDL cholesterol from the bloodstream and converts that cholesterol into bile acid--replacing that impaired by the fiber in your meal. In addition, the ADA claims that fiber may have a negative impact on the body's ability to synthesize cholesterol from food--further reducing your LDL cholesterol level.

LIPIDS
Lipids are another type of organic molecule. Remember that organic means they contain carbon (C) atoms. It's not like organic farming at all. When you think of fats, you should know that they are lipids. Lipids are also used to make steroids and waxes. So, if you pick out some earwax and smell it, that's a lipid, too!
Functions
Energy storage, mobilization, and utilization protection of organs insulation Storage of vitamins-ADEK
Hormone production

Many different types of molecules in the body, such as fats, waxes, and fat-soluble vitamins, fall into the category of "lipids." Energy storage is the most common of the many functions of lipids, though they can also provide cellular structure or act as signaling molecules. Other important but less common functions of lipids in the body include enzyme activation, molecular transportation, and metabolism. Humans must consume lipids as a part of their diets because of the nutrients they contain and because some fats are required in order to store fat-soluble vitamins. They are also important because lipid bilayers are used to moderate what is able to enter a cell and what is not.

One of the major functions of lipids in the body is energy storage because triglycerides and other similar molecules, which contain substantial lipid components, have a very high energy content. When the body is in need of stored energy, hormone signals initiate a biochemical process that breaks down the molecules into a usable form. Lipids are also valuable for energy storage because they can be stored with very little water. Carbohydrates, on the other hand, bind to water, which would result in a significantly higher mass-to-energy ratio if carbohydrates were used as the primary means of energy storage.

1) Fat/lipids are needed to absorb and utalise fat souluble vitamins, specifically vitamins A, S, E, K.
2) Fat/lipids provides a protective cushoning layer around important internal organs. Obviously too much is not a good thing but without the cushioning affect that fat provides your internal organs are very suseptible to impact damage
3) Fat/lipids are used as the body's back up energy store. When carbohydrates (in all forms) are exhausted your body will use the energy it has previously stored as fat. Without this back up energy store, if carbohydrate energy sources were depleted, you would immediately start to burn stored protein e.g muscle
4) Fat/lipids are needed for normal hormonal functions throughout the body

Protiens
Proteins are very important molecules in cells. By weight, proteins are collectively the major component of the dry weight of cells. They can be used for a variety of functions from cellular support to cellular locomotion. While proteins have many diverse functions, all are typically constructed from one set of 20 amino acids.
Proteins are made of amino acids. Even though a protein can be very complex, it is basically a long chain of amino acid subunits all twisted around like a knot.
Proteins are the building blocks of life. The body needs protein to repair and maintain itself. The basic structure of protein is a chain of amino acids.
Function
Every cell in the human body contains protein. It is a major part of the skin, muscles, organs, and glands. Protein is also found in all body fluids, except bile and urine.
You need protein in your diet to help your body repair cells and make new ones. Protein is also important for growth and development during childhood, adolescence, and pregnancy. * Body building blocks * Repair and maintenance of body tissues. * Maintainence of osmotic pressure * Synthensis of bioactive substance and other vital molecules

Food Sources
When proteins are digested, amino acids are left. The human body needs a number of amino acids to break down food. Amino acids need to be eaten in large enough amounts for optimal health.

Amino acids are found in animal sources such as meats, milk, fish, and eggs, as well as in plant sources such as soy, beans, legumes, nut butters, and some grains (such as wheat germ). You do not need to eat animal products to get all the protein you need in your diet.

Amino acids are classified into three groups:

Essential
Nonessential
Conditional
Essential amino acids cannot be made by the body, and must be supplied by food. They do not need to be eaten at one meal. The balance over the whole day is more important. The nine essential amino acids are:

Histidine
Isoleucine
Leucine
Lycine
Methionine
Phenylalanine
Threonine
Tryptophan
Valine
Nonessential amino acids are made by the body from essential amino acids or in the normal breakdown of proteins. They include:

Alanine
Asparagine
Aspartic acid
Glutamic acid
Conditional amino acids are usually not essential, except in times of illness and stress. They include:

Arginine
Cysteine
Glutamine
Glycine
Ornithine
Proline
Serine
Tyrosine
Protein foods are no longer described as being "complete proteins" or "incomplete proteins."
Side Effects
A diet high in meat can contribute to high cholesterol levels or other diseases such as gout. A high-protein diet may also put a strain on the kidneys.

Recommendations
A nutritionally balanced diet provides enough protein. Healthy people rarely need protein supplements.Vegetarians are able to get enough essential amino by eating a variety of plant proteins.
The amount of recommended daily protein depends upon your age and health. Two to three servings of protein-rich food will meet the daily needs of most adults.
The following are the recommended serving sizes for protein:
2 to 3 ounces of cooked lean meat, poultry, or fish (a portion about the size of a deck of playing cards)
1/2 cup of cooked dried beans
1 egg, 2 tablespoons of peanut butter, or 1 ounce of cheese
For recommended serving sizes of protein for children and adolescents, see age-appropriate diet for children.

Non energy nutrients
Vitamins
Minerals
Water

Vitamins
Vitamins are organic compounds that are needed in small quantities . They are used to regulate growth ,maintain tissues ,help carbohydrates,proteins and fat release energy.
Vitamins are organic compounds which are needed in small quantities to sustain life. We get vitamins from food, because the human body either does not produce enough of them, or none at all. An organic compound contains carbon. When an organism (living thing) cannot produce enough of an organic chemical compound that it needs in tiny amounts, and has to get it from food, it is called a vitamin.
Sometimes the compound is a vitamin for a human but not for some other animals. For example, vitamin C (ascorbic acid) is a vitamin for humans but not for dogs, because dogs can produce (synthesize) enough for their own needs, while humans cannot.
Put simply, a vitamin is both:
An organic compound (contains carbon).
An essential nutrient the body cannot produce enough of on its own, so it has to get it (tiny amounts) from food.
There are currently 13 recognized vitamins.

According to Medilexicon's medical dictionary:
A vitamin is One of a group of organic substances, present in minute amounts in natural foodstuffs, that are essential to normal metabolism; insufficient amounts in the diet may cause deficiency diseases.
Fat soluble and water soluble vitamins

There are fat-soluble and water-soluble vitamins. Fat-soluble vitamins are stored in the fat tissues of our bodies, as well as the liver. Fat-soluble vitamins are easier to store than water-soluble ones, and can stay in the body as reserves for days, some of them for months.
Water-soluble vitamins do not get stored in the body for long - they soon get expelled through urine.
Water-soluble vitamins need to be replaced more often than fat-soluble ones.

Vitamins A, D, E and K are fat-soluble.
Vitamins C and all the B vitamins are water-soluble.
Fat-soluble vitamins are absorbed through the intestinal tract with the help of fats (lipids).
List of vitamins

Vitamin A.
Chemical names (vitaminer) - retinol, retinal, and four carotenoids (including beta carotene).
Fat soluble.
Deficiency may cause night-blindness and keratomalacia (eye disorder that results in a dry cornea)
Good sources - liver, cod liver oil, carrot, broccoli, sweet potato, butter, kale, spinach, pumpkin, collard greens, some cheeses, egg, apricot, cantaloupe melon, milk.
Vitamin B1.
Chemical name (vitaminer) - thiamine
Water soluble.
Deficiency may cause beriberi, Wernicke-Korsakoffsyndrome
Good sources - yeast, pork, cereal grains, sunflower seeds, brown rice, whole grain rye, asparagus, kale, cauliflower, potatoes, oranges, liver, and eggs.
Vitamin B2.
Chemical name (vitaminer) - riboflavin
Water soluble.
Deficiency may cause ariboflavinosis
Good sources - asparagus, bananas, persimmons, okra, chard, cottage cheese, milk, yogurt, meat, eggs, fish, and green beans.
Vitamin B3.
Chemical names (vitaminer) - niacin, niacinamide Water soluble. Deficiency may cause pellagra
Good sources - liver, heart, kidney, chicken, beef, fish (tuna, salmon), milk, eggs, avocados, dates, tomatoes, leafy vegetables, broccoli, carrots, sweet potatoes, asparagus, nuts, whole grains, legumes, mushrooms, and brewer's yeast.
Vitamin B5.
Chemical name (vitaminer) - pantothenic acid
Water soluble.
Deficiency may cause paresthesia
Good sources - meats, whole grains (milling may remove it), broccoli, avocados, royal jelly, fish ovaries.
Vitamin B6.
Chemical names (vitaminer) - pyridoxine, pyridoxamine, pyridoxal
Water soluble.
Deficiency may cause anemia, peripheral neuropathy
Good sources - meats, bananas, whole grains, vegetables, and nuts. When milk is dried it loses about half of its B6. Freezing and canning can also reduce content.
Vitamin B7.
Chemical name (vitaminer) - biotin
Water soluble.
Deficiency may cause dermatitis, enteritis
Good sources - egg yolk, liver, some vegetables.
Vitamin B9.
Chemical names (vitaminer) - folic acid, folinic acid
Water soluble.
Deficiency may cause pregnancy deficiency linked to birth defects
Good sources - leafy vegetables, legumes, liver, baker's yeast, some fortified grain products, sunflower seeds. Several fruits have moderate amounts, as does beer.
Vitamin B12.
Chemical names (vitaminer) - cyanocobalamin, hydroxycobalamin, methylcobalamin
Water soluble.
Deficiency may cause megaloblastic anemia
Good sources - fish, shellfish, meat, poultry, eggs, milk, and dairy products. Some fortified cereals and soy products, as well as fortified nutritional yeast.
Vitamin C.
Chemical names (vitaminer) - ascorbic acid
Water soluble.
Deficiency may cause megaloblastic anemia
Good sources - fruit and vegetables. The Kakadu plum and the camucamu fruit have the highest vitamin C contents of all foods. Liver also has vitamin C.
Vitamin D.
Chemical names (vitaminer) - ergocalciferol, cholecalciferol
Fat soluble.
Deficiency may cause rickets, osteomalacia
Good sources - produced in the skin after exposure to ultraviolet B light from the sun or artificial sources. Found in fatty fish, eggs, beef liver, and mushrooms.
Vitamin E.
Chemical names (vitaminer) - tocopherols, tocotrienols
Fat soluble.
Deficiency is uncommon. May cause mild hemolytic anemia in newborns
Good sources - kiwi fruit, almonds, avocado, eggs, milk, nuts, leafy green vegetables, unheated vegetable oils, wheat germ, and wholegrains.
Vitamin K.
Chemical names (vitaminer) - phylloquinone, menaquinones
Fat soluble.
Deficiency may cause bleeding diathesis
Good sources - leafy green vegetables, avocado, kiwi fruit. Parsley contain a lot of vitamin K.

MINERALS
Dietary minerals (also known as mineral nutrients) are the chemical elements required by living organisms, other than the four elements carbon, hydrogen, nitrogen, and oxygen present in common organic molecules.
Minerals in order of abundance in the human body include the seven major minerals calcium, phosphorus, potassium, sulfur, sodium, chlorine, and magnesium. Important "trace" or minor minerals, necessary for mammalian life, include iron, cobalt, copper, zinc, molybdenum, iodine, and selenium (see below for detailed discussion). small amounts of some minerals are also in foods — for instance, red meat, such as beef, is a good source of iron.
Just like vitamins, minerals help your body grow, develop, and stay healthy. The body uses minerals to perform many different functions — from building strong bones to transmitting nerve impulses. Some minerals are even used to make hormones or maintain a normal heartbeat.
Macro and Trace
The two kinds of minerals are: macrominerals and trace minerals. Macro means "large" in Greek (and your body needs larger amounts of macrominerals than trace minerals). The macromineral group is made up of calcium, phosphorus, magnesium, sodium, potassium, chloride, and sulfur.
A trace of something means that there is only a little of it. So even though your body needs trace minerals, it needs just a tiny bit of each one. Scientists aren't even sure how much of these minerals you need each day. Trace minerals includes iron, manganese, copper, iodine, zinc, cobalt, fluoride, and selenium.
Let's take a closer look at some of the minerals you get from food.

Calcium
Calcium is the top macromineral when it comes to your bones. This mineral helps build strong bones, so you can do everything from standing up straight to scoring that winning goal. It also helps build strong, healthy teeth, for chomping on tasty food.
Which foods are rich in calcium? dairy products, such as milk, cheese, and yogurt canned salmon and sardines with bones leafy green vegetables, such as broccoli calcium-fortified foods — from orange juice to cereals and crackers
Iron
The body needs iron to transport oxygen from your lungs to the rest of your body. Your entire body needs oxygen to stay healthy and alive. Iron helps because it's important in the formation of hemoglobin (say: HEE-muh-glo-bun), which is the part of your red blood cells that carries oxygen throughout the body.

Which foods are rich in iron? meat, especially red meat, such as beef tuna and salmon eggs beans baked potato with skins dried fruits, like raisins leafy green vegetables, such as broccoli whole and enriched grains, like wheat or oats
Potassium
Potassium (say: puh-TAH-see-um) keeps your muscles and nervous system working properly. Did you know your blood and body tissues, such as muscles, contain water? They do, and potassium helps make sure the amount of water is just right between cells and body fluids.

Which foods are rich in potassium?

bananas tomatoes potatoes and sweet potatoes, with skins green vegetables, such as spinach and broccoli citrus fruits, like oranges low-fat milk and yogurt legumes, such as beans, split peas, and lentils
Zinc
Zinc helps your immune system, which is your body's system for fighting off illnesses and infections. It also helps with cell growth and helps heal wounds, such as cuts.
Which foods are rich in zinc? beef, pork, and dark meat chicken nuts, such as cashews, almonds, and peanuts legumes, such as beans, split peas, and lentils
When people don't get enough of these important minerals, they can have health problems. For instance, too little calcium — especially when you're a kid — can lead to weaker bones. Some kids may take mineral supplements, but most kids don't need them if they eat a nutritious diet. So eat those minerals and stay healthy! Major minerals | Mineral | Function | Sources | Sodium | Needed for proper fluid balance, nerve transmission, and muscle contraction | Table salt, soy sauce; large amounts in processed foods; small amounts in milk, breads, vegetables, and unprocessed meats | Chloride | Needed for proper fluid balance, stomach acid | Table salt, soy sauce; large amounts in processed foods; small amounts in milk, meats, breads, and vegetables | Potassium | Needed for proper fluid balance, nerve transmission, and muscle contraction | Meats, milk, fresh fruits and vegetables, whole grains, legumes | Calcium | Important for healthy bones and teeth; helps muscles relax and contract; important in nerve functioning, blood clotting, blood pressure regulation, immune system health | Milk and milk products; canned fish with bones (salmon, sardines); fortified tofu and fortified soy milk; greens (broccoli, mustard greens); legumes | Phosphorus | Important for healthy bones and teeth; found in every cell; part of the system that maintains acid-base balance | Meat, fish, poultry, eggs, milk, processed foods (including soda pop) | Magnesium | Found in bones; needed for making protein, muscle contraction, nerve transmission, immune system health | Nuts and seeds; legumes; leafy, green vegetables; seafood; chocolate; artichokes; "hard" drinking water | Sulfur | Found in protein molecules | Occurs in foods as part of protein: meats, poultry, fish, eggs, milk, legumes, nuts |
Trace minerals (microminerals)
The body needs trace minerals in very small amounts. Note that iron is considered to be a trace mineral, although the amount needed is somewhat more than for other microminerals. Trace minerals | Mineral | Function | Sources | Iron | Part of a molecule (hemoglobin) found in red blood cells that carries oxygen in the body; needed for energy metabolism | Organ meats; red meats; fish; poultry; shellfish (especially clams); egg yolks; legumes; dried fruits; dark, leafy greens; iron-enriched breads and cereals; and fortified cereals | Zinc | Part of many enzymes; needed for making protein and genetic material; has a function in taste perception, wound healing, normal fetal development, production of sperm, normal growth and sexual maturation, immune system health | Meats, fish, poultry, leavened whole grains, vegetables | Iodine | Found in thyroid hormone, which helps regulate growth, development, and metabolism | Seafood, foods grown in iodine-rich soil, iodized salt, bread, dairy products | Selenium | Antioxidant | Meats, seafood, grains | Copper | Part of many enzymes; needed for iron metabolism | Legumes, nuts and seeds, whole grains, organ meats, drinking water | Manganese | Part of many enzymes | Widespread in foods, especially plant foods | Fluoride | Involved in formation of bones and teeth; helps prevent tooth decay | Drinking water (either fluoridated or naturally containing fluoride), fish, and most teas | Chromium | Works closely with insulin to regulate blood sugar (glucose) levels | Unrefined foods, especially liver, brewer's yeast, whole grains, nuts, cheeses | Molybdenum | Part of some enzymes | Legumes; breads and grains; leafy greens; leafy, green vegetables; milk; liver |
Other trace nutrients known to be essential in tiny amounts include nickel, sil

Food group pyramids
The Food Guide Pyramid was the model for healthy eating
Eat a variety of foods.
Eat less of some foods and more of others.
Food pyramid
1)Maintain a healthy weight
Studies shows that the healthiest range for body weight is when the body mass index is about 17 to 22
2)Eat good fats and avoid bad fats
Good fats are the oils found in nuts ,seeds,grain and fish. They are high in unsaturated fats necessary for good health. Avoid saturated fats to minimize the risk of heart disease.
3)Eat whole grain carbohydrates
Whole grains are more nutritious than refined carbohydrates. Being more slowly digested. Place less stress on pancreatic insulin production. Source of whole grain carbohydrates include whole meal bread,whole wheat ,brown rice.
4)Avoid red meat as a protein source and emphasize plant proteins
Red meat consumption is linked to a variety of chronic disease. Animal protiens usually have saturated fat.
5)Eat plenty of vegetables and fruits.
Dark green leafy vegetables and fruit are beneficial . A deit high in fruits and vegetables lowers blood pressure and cholesterol and reduces the risk of cancer.
6)Take multivitamin daily
This recommendation assures

The pyramid had six vertical stripes to represent the five food groups plus oils. The plate features four sections (vegetables, fruits, grains, and protein) plus a side order of dairy in blue.
The big message is that fruits and vegetables take up half the plate, with the vegetable portion being a little bigger than the fruit section.
And just like the pyramid where stripes were different widths, the plate has been divided so that the grain section is bigger than the protein section. Why? Because nutrition experts recommend you eat more vegetables than fruit and more grains than protein foods.
The divided plate also aims to discourage super-big portions, which can cause weight gain.

Unit ix
Sleep Rest pattern
Physiology of sleep
Rest is a state of feeling mentally and physically relaxed ,feeling calm and free from worry ,and sleep is a basic physiological need that is naturally occurring and is necessary for survival .It can be defined as a period of reduced consciousness,diminished muscular activity and depressed metabolism. Sleep provides the greatest degree of rest,with all body systems functioning at a reduced level.Although sleep is a state of reduced consciousness ,certain stimuli ,for example a sudden loud noise ,will usually rouse the person ,although not necessary to fulfill alertness.

Factors affecting Sleep
The factors which favour the onset of natural sleep are * Darkened room * Comfortable surrounding temperature * Silence * Physical and mental relaxation * Consumption of a basic urge such as hunger or sex, and * Low frequency stimulation ,such as by patting or rocking in a cradle or sitting in a vehicle.
There are two main types of sleep: * Non-REM (NREM) sleep consists of four stages of sleep, each deeper than the last. * REM (Rapid Eye Movement) sleep is when you do most active dreaming. Your eyes actually move back and forth during this stage, which is why it is called Rapid Eye Movement sleep. The Stages of Sleep | Non-REM sleep | Stage N1 (Transition to sleep) – This stage lasts about five minutes. Your eyes move slowly under the eyelids, muscle activity slows down, and you are easily awakened. | Stage N2 (Light sleep) – This is the first stage of true sleep, lasting from 10 to 25 minutes. Your eye movement stops, heart rate slows, and body temperature decreases. | Stage N3 (Deep sleep) – You’re difficult to awaken, and if you are awakened, you do not adjust immediately and often feel groggy and disoriented for several minutes. In this deepest stage of sleep, your brain waves are extremely slow. Blood flow is directed away from your brain and towards your muscles, restoring physical energy. | REM sleep | REM sleep (Dream sleep) – About 70 to 90 minutes after falling asleep, you enter REM sleep, where dreaming occurs. Your eyes move rapidly, your breathing shallows, and your heart rate and blood pressure increase. Also during this stage, your arm and leg muscles are paralyzed. | *
Types and stages of sleep.
Sleep is of two types non REM sleep and REM sleep,which alternate is a sleep cycle
NON REM SLEEP
Non REM Sleep i.e non rapid eye movement sleep is also known as slow wave sleep,because in this type of sleep brain waves are very slow.
In normal adults,sleep mostly begins with non REM sleep .It is rest type of sleep which a person experience during first hour of sleep after having been kept awake from many hours.
PHYSIOLOGICAL CHANGES DURING NON REM SLEEP * Muscle tone decreases progressively * Heart rate and blood pressure are decreased * Respiration rate is also decreased * Eyes begin slow,rolling movement until they finally stop in stage 4 with eyes turned upwards * Body metabolism is lowered * Pituitary shows pulsatile release of growth harmone and gonatropine.
REM SLEEP
Rem sleep i.e Rapid eye movement sleep is also called fast wave (Desynchonized ) sleep or paradoxical sleep or dream sleep or deepest sleep
Physiological changes during REM sleep * Rapid eye movements are the hallmark of this state of sleep and that is why the REM sleep.Rapid eye movement are burst of small jerky movements that brings the eye from fixation point to another to allow a sweaping of visual images of dreams. * Heart rate and respiration rate become irregular * Muscle tone is reduced * Penile erection in erection in males and engorgement of clitoris in female may occur during REM sleep. * Teeth grinding may be seen in children
Nursing intervention to promote sleep
Establish a bedtime ritual that is effective for you and
Sleep Disorders
1)Insomania
Insomania refers to an inability to have sufficient or restful sleep despite an adequate opportunity for sleep.
2)Narcolepsy
Narcolepsy refers to an irresistible urge to sleep .In narcolepsy ,REM sleep is entered directly from the walking states..Narcolepsy may manifest as episodes of sudden sleep.The individuals go to sleep while performing day time tasks.
3)Sleep walking
Episodes of sleep walking are more common in children than in adults and occur predominantly in males.such individuals walk with their eyes open and avoid obstacles, but awakened they recall the episodes.
4)BED WETTING
Involuntary voiding urine ,occurs in some children during slow wave sleep.

Why do we need sleep?
The importance of sleep is clear from the strong evolutionary conservation of sleep. Most animals have evolved in such a way that they spend considerable periods of time sleeping, despite sleep making us vulnerable (e.g. to attack from predators). The functions of sleep, that is, how sleep functions to support other bodily processes, are still uncertain. However, it is known that REM and non-REM sleep perform different functions, and biochemical, physiological, neurological and psychological process occur differently when an individual sleeps compared to when they are awake.

Biochemical
Different hormones are secreted depending upon whether an individual is asleep or awake. For example growth hormone is secreted during sleep while cortisol is secreted during wakefulness.
Metabolic rate falls during non-REM sleep, energy is conserved and body temperature drops. During this period protein synthesis and the production of complex molecules within the body is increased.
When we are awake our brain cells use a considerable amount of glucose to function and the intracellular glycogen stores become depleted. During sleep this process is reversed so that glucose is available during the next bout of wakefulness.

Physiological
Sleep has been considered a restorative or a recovery phase that prepares the body for the next episode of wakefulness. Cell division is more rapid during non-REM sleep and sleep has an important function on the immune system.

Neurological
Sleep may have some role in development of brain cells and connections between brain cells during development. The ability to form new neurons (neurogenesis) slows early in life and it is the development of new neuronal networks that is responsible for new behaviours.
Synchronisation of cortical activity during non-REM sleep may in some way coordinate cortical connections. The prefrontal cortex is inactive during all phases of sleep (this may also confer some benefit). During REM sleep thecerebral cortex is open to sensory inputs and forms loose associations that cannot be formed during wakefulness.

Psychological
Both phases of sleep are involved in memory consolidation. Very little new information is gained during sleep, but consolidation and maintenance of memory from experiences of the previous day is considerable. It is known that learning of visual information is improved during the first night of sleep and that sleep deprivation impairs recall of the information. Different types of sleep have a different effect on memory consolidation and retention of information. Retention is best if stage 3 and 4 non-REM sleep occurs in the first 2 hours of sleep and if the last 25% of sleep is REM sleep.
The type of sleep also affects the type of information which is consolidated by the brain. Learning of movement sequences is best if stage 2 non-REM sleep occurs late in the night, while learning of cognitive sequences occurs best if there is a cycle of REM and non-REM sleep.
Dreams are a manifestation of underlying brain activity and reflect the loose associative connections made during REM sleep. These loose associations are likely to result in increased creative mental activity and problem-solving abilities.

UNIT VI
ELIMINATION PATTERN

1)define elimination pattern
Elimination patterns describe the regulation,control and removal of by products and wastes in the body .The term usually refers to the movement of feces,urine and sweat from the body

ORGANS OF URINARY SYSTEM
Urinary system consist of six organs
Two kidneys
Two ureters
One urinary bladder
One urethra
Functions of kidney
The main functions of the kidney in order of importance are: * blood pressure control * salt and water balance * erythropoietin (a hormone) production * vitamin D metabolism
The kidneys secrete hormones: * renin (instrumental in controlling blood pressure) * erythropoeitin (which helps control the production of red blood cells)
They filter the blood to get rid of excess fluid, waste products, many drugs and regulate the composition of body fluids and salts.
They are essential for Vitamin D metabolism (with the result of stimulating the absorption of calcium and phosphorus from the small intestine, and keeping it in balance).
The kidneys are two organs which lie in the back of the abdominal cavity. They are around four to five inches long, and they have several functions.
The blood supply to the kidneys comes from the renal arteries, which branch off the aorta. The kidneys have a very considerable blood supply, (25% of the total cardiac output, or 1300 millilitres of blood pass through the kidneys per minute).
Each kidney has around one million nephrons, which are microscopic units which filter the blood (removing wastes and extra water) and which produce urine. A person, who normally has two kidneys will have two million nephrons.
A person can live a healthy life with one healthy kidney as it can cope with all the necessary functions.
The filtration of blood produces urine. The urine is then collected in the ureters, which are long muscular tubes which act as conduits, taking the urine produced by the kidneys to the bladder. Urine is stored in the bladder, an expandable muscular organ, until it is full, until the need to urinate is signalled to the brain through the nervous system, and the bladder sphincter opens (as a voluntary action) to allow the urine to flow out through another tube called the urethra. The kidneys perform the essential function of removing waste products from the blood and regulating the water fluid levels. The diagram below shows the basic structure of the kidney.

[8]
The kidneys receive blood through the renal artery. The blood is passed through the structure of the kidneys called nephrons, where waste products and excess water pass out of the blood stream, as shown in the diagram below.
[9]
When the venom induces clotting, the fibrin is deposited in the tubules. As the tubules are blocked, the kidneys are not able to remove the same amount of waste products from the blood, and urea and cretinine begin to accumulate in the blood. If these chemicals are not removed, the concentrations become lethal.
When the kidneys are not functional, dialysis becomes necessary to save the victim. In dialysis, the blood passes through an external membrane which allows waste products from the blood to pass out of the blood and into the dialysis fluid. Because of the rate of buildup of the waste products, it may be necessary to perform dialysis as many as 3 times per week.

Elimination Pattern
It’s focused on excretory patterns (bowel, bladder, skin). * Bowel incontinence * Constipation * Diarrhea * Functional urinary incontinence * Impaired urinary elimination * Overflow urinary incontinence * Perceived constipation * Readiness for enhanced urinary elimination, * Reflex urinary incontinence * Risk for constipation * Risk for urge urinary incontinence * Stress urinary incontinence * Total urinary incontinence * Urge urinary incontinence * [acute/chronic] Urinary retention

Diuretics
A Diuretic is any drug that elevates the rate of urination and thus provides a means of forced diuresis. There are several categories of diuretics. All diuretics increase the excretion of water from bodies, although each class does so in a distinct way.
High ceiling loop diuretic
High ceiling diuretics may cause a substantial diuresis – up to 20%[1] of the filtered load of NaCl (salt) and water. This is huge when compared to normal renal sodium reabsorption which leaves only about 0.4% of filtered sodium in the urine.
Loop diuretics have this ability, and are therefore often synonymous with high ceiling diuretics. Loop diuretics, such as furosemide, inhibit the body's ability to reabsorb sodium at the ascending loop in the nephron, which leads to an excretion of water in the urine, whereas water normally follows sodium back into the extracellular fluid. Other examples of high ceiling loop diuretics include ethacrynic acid, torsemide and bumetanide. Thiazides
Thiazide-type diuretics such as hydrochlorothiazide act on the distal convoluted tubule and inhibit the sodium-chloride symporter leading to a retention of water in the urine, as water normally follows penetrating solutes. Frequent urination is due to the increased loss of water that has not been retained from the body as a result of a concomitant relationship with sodium loss from the convoluted tubule. The short-term anti-hypertensive action is based on the fact that thiazides decrease preload, decreasing blood pressure. On the other hand the long-term effect is due to an unknown vasodilator effect that decreases blood pressure by decreasing resistance.
[edit] Carbonic anhydrase inhibitors
Carbonic anhydrase inhibitors inhibit the enzyme carbonic anhydrase which is found in the proximal convoluted tubule. This results in several effects including bicarbonate retention in the urine, potassium retention in urine and decreased sodium absorption. Drugs in this class include acetazolamide and methazolamide.
[edit] Potassium-sparing diuretics
These are diuretics which do not promote the secretion of potassium into the urine; thus, potassium is spared and not lost as much as in other diuretics. The term "potassium-sparing" refers to an effect rather than a mechanism or location; nonetheless, the term almost always refers to two specific classes that have their effect at similar locations: * Aldosterone antagonists: spironolactone, which is a competitive antagonist of aldosterone. Aldosterone normally adds sodium channels in the principal cells of the collecting duct and late distal tubule of the nephron. Spironolactone prevents aldosterone from entering the principal cells, preventing sodium reabsorption. A similar agent is potassium canreonate. * Epithelial sodium channel blockers: amiloride and triamterene.

Calcium-sparing diuretics
The term "calcium-sparing diuretic" is sometimes used to identify agents that result in a relatively low rate of excretion of calcium.[2]
The reduced concentration of calcium in the urine can lead to an increased rate of calcium in serum. The sparing effect on calcium can be beneficial in hypocalcemia, or unwanted in hypercalcemia.
The thiazides and potassium-sparing diuretics are considered to be calcium-sparing diuretics.[3] * The thiazides cause a net decrease in calcium lost in urine.[4] * The potassium-sparing diuretics cause a net increase in calcium lost in urine, but the increase is much smaller than the increase associated with other diuretic classes.[4]
By contrast, loop diuretics promote a significant increase calcium excretion.[5] This can increase risk of reduced bone density.[6]
Osmotic diuretics
Compounds such as mannitol are filtered in the glomerulus, but cannot be reabsorbed. Their presence leads to an increase in the osmolarity of the filtrate. To maintain osmotic balance, water is retained in the urine.
Glucose, like mannitol, is a sugar that can behave as an osmotic diuretic. Unlike mannitol, glucose is commonly found in the blood. However, in certain conditions, such as diabetes mellitus, the concentration of glucose in the blood (hyperglycemia) exceeds the maximum reabsorption capacity of the kidney. When this happens, glucose remains in the filtrate, leading to the osmotic retention of water in the urine. Glucosuria causes a loss of hypotonic water and Na+, leading to a hypertonic state with signs of volume depletion, such as dry mucosa, hypotension, tachycardia, and decreased turgor of the skin. Use of some drugs, especially stimulants, may also increase blood glucose and thus increase urination.
Low ceiling diuretics
The term "low ceiling diuretic" is used to indicate a diuretic has a rapidly flattening dose effect curve (in contrast to "high ceiling", where the relationship is close to linear). It refers to a pharmacological profile, not a chemical structure. However, certain classes of diuretic usually fall into this category, such as the thiazides.[7]

Action of Diuretics
MECHANISM OF ACTION
The diuretics are generally divided into three major classes, which are distinguished by the site at which they impair sodium reabsorption.
• Loop diuretics (like lasix) act in the thick ascending limb of the loop of Henle.
• Thiazide diuretics in the distal tubule and connecting segment (and perhaps the early cortical collecting tubule).
• Potassium-sparing diuretics in the aldosteronesensitive principal cells in the cortical collecting tubule. Bowel Elimination The Large Intestine * Primary organ of bowel elimination * Extends from the ileocecal valve to the anus Functions * Completion of absorption of H2O, Nutrients (chyme from sm. intest. - 1-1.5 L) * Manufacture of some vitamins * Formation of feces * Expulsion of feces from the body
The Small and Large Intestines

Process of Peristalsis * Peristalsis is under control of nervous system * Contractions occur every 3 to 12 minutes * Mass peristalsis sweeps occur 1 to 4 times each 24-hour period * One-third to one-half of food waste is excreted in stool within 24 hours Peristalic Movements in the Intestine – Colonic peristalsis is slow. Mass peristalsis is strong, few waves per day, stimulated by food in small intestine.

Factors that influence Bowel Elimination 1. Age 2. Diet 3. Position 4. Pregnancy 5. Fluid Intake 6. Activity 7. Psychological 8. Personal Habits 9. Pain 10. Medications 11. Surgery/Anesthesia
Developmental Considerations * Infants—characteristics of stool and frequency depend on formula or breast feedings * Toddler physiologic maturity is first priority for bowel training (1 ½ – 2 yrs) * Child, adolescent, adult—defecation patterns vary in quantity, frequency, and rhythmicity * Older adult—constipation is often a chronic problem
Foods Affecting Bowel Elimination * Constipating foods cheese, lean meat, eggs, & pasta * Foods with laxative effect—fruits and vegetables, bran, chocolate, alcohol, coffee * Gas-producing foods—onions, cabbage, beans, cauliflower
Effect of Medications on Stool * Aspirin, anticoagulants pink, red, or black stool * Iron salts—black stool * Antacids white discoloration or speckling in stool * Antibiotics—green-gray color
Physical Assessment of the Abdomen * Inspection—observe contour, any masses, scars, or distension * Auscultation—listen for bowel sounds in all quadrants * Note frequency and character, audible clicks, and flatus * Describe bowel sounds as audible, hyperactive, hypoactive, or inaudible Percussion—expect resonant sound or tympany * Areas of increased dullness may be caused by fluid, a mass, or tumor * Palpation—note any muscular resistance, tenderness, enlargement of organs, masses
Physical Assessment of the Anus and Rectum * Inspection and palpation * Examine anal area for cracks, nodules, distended veins, masses or polyps, fecal mass * Insert gloved finger into anus to assess sphincter tone & smoothness of mucosal lining * Inspect perineal area for skin irritation secondary to diarrhea Stool Collection * Medical aseptic technique is imperative * Wear disposable gloves * Wash hands before and after glove use * Do not contaminate outside of container with stool * Obtain stool and package, label, and transport according to agency policy
Patient Guidelines for Stool Collection * Void first so urine is not in stool sample * Defecate into the container rather than toilet bowl * Do not place toilet tissue in bedpan or specimen container * Notify nurse when specimen is available * get to lab quickly (30 min) if anything viable in sample ie. parasites, C-diff. etc
Types of Direct Visualization Studies * Esophagogastroduodenoscopy (EGD) * Colonoscopy * Sigmoidoscopy * Wireless capsule endoscopy
Indirect Visualization Studies * Upper gastrointestinal (UGI) * Small bowel series * Barium enema
Scheduling Diagnostic Tests * 1 — fecal occult blood test * 2 — barium studies (should precede UGI) make sure ALL barium is removed* * 3 — endoscopic examinations Noninvasive procedures take precedence over invasive procedures

Patient Outcomes for Normal Bowel Elimination * Patient has a soft-formed bowel movement every 1-3 days without discomfort * The relationship between bowel elimination and diet, fluid, and exercise is explained * Patient should seek medical evaluation if changes in stool color or consistency persist
Promoting Regular Bowel Habits * Timing -attend to urges promptly * Positioning – have pt. sit up, gravity aids in BM * Privacy – close door & pull curtain * Nutrition * Exercise – abdominal muscles & thighs * Abdominal settings * Thigh strengthening
Individuals at High Risk for Constipation * Patients on bed rest taking constipating medications * Patients with reduced fluids or bulk in their diet * Patients who are depressed * Patients with central nervous system disease or local lesions that cause pain *Valsalva maneuver (straining & holding breath) ↑intrathoracic / intracranial pressure – possible brain injury

Nursing Measures for the Patient With Diarrhea * Answer call lights immediately * Remove the cause of diarrhea whenever possible (e.g., medication) * If there is impaction, obtain physician order for rectal examination * Give special care to the region around the anus * After diarrhea stops, suggest the intake of fermented dairy products * Fecal seepage may indicate impaction
Preventing Food Poisoning * Never buy food with damaged packaging * Never use raw eggs in any form * Do not eat ground meat uncooked * Never cut meat on a wooden surface * Do not eat seafood that is raw or has unpleasant odor * Clean all vegetables and fruits before eating * Refrigerate leftovers within 2 hours of eating them * Give only pasteurized fruit juices to small children
Methods of Emptying the Colon of Feces * Enemas * Rectal suppositories * Rectal catheters * Digital removal of stool Types of Enemas * Cleansing – high volume * Retention - oil * Return-flow – bag of solution taken in (100-300 ml fluid) for pt with gas Retention Enemas * Oil-retention—lubricate the stool and intestinal mucosa easing defecation * Carminative—help expel flatus from rectum * Medicated—provide medications absorbed through rectal mucosa * Anthelmintic—destroy intestinal parasites * Nutritive—administer fluids and nutrition rectally
Bowel Training Programs * Manipulate factors within the patient's control * Food and fluid intake, exercise, time for defecation * Eliminate a soft, formed stool at regular intervals without laxatives * When achieved, discontinue use of suppository if one was used
Types of Colostomies – each has different stool consistency * Sigmoid colostomy * Descending colostomy * Transverse colostomy * Ascending colostomy * Ileostomy Location of (A) a Sigmoid Colostomy and (B) a Descending Colostomy
Location of (C) a Transverse Colostomy and (D) an Ascending Colostomy
Location of an Ileostomy

Colostomy Care * Keep patient as free of odors as possible; empty appliance frequently * Inspect the patient's stoma regularly * Note the size, which should stabilize within 6 to 8 weeks * Keep the skin around the stoma site clean and dry * Measure the patient's fluid intake & output * Explain each aspect of care to the patient and self-care role * Encourage patient to care for and look at ostomy
Normal-Appearing Stoma

Patient Teaching for Colostomies * Community resources are available for assistance * Initially encourage patients to avoid foods high in fiber * Avoid foods that cause diarrhea or flatus * Drink two quarts of water daily * Teach about medications * Teach about odor control (intake of dark green vegetables helps control odor) * Resume normal activity including work and sexual relations Comfort Measures * Encourage recommended diet and exercise * Use medications only as needed * Apply ointments or astringent (witch hazel) * Use suppositories that contain anesthetics
Characteristics of Normal Stool 1. Color – varies from light to dark brown foods & medications may affect color 2. Odor – aromatic, affected by ingested food and person’s bacterial flora 3. Consistency – formed, soft, semi-solid; moist 4. Frequency – varies with diet (about 100 to 400 g/day) 5. 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)
Common Bowel Elimination Problems 1. Constipation – abnormal frequency of defecation and abnormal hardening of stools 2. Impaction – accumulated mass of dry feces that cannot be expelled 3. 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 4. Incontinence – involuntary elimination of feces 5. Flatulence – expulsion of gas from the rectum 6. Hemorrhoids – dilated portions of veins in the anal canal causing itching and pain and bright red bleeding upon defecation. |
Fecal elimination
Defecation (bowel movement): is the expulsion of feces from the anus and rectum
The frequency of defecation is highly individual, varying from several times per day to two or three time per week
Normal feces are made about 75% water and 25% solid material
Feces are normally brown
Factors that affect defecation
Development:
newborn and infant pass meconium (the firs fecal material possessed by the newborn).
In Elderly constipation is common problem duo to reduce activity level, inadequate amount of fluid and fiber intake and muscle weakness
Diet:
fiber diet necessary to provide fecal volume
Spicy food can produce diarrhea and flatus
Excessive sugar can do diarrhea
Gas produces food such as cabbage, onion, banana, and apples
Laxative produce food such as bran, brines, figs, chocolate and alcohol
Constipation produces food such as cheese, pasta, eggs, and lean meat
Fluid intake

UNIT VII
Activity Exercise Pattern
Assessment is focused on the activities of daily living requiring energy expenditure, including self-care activities, exercise, and leisure activities. The status of major body systems involved with activity and exercise is evaluated, including the respiratory, cardiovascular, and musculoskeletal systems. Pattern of exercise, activity, leisure, recreation, ability to perform activities of daily living. Inquire about – activities of daily living, leisure activities, home care, respiratory function, mobility.
Activity and Exercise Pattern
It’s focused on the activities of daily living requiring energy expenditure, including self-care activities, exercise, and leisure activities. * Activity intolerance * Autonomic dysreflexia * Decreased cardiac output * Decreased intracranial adaptive capacity * Deficient diversonal activity * Delayed growth and development * Delayed surgical recovery * Disorganized infant behavior * Dysfunctional ventilatory weaning response * Fatigue * Impaired spontaneous ventilation * Impaired bed mobility * Impaired gas exchange * Impaired home maintenance * Impaired physical mobility * Impaired transfer ability * Impaired walking * Impaired wheelchair mobility * Ineffective airway clearance * Ineffective breathing pattern * Ineffective tissue perfusion * Readiness for enhanced organized infant behavior * Readiness for enhanced self care * Risk for delayed development * Risk for disorganized infant behavior * Risk for disproportionate growth * Risk for activity intolerance * Risk for autonomic dysreflexia * Risk for disuse syndrome * Sedentary lifestyle * Self-care deficit * Wandering
Nursing Diagnosis: Activity Intolerance

Activity Tolerance

NANDA Definition: Insufficient physiological or psychological energy to endure or complete required or desired daily activities

Most activity intolerance is related to generalized weakness and debilitation secondary to acute or chronic illness and disease. This is especially apparent in elderly patients with a history of orthopedic, cardiopulmonary, diabetic, or pulmonary- related problems. The aging process itself causes reduction in muscle strength and function, which can impair the ability to maintain activity. Activity intolerance may also be related to factors such as obesity, malnourishment, side effects of medications (e.g., -blockers), or emotional states such as depression or lack of confidence to exert one's self. Nursing goals are to reduce the effects of inactivity, promote optimal physical activity, and assist the patient to maintain a satisfactory lifestyle.

Defining Characteristics: * Verbal report of fatigue or weakness * Inability to begin or perform activity * Abnormal heart rate or blood pressure (BP) response to activity * Exertional discomfort or dyspnea
Related Factors: * Generalized weakness * Deconditioned state * Sedentary lifestyle * Insufficient sleep or rest periods * Depression or lack of motivation * Prolonged bed rest * Imposed activity restriction * Imbalance between oxygen supply and demand * Pain * Side effects of medications
Expected Outcomes * Patient maintains activity level within capabilities, as evidenced by normal heart rate and blood pressure during activity, as well as absence of shortness of breath, weakness, and fatigue. * Patient verbalizes and uses energy-conservation techniques.
Ongoing Assessment * Determine patient's perception of causes of fatigue or activity intolerance. These may be temporary or permanent, physical or psychological. Assessment guides treatment. * Assess patient's level of mobility. This aids in defining what patient is capable of, which is necessary before setting realistic goals. * Assess nutritional status. Adequate energy reserves are required for activity. * Assess potential for physical injury with activity. Injury may be related to falls or overexertion. * Assess need for ambulation aids: bracing, cane, walker, equipment modification for activities of daily living (ADLs). Some aids may require more energy expenditure for patients who have reduced upper arm strength (e.g., walking with crutches). Adequate assessment of energy requirements is indicated. * Assess patient's cardiopulmonary status before activity using the following measures: * Heart rate Heart rate should not increase more than 20 to 30 beats/min above resting with routine activities. This number will change depending on the intensity of exercise the patient is attempting (e.g., climbing four flights of stairs versus shoveling snow). * Orthostatic BP changes Elderly patients are more prone to drops in blood pressure with position changes. * Need for oxygen with increased activity Portable pulse oximetry can be used to assess for oxygen desaturation. Supplemental oxygen may help compensate for the increased oxygen demands. * How Valsalva maneuver affects heart rate when patient moves in bed Valsalva maneuver, which requires breath holding and bearing down, can cause bradycardia and related reduced cardiac output. * Monitor patient's sleep pattern and amount of sleep achieved over past few days. Difficulties sleeping need to be addressed before activity progression can be achieved. * Observe and document response to activity. Report any of the following: * Rapid pulse (20 beats/min over resting rate or 120 beats/min) * Palpitations * Significant increase in systolic BP (20 mm Hg) * Significant decrease in systolic BP (20 mm Hg) * Dyspnea, labored breathing, wheezing * Weakness, fatigue * Lightheadedness, dizziness, pallor, diaphoresis
Close monitoring serves as a guide for optimal progression of activity. * Assess emotional response to change in physical status. Depression over inability to perform required activities can further aggravate the activity intolerance.
Therapeutic Interventions * Establish guidelines and goals of activity with the patient and caregiver. Motivation is enhanced if the patient participates in goal setting. Depending on the etiological factors of the activity intolerance, some patients may be able to live independently and work outside the home. Other patients with chronic debilitating disease may remain homebound. * Encourage adequate rest periods, especially before meals, other ADLs, exercise sessions, and ambulation. Rest between activities provides time for energy conservation and recovery. Heart rate recovery following activity is greatest at the beginning of a rest period. * Refrain from performing nonessential procedures. Patients with limited activity tolerance need to prioritize tasks. * Anticipate patient's needs (e.g., keep telephone and tissues within reach). * Assist with ADLs as indicated; however, avoid doing for patient what he or she can do for self. Assisting the patient with ADLs allows for conservation of energy. Caregivers need to balance providing assistance with facilitating progressive endurance that will ultimately enhance the patient's activity tolerance and self-esteem. * Provide bedside commode as indicated. This reduces energy expenditure. NOTE: A bedpan requires more energy than a commode. * Encourage physical activity consistent with patient's energy resources. * Assist patient to plan activities for times when he or she has the most energy. Not all self-care and hygiene activities need to be completed in the morning. Likewise, not all housecleaning needs to be completed in 1 day. * Encourage verbalization of feelings regarding limitations. Acknowledgment that living with activity intolerance is both physically and emotionally difficult aids coping. * Progress activity gradually, as with the following: * Active range-of-motion (ROM) exercises in bed, progressing to sitting and standing * Dangling 10 to 15 minutes three times daily * Deep breathing exercises three times daily * Sitting up in chair 30 minutes three times daily * Walking in room 1 to 2 minutes three times daily * Walking in hall 25 feet or walking around the house, then slowly progressing, saving energy for return trip
This prevents overexerting the heart and promotes attainment of short-range goals. * Encourage active ROM exercises three times daily. If further reconditioning is needed, confer with rehabilitation personnel. Exercises maintain muscle strength and joint ROM. * Provide emotional support while increasing activity. Promote a positive attitude regarding abilities. * Encourage patient to choose activities that gradually build endurance. * Improvise in adapting ADL equipment or environment. Appropriate aids will enable the patient to achieve optimal independence for self-care.
Education/Continuity of Care * Teach patient/caregivers to recognize signs of physical overactivity. This promotes awareness of when to reduce activity. * Involve patient and caregivers in goal setting and care planning. Setting small, attainable goals can increase self-confidence and self-esteem. * When hospitalized, encourage significant others to bring ambulation aid (e.g., walker or cane). * Teach the importance of continued activity at home. This maintains strength, ROM, and endurance gain. * Assist in assigning priority to activities to accommodate energy levels. * Teach energy conservation techniques. Some examples include the following: * Sitting to do tasks Standing requires more work. * Changing positions often This distributes work to different muscles to avoid fatigue. * Pushing rather than pulling * Sliding rather than lifting * Working at an even pace This allows enough time so not all work is completed in a short period. * Storing frequently used items within easy reach This avoids bending and reaching. * Resting for at least 1 hour after meals before starting a new activity Energy is needed to digest food. * Using wheeled carts for laundry, shopping, and cleaning needs * Organizing a work-rest-work schedule
These reduce oxygen consumption, allowing more prolonged activity. * Teach appropriate use of environmental aids (e.g., bed rails, elevating head of bed while patient gets out of bed, chair in bathroom, hall rails). These conserve energy and prevent injury from fall. * Teach Range Of Motion and strengthening exercises. * Encourage patient to verbalize concerns about discharge and home environment. These reduce feelings of anxiety and fear.

Activity Intolerance — Hospice Care Nursing Care Plan (NCP): Nursing Interventions & Rationale Nursing Interventions | Rationale | Assess sleep patterns and note changes in thought processes/behaviors. | Multiple factors can aggravate fatigue, including sleep deprivation, emotional distress, side effects of medication, and progression of disease process. | Recommend scheduling activities for periods when patient has most energy. Adjust activities as necessary, reducing intensity level/discontinuing activities as indicated. | Prevents overexertion, allows for some activity within patient ability. | Encourage patient to do whatever possible, e.g., self-care, sit in chair, visit with family/friends. | Provides for sense of control and feeling of accomplishment. | Instruct patient/family/caregiver in energy conservation techniques. Stress necessity of allowing for frequent rest periods following activities. | Enhances performance while conserving limited energy, preventing increase in level of fatigue. | Demonstrate proper performance of ADLs, ambulation/position changes. Identify safety issues, e.g., use of assistive devices, temperature of bath water, keeping travel-ways clear of furniture. | Protects patient/caregiver from injury during activities. | Encourage nutritional intake/use of supplements as appropriate. | Necessary to meet energy needs for activity. | Document cardiopulmonary response to activity (i.e., weakness, fatigue, dyspnea, arrhythmias, and diaphoresis). | Can provide guidelines for participation in activities. | Monitor breath sounds. Note feelings of panic/air hunger. | Hypoxemia increases sense of fatigue, impairs ability to function. | Provide supplemental oxygen as indicated and monitor response. | Increases oxygenation. Evaluates effectiveness of therapy. |
NURSING DIAGNOSIS: Activity Intolerance/Fatigue
May be related to * Generalized weakness * Bedrest or immobility; progressive disease state/debilitating condition * Imbalance between oxygen supply and demand * Cognitive deficits/emotional status, secondary to underlying disease process/depression * Pain, extreme stress
Possibly evidenced by * Report of lack of energy, inability to maintain usual routines * Verbalizes no desire and/or lack of interest in activity * Lethargic; drowsy; decreased performance * Disinterested in surroundings/introspection
Desired Outcomes * Identify negative factors affecting performance and eliminate/reduce their effects when possible. * Adapt lifestyle to energy level. * Verbalize understanding of potential loss of ability in relation to existing condition. * Maintain or achieve slight increase in activity tolerance evidenced by acceptable level of fatigue/weakness. * Remain free of preventable discomfort and/or complications.

Impaired Physical Mobility — Fracture

Nursing Diagnosis: Impaired Physical Mobility
May be related to * Neuromuscular skeletal impairment; pain/discomfort; restrictive therapies (limb immobilization) * Psychological immobility
Possibly evidenced by * Inability to move purposefully within the physical environment, imposed restrictions * Reluctance to attempt movement; limited ROM * Decreased muscle strength/control
Desired Outcomes * Regain/maintain mobility at the highest possible level. * Maintain position of function. * Increase strength/function of affected and compensatory body parts. * Demonstrate techniques that enable resumption of activities. Nursing Interventions | Rationale | Assess degree of immobility produced by injury/treatment and note patient’s perception of immobility. | Patient may be restricted by self-view/self-perception out of proportion with actual physical limitations, requiring information/interventions to promote progress toward wellness. | Encourage participation in diversional/recreational activities. Maintain stimulating environment, e.g., radio, TV, newspapers, personal possessions/pictures, clock, calendar, visits from family/friends. | Provides opportunity for release of energy, refocuses attention, enhances patient’s sense of self-control/self-worth, and aids in reducing social isolation. | Instruct patient in/assist with active/passive ROM exercises of affected and unaffected extremities. | Increases blood flow to muscles and bone to improve muscle tone, maintain joint mobility; prevent contractures/atrophy and calcium resorption from disuse | Encourage use of isometric exercises starting with the unaffected limb. | Isometrics contract muscles without bending joints or moving limbs and help maintain muscle strength and mass. Note: These exercises are contraindicated while acute bleeding/edema is present. | Provide footboard, wrist splints, trochanter/hand rolls as appropriate. | Useful in maintaining functional position of extremities, hands/feet, and preventing complications (e.g., contractures/footdrop). | Place in supine position periodically if possible, when traction is used to stabilize lower limb fractures. | Reduces risk of flexion contracture of hip. | Instruct in/encourage use of trapeze and “post position” for lower limb fractures. | Facilitates movement during hygiene/skin care and linen changes; reduces discomfort of remaining flat in bed. “Post position” involves placing the uninjured foot flat on the bed with the knee bent while grasping the trapeze and lifting the body off the bed. | Assist with/encourage self-care activities (e.g., bathing, shaving). | Improves muscle strength and circulation, enhances patient control in situation, and promotes self-directed wellness. | Provide/assist with mobility by means of wheelchair, walker, crutches, canes as soon as possible. Instruct in safe use of mobility aids. | Early mobility reduces complications of bed rest (e.g., phlebitis) and promotes healing and normalization of organ function. Learning the correct way to use aids is important to maintain optimal mobility and patient safety. | Monitor blood pressure (BP) with resumption of activity. Note reports of dizziness. | Postural hypotension is a common problem following prolonged bed rest and may require specific interventions (e.g., tilt table with gradual elevation to upright position). | Reposition periodically and encourage coughing/deep-breathing exercises. | Prevents/reduces incidence of skin and respiratory complications (e.g., decubitus, atelectasis, pneumonia). | Auscultate bowel sounds. Monitor elimination habits and provide for regular bowel routine. Place on bedside commode, if feasible, or use fracture pan. Provide privacy. | Bed rest, use of analgesics, and changes in dietary habits can slow peristalsis and produce constipation. Nursing measures that facilitate elimination may prevent/limit complications. Fracture pan limits flexion of hips and lessens pressure on lumbar region/lower extremity cast. | Encourage increased fluid intake to 2000–3000 mL/day (within cardiac tolerance), including acid/ash juices. | Keeps the body well hydrated, decreasing risk of urinary infection, stone formation, and constipation | Provide diet high in proteins, carbohydrates, vitamins, and minerals, limiting protein content until after first bowel movement. | In the presence of musculoskeletal injuries, nutrients required for healing are rapidly depleted, often resulting in a weight loss of as much as 20/30 lb during skeletal traction. This can have a profound effect on muscle mass, tone, and strength. Note: Protein foods increase contents in small bowel, resulting in gas formation and constipation. Therefore, gastrointestinal (GI) function should be fully restored before protein foods are increased. | Increase the amount of roughage/fiber in the diet. Limit gas-forming foods. | Adding bulk to stool helps prevent constipation. Gas-forming foods may cause abdominal distension, especially in presence of decreased intestinal motility. | Consult with physical/occupational therapist and/or rehabilitation specialist. | Useful in creating individualized activity/exercise program. Patient may require long-term assistance with movement, strengthening, and weight-bearing activities, as well as use of adjuncts, e.g., walkers, crutches, canes; elevated toilet seats; pickup sticks/reachers; special eating utensils. | Initiate bowel program (stool softeners, enemas, laxatives) as indicated. | Done to promote regular bowel evacuation. | Refer to psychiatric clinical nurse specialist/therapist as indicated. | Patient/SO may require more intensive treatment to deal with reality of current condition/prognosis, prolonged immobility, perceived loss of control. |

Nursing Care Plan Nursing Diagnosis
Decreased cardiac output related to decreased myocardial contractility | Long Term Goal:
Patient will display hemodynamic stability (BP, cardiac output, urinary output and peripheral pulses WNL) | Short Term Goals / Outcomes:
Patients lungs sounds will be clear to auscultation
Patient will have no signs of dyspnea
Patient will demonstrate an increase in activity intolerance | Intervention | Rationale | Evaluation | Assess patient respirations by observing respiratory rate and depth and use of accessory muscles | Increased respiratory rate and use of accessory muscles may be seen in patients with hypoxia | Patient has regular, even, non-labored respirations. | Observe patient for restlessness, agitation, confusion and (late stages) lethargy | Changes in behavior and mental status can be early signs of impaired gas exchange which will result from decreased cardiac output | Patient will be alert, oriented x 3 and calm | Auscultate lungs for presence of normal or adventitious lung sounds | Crackles may indicate heart failure which can contribute to decreased cardiac output. Respiratory distress/failure often occurs as shock progresses. | Patient’s lungs sounds are clear to auscultation in all lobes | Assess patient for positive hepatojugular reflex | A positive hepatojugular reflex is indicative of right-sided heart failure | Patient has normal hepatojugular reflex. | Assess for mental status changes. | Increasing lethargy, confusion, restlessness and / or irritability can be early signs of cerebral hypoxia from decreased cardiac output | Patient is awake, alert and oriented X3. | Weigh patient daily at same time with same clothing on same scale. | Weight gain can be one of the earliest indicators of heart failure as a result of impaired ventricular pumping ability. An acute gain in weight of 1kg. can signal a l liter gain in fluid | Patient maintains baseline weight or less daily | Observe patient for sleep apnea | Sleep apnea is a common disorder in patients with chronic heart failure | Patient will have no episodes of sleep apnea | Assess patient for chest pain or discomfort noting location, severity, duration, quality and radiation | Chest pain is generally indicative of inadequate blood supply to the heart which can result in decreased cardiac output | Patient is free of chest pain. | Elevate legs when in sitting position and edematous extremities when at rest | Improves venous return and increases cardiac output | Patient will have decreased edema in legs | Monitor hourly urine output | Decreased cardiac output results in decreased perfusion to the kidneys and decreased urine output. Urinary output < 30 ml/hr. indicates inadequate renal perfusion. | Patient will have a minimum of 30ml/hr. urinary output | Assess patient heart sounds | Heart sounds may sound distant and have an S3 or S4 sound present with the presence of heart failure | Patient has normal heart sounds of S1 and S2 | Monitor patient for changes in heart rate and/or rhythm | Heart irritability is common with conduction defects and/or ischemia from a poorly perfused heart (Tachycardia at rest, atrial fibrillation, bradycardia, or multiple dysrhythmias) | Patient will have normal sinus rhythm | Assess peripheral pulses | Weak, thready peripheral pulses may reflect hypotension, vasoconstriction, shunting and venous congestion | Patient will have strong, palpable peripheral pulses in all extremities | Observe patient for changes in skin color, moisture, temperature and capillary refill time | Pallor or cyanosis, cool moist skin and slow capillary refill time may be present from peripheral vasoconstriction and decreased oxygen saturation | Patient will have normal skin color, be dry to touch and have capillary refill time of 3 seconds or less or 5 seconds or less (if patient is elderly) | Administer supplemental Oxygen as indicated by cannula, mask, or ET/trach tube. | Supplemental oxygen helps to improve cardiac function by increasing available oxygen and reducing oxygen consumption | Patient’s oxygen saturation will remain at 93% or above at all times. | Promote rest | Rest and a quiet environment reduces a catecholamine-induced stress response and decreases cardiac workload thus increasing cardiac output | Patient will get adequate rest in a stress-free environment. | Educate patient and caregivers about the importance of taking prescribed medications at prescribed times | Patient is often on multiple medications which can be difficult to manage, thus increasing the likelihood that medications can be missed or incorrectly used | Patient and/or caregiver will verbalize an understanding of patient medications and dosing schedule |

NURSING DIAGNOSIS: Breathing Pattern, ineffective
May be related to * Pain * Muscular impairment * Decreased energy/fatigue
Possibly evidenced by * Tachypnea; respiratory depth changes, reduced vital capacity * Holding breath; reluctance to cough
Desired Outcomes * Establish effective breathing pattern. * Experience no signs of respiratory compromise/complications. Nursing Interventions | Rationale | Observe respiratory rate/depth. | Shallow breathing, splinting with respirations, holding breath may result in hypoventilation/atelectasis. | Auscultate breath sounds. | Areas of decreased/absent breath sounds suggest atelectasis, whereas adventitious sounds (wheezes, rhonchi) reflect congestion. | Assist patient to turn, cough, and deep breathe periodically. | Promotes ventilation of all lung segments and mobilization and expectoration of secretions. | Show patient how to splint incision. Instruct in effective breathing techniques. | Facilitates lung expansion. Splinting provides incisional support/decreases muscle tension to promote cooperation with therapeutic regimen. | Elevate head of bed, maintain low-Fowler’s position. | Maximizes expansion of lungs to prevent/resolve atelectasis. | Support abdomen when coughing, ambulating. | Facilitates more effective coughing, deep breathing, and activity |

UNIT VIII
COPING AND STRESS TOLERANCE PATTERN
WHAT IS STRESS?
Stress is an internal reaction to events and circumstances that challenge us to make changes in our lives. There are both external and internal causes of stress.
External
* Getting diagnosed with a serious illness * Moving * Failing a test * Having a baby * Sleeping through the alarm clock * Losing a job * Being in an automobile accident * Being late for class * Having a fight with your boyfriend/girlfriend
Internal
1. Physical changes that occur in the body
- Illness
- Injury
- Being in poor physical shape 2. Worrying excessively 3. Thinking negatively 4. Decision-making 5. Setting unrealistic expectations for ourselves/others
WHAT DOES STRESS DO TO US?
When we are stressed, our body responds in certain way called the Stress Response. The Stress Response includes the following bodily reactions: * Muscle tension * Increase in heart rate * Sweating * Rapid and shallow breathing * Increase in blood pressure * Cold and/or clammy hands and feet * Queasy stomach * Feeling fidgety
When we experience a number of internal and/or external stressors over a period of time (i.e., weeks, months, years), there is a negative impact on us physically, mentally, and emotionally. As a result, people frequently turn to ineffective and, usually, self-destructive behaviors to try to cope. Fortunately, there are numerous healthy strategies and techniques available to cope with stress effectively.

Medical Diagnoses: Stress overload related to multiple co-existing stressors Nursing DX/Clinical Problem | Client Goals/Desired Outcomes/Objectives | Nursing Interventions/Actions/Orders | *I | Evaluation | | | | | Goals | Interventions | Stress overload related to multiple co-existing stressors as evidenced by patient statements, “My husband used to beat me,” and “My daughter cusses me but I don’t care. I cuss her back.” | Short Term: Patient will review the amounts and types of stressors in daily living as measured by patient identification of two stressors, identifying amount and type by [date] at 3:00 pm.Long Term:Client will reduce stress levels through use of relaxation techniques and other strategies as measured by patient statement of implementation of at least one alternative method of reducing stress by [date] at 3:00 pm. | -Listen actively to descriptions of stressors and the stress response. Having an opportunity to speak about stressors is helpful in dealing with stress overload. Listening engenders trust and trust is the first step in the process of helping clients to reduce the psychological distress of stress overload (Ackley & Ladwig). -Categorize stressors as modifiable or nonmodifiable. Removing or minimizing some stressors, changing responses to stressors, and modifying the long-term effects of stress are all actions that can assist those with diabetes and stress (Ackley & Ladwig). -Encourage social support for older adults. Stressors in highly valued roles affect physical health only when there is insufficient emotional support from social networks (Ackley & Ladwig). -Explore possible therapeuticapproaches such as cognitive behavior therapy, biofeedback, neurofeedback, pharmacologic agents, and complimentary and alternative therapies. These types of therapies decrease the sympathetic nervous system response to stress. Neurofeedback promotes optimum functioning of the central nervous system, induces relaxation, and supports healthy balance, flexibility, and resilience. Adults who had experienced hospitalizations of at least 5 days said that spirituality strengthened their coping ability (Ackley & Ladwig). | | Goal met. Patient identified two stressors and patient identified amount and type of stressors on [date].Goal is set to be measured on [date] at 3:00 pm. Client has made progress. Client has requested that she receive students from the School for therapeutic communication sessions for the fall semester on [date]. | -Active listening is used to assess descriptions of stressors and the stress response, every Tuesday afternoon. - Stressors are categorized as modifiable or non-modifiable, every Tuesday afternoon.-Social support has been encouraged, every Tuesday afternoon. -Possible therapeutic approaches and complimentary and alternative therapies were explored on [date]. | Assessment | | | | | | Subjective Data:-Patient statement “My husband used to beat me.”- Patient statement “My daughter cusses me but I don’t care. I cuss her back.”Objective Data:-Patient appears aggravated on assessment.- Patient cries during visit while talking about her children.-Patient expresses anger and strong emotion while talking about past abuse and uncomfortable situations. | | | | | |

INEFFECTIVE COPING STRATEGIES
Behavioral
* Overeating * Consuming too much alcohol * Taking excessive drugs (legal and illegal) * Isolating * Acting out behavior (including physical aggression) * Quitting jobs, relationships, etc. * Procrastinating
Mental
* Excessive worrying * Denying that a problem exists
COPING to deal successfully with a difficult situation.

ACTIVE COPING * Active coping involves taking responsibility for one's own life and actions instead of feeling at the mercy of fate, chance, luck or destiny. Instead of using aggression, regression, withdrawal, denial, repression and rationalization to cope. Rather than use self deception, we ACTIVELY and FIRMLY address and deal with the stress in our life. If we are unhappy with our lives and the things that are happening to us then we have to take charge of our lives to change our life. * There are two kinds of people in this world. EXTERNALIZERS and INTERNALIZERS. What determines which one we are is how we assign or accept the responsibility for the things that happen in our life. If we live on the basis of chance or luck as the controlling factor, then we are an externalizer. If you live your life according to your horoscope or Cleo, you are an externalizer. If on the other hand you believe that success in life is based on hard work and practice and you are not at the mercy of fate, then you are an internalizer. * There are no good days or bad days. The Sun rises and falls, the same things happen day after day. Remember it is all in how we perceive the situation, not how the situation perceives us. True there are less desirable things that happen on some days. But do they control our reactions? Or are WE in control of them? Do you want to be ruled by events? Or do you want to rule OVER events. The choice is yours! * When you take the responsibility for your own fate you stop blaming people, places and things for your problems. So you more actively cope with the stresses in your life. * But how do you become an internalizer instead of an externalizer? It doesn't happen overnight, but begins with a change of thinking.
Compromised family coping
Compromise family coping occurs when a usually supportive primary person(family member or close friend) is providing insufficient ,ineffective ,or compromised support ,comfort,assistance or encouragement that the patient may need to manage or master adaptive tasks related to his health challenge .This plan focuses on the family’s ability to manage the stressor that affect them during the pateint’s hospital day.
Defensive coping
Repeated projection of falsely self evaluation based on self protective pattern that defends against perceived threats to positive self regard.
COPING INEFFECTIVE Inability to form a valid appraisal of internal or external stressor, inadequate choices of practical responses, and or to access or use available.
Avoidance
In avoidance, we simply find ways of avoiding having to face uncomfortable situations, things or activities. The discomfort, for example, may come from unconscious sexual or aggressive impulses.
Avoidance may include removing oneself physically from a situation. It may also involve finding ways not to discuss or even think about the topic in question.
Example
I dislike another person at work. I avoid walking past their desk. When people talk about them, I say nothing.
My son does not like doing homework. Whenever the subject of school comes up, he changes the topic. He also avoids looking directly at me.
Discussion
Avoidance is a simple way of coping by not having to cope. When feelings of discomfort appear, we find ways of not experiencing them.
According to the dynamic theory, avoidance is a major defense mechanism in phobias.
Procrastination is another form of avoidance where we put off to tomorrow those things that we can avoid today.
So what?
To get someone to face what they are avoiding, you may have to corner them or otherwise present them with a situation where they are unable to avoid the situation. If the discomfort is very strong, they may fight back hard, so be careful.
You can also use avoidance to persuade a person to do something. Give them a choice of two actions, one of which is something you know that they tend to avoid or which is likely to be less desirable. They will pick the path you want in order to avoid the less desirable way.
Denial
Description
Denial is simply refusing to acknowledge that an event has occurred. The person affected simply acts as if nothing has happened, behaving in ways that others may see as bizarre.
In its full form, it is totally subconscious, and sufferers may be as mystified by the behavior of people around them as those people are by the behavior of the sufferers. It may also have a significant conscious element, where the sufferer is simply 'turning a blind eye' to an uncomfortable situation.
Example
A man hears that his wife has been killed, and yet refuses to believe it, still setting the table for her and keeping her clothes and other accoutrements in the bedroom.
A person having an affair does not think about pregnancy or sexually transmitted diseases.
People take credit for their successes and find 'good reason' for their failures, blaming the situation, other people, etc.
Alcoholics vigorously deny that they have a problem.
Optimists deny that things may go wrong. Pessimists deny they may succeed.
Discussion
Denial is a form of repression, where stressful thoughts are banned from memory. If I do not think about it, then I do not suffer the associated stress have to deal with it. However, people engaging in Denial can pay a high cost in terms of the psychic energy needed to maintain the denial state.
Repression and Denial are two primary defense mechanisms which everybody uses.
Children find denial easier, as with age, the ego matures and understands more about the "objective reality" it must operate within.
RAPE TRAUMA SYNDROME
Sustained maladaptive response to forced , violent sexual act ( Penetration may not actually occur ) against victims will and consent

Unit X

Reproduction -- biological processes by which existing organisms give rise to new organisms-- since no individual organism is immortal, reproduction is required if species are to persist through time -- extinction occurs when reproductive rates fall below mortality rates.
As we discussed earlier in the semester, there are two modes of reproduction:
1. Asexual reproduction -- only one parent required and the offspring are genetically identical to parent -- mitosis is the mechanism underlying this mode of reproduction.
2. Sexual reproduction -- permits greater genetic variation and evolutionary flexibility -- 2 parents each produce specialized haploid sex cells (gametes) by meiosis -- gametes either sperm or ovum -- different gametes may be produced by same individual (hermaphroditic species) or one individual may belong to one sex or the other -- gametes fuse in a process called fertilization and the resulting single-cell progeny is called a zygote -- zygote then undergoes a period of development.
Let's look at some general patterns of reproduction displayed by animals.
Asexual reproduction -- generally seen in lower animals.
1. budding -- part of individual undergoes repeated mitotic divisions to produce a new individual that breaks off -- e.g. hydra, sea anemone.
2. fragmentation -- part of parent falls off or is broken off -- fragment undergoes repeated mitotic divisions to produce an entire individual -- e.g. starfish.
Some species of animals have evolved from a sexual mode of reproduction back to an asexual mode:
Parthenogenesis -- development of new individuals from ova that are not fertilized by male gametes -- two types:
1. haplodiploidy -- unfertilized eggs develop into individuals that are haploid -- e.g. in honey bees, queens lay two kinds of eggs -- eggs that are fertilized develop into diploid female bees called workers, while unfertilized eggs develop into haploid males called drones.
2. unisexual reproduction -- females produce diploid eggs that develop without fertilization into more females -- species contain only female individuals -- some species of fish and reptiles show this mode of reproduction.
Sexual reproduction -- involves production of haploid gametes and formation of zygotes through fertilization -- zygote then undergoes development -- variety of ways that this is accomplished.
Fertilization may be external of internal to the animal.
External fertilization-- usually seen in aquatic animals such as fish -- male and females shed gametes into water at same time and place and fertilization occurs in the water -- probability of fertilization increased by production of huge numbers of gametes.
Internal fertilization -- increases probability that egg and sperm will meet and that fertilization will occur -- structural adaptations to facilitate passage of sperm into female reproductive tract.
Timing of reproduction: most sexually reproducing animals have a single breeding period per year -- individuals physiologically unable to reproduce at other times of the year-- offspring born at the time of year most favorable for their survival -- e.g. abundant resources, mild climatic conditions.
As mentioned earlier, species must have a reproductive rate that offsets losses due to mortality in order to avoid extinction -- species display reproductive strategies that have been shaped by evolution -- reproductive strategies reflect the environment where the organism lives and its role in its ecological community.
Let’s look at the components of reproductive strategies.
1. age at first reproduction -- usually related to how long individuals live -- animals having short life-spans reproduce at an early age -- e.g. certain bacteria can divide every 8 minutes; fruitflies are sexually mature 14 days after they are born; redwoods become sexually mature in 100 years.
2. number of offspring per reproductive effort -- tremendous variation seen -- one female oyster can produce 60 million eggs in one reproductive effort -- other species (e.g. our own) may have only a single offspring per effort.
3. number of lifetime reproductive efforts -- some species display a pattern called semelparity = only one reproductive effort in lifetime -- e.g. salmon return to the stream where they were born to spawn once and then die -- other species display iteroparity = multiple reproductive efforts per lifetime.
4. amount of parental care -- parental care increases survival of offspring and therefore increases reproductive success -- amount of parental care is inversely related to the number of offspring per reproductive effort -- little or no care in species having large reproductive efforts (e.g. oysters) -- much parental care in animals having small reproductive efforts (e.g. humans).
Now, let's consider the structure and function of the human reproductive system
Male Reproductive System:
1. testes -- male gonads (= gamete producing organs) -- paired organs contained in sac of skin called the scrotum -- two functions of testes are a) production of sperm ( by seminiferous tubules) and b) production of male sex hormone testosterone (by Leydig cells) -- sperm stored and mature in a highly coiled, tube-like structure called the epididymas.
2. vas deferens -- duct (tube) that passes from epididymas up and out of scrotum, over and behind urinary bladder and then merges with the urethra.
a. seminal vesicles -- contribute about 60% of seminal fluid volume -- fructose sugar secreted as energy source for sperm.
b. prostate gland -- alkaline secretions that neutralize acids in urethra -- secretions also contain sugars for energy and other chemicals for sperm activation.
c. bulbourethral glands -- paired glands that secrete a small amount of clear fluid into the urethra -- neutralizes acidic environment of urethra.
3. penis -- special accessory organ which facilitates transfer of sperm from male directly into female reproductive system -- cylindrical organ composed largely of spongy, cavity-filled tissue called corpora cavernosa -- during sexual arousal, blood flow to pelvis and the penis is increased -- cavities in this tissue fill with blood causing the normally flacid penis to become erect -- changes called erection.

Female Reproductive System:
1. ovaries -- paired female gonads -- ovaries contain follicles (400,000 at sexual maturity) -- follicles contain cells that will mature to become ova (eggs) -- one or several follicle produce mature eggs each month after female reaches reproductive age -- follicle ruptures and releases ovum (ovulation) -- ovary also produces the female hormones estrogen and progesterone.
2. oviducts (Fallopian tubes) -- tubes leading away from each ovary and joining to form a large cavity called the uterus (womb) -- tubes lined with cilia to help egg move -- fertilization normally occurs in oviduct.
3. uterus -- cavity where zygote will implant and develop during pregnancy -- opening at bottom called the cervix-- consists of three layers: 1) endometrium -- inner lining consisting of highly vascularized tissue -- sloughed off during menstruation unless pregnancy occurs; 2) myometrium -- muscular layer that produces labor contractions during the birth process; 3) perimetrium -- external covering of uterus.
4. vagina -- cavity below uterus that opens to outside -- "birth canal" -- highly elastic organ into which penis is inserted during intercourse -- surrounded by pelvic floor muscles -- cells of vagina secrete fluids for lubrication during intercourse -- opening to vagina surrounded by two folds of skin: labia majora (outer) and labia minor (inner).
5. clitoris -- knob of erectile (corpora cavernosa) tissue above opening to vagina -- extremely sensitive and has no known function other than to facilitate sexual arousal in the female.

Organ | Functions | 1. Vagina | a. Passageway of menstrual flow
b. Female organ for coitus; receives male penis
c. Passageway for the fetus during birth | 2. Uterus | a. Houses and nourishes fetus until sufficiently mature to function outside the mother’s body
b. Uterine muscles propels fetus outside. | 3. Fallopian Tube | a. Provides passageway for ovum as it travels from ovary to uterus.
b. Site of Fertilization. | 4. Ovaries | a. Endocrine glands that secrete estrogen and progesterone.
b. Contain ova within follicles for maturation during the woman’s reproductive life. |

Organ | Function | 1. Penis | a. Conduit for urine form bladder
b. Male organ for sexual intercourse | 2. Scrotum | a. House testes and maintains their temperature at a level cooler than the body thus promoting normal sperm formation | 3. Testes | a. Endocrine glands that secrete the primary male hormone, testosterone | 4. Seminiferous Tubules | a. Location of spermatogenesis (within the testes) | 5. Epididymis | a. Storage for some sperm
b. Final sperm maturation
c. Where sperm develops the ability to be motile. | 6. Vas Deferens | a. Storage of sperms
b. Conduction of sperm form epididymis to urethra | 7. Seminal Vesicle, Prostate, Bulbourethral gland | a. Secretion of seminal fluids that carry sperm and provide for:
- Nourishment of sperm
- Protection of sperm from hostile acidic environment of vagina
- Enhancement of motility of sperm
- Washing of all sperm from urethra |

Bisexual
A person who is attracted to members of either gender.
"Date" rape
When one person forces another person to have sex. It differs from rape because the victim agreed to spend time with the attacker. Perhaps he or she even went out with his or her attacker more than once.
Heterosexual
A person who is attracted to individuals of the opposite gender.
Homosexual
A person who is attracted to individuals of the same gender.
Menstruation
The periodic shedding of the uterine lining.
Menopause
When a woman’s ovaries stop producing hormones because the number of eggs (follicles) is limited. Defined as 12 months without any menstrual bleeding. In the US, the average age of natural menopause is 51 years. Surgical menopause can occur when the uterus and/or ovaries are removed (hysterectomy.)
Orgasm
Sexual climax
Rape
A situation when a person has sex with another person against his or her will.
Sexual health
Sexual health refers to the many factors that impact sexual function and reproduction. These factors include a variety of physical, mental and emotional issues. Disorders that affect any of these factors can impact a person’s physical and emotional health, as well as his or her relationships and self-image.
Sexually transmitted disease (STD)
A disease passed from one person to another by unprotected sexual contact. You can get a sexually transmitted disease from sexual activity that involves the mouth, anus or vagina.
Testosterone
The male hormone that is essential for sperm production and the development of male characteristics, including muscle mass and strength, fat distribution, bone mass and sex drive.Women also make small amounts of testosterone in the ovary.
Transsexual
An individual who is committed to altering his or her physical appearance—through cosmetics, hormones and, in some cases, surgery—to resemble the opposite sex.
Urinary tract infection (UTI)
A condition that occurs when bacteria from outside the body get into the urinary tract and cause infection and inflammation.

Glossary of Terms
Many Americans refrain from talking about sexual orientation and gender expression identity because it feels taboo, or because they’re afraid of saying the wrong thing. This glossary was written to help give people the words and meanings to help make conversations easier and more comfortable.
Bisexual – A person emotionally, romantically, sexually and relationally attracted to both men and women, though not necessarily simultaneously; a bisexual person may not be equally attracted to both sexes, and the degree of attraction may vary as sexual identity develops over time.
Coming out – The process in which a person first acknowledges, accepts and appreciates his or her sexual orientation or gender identity and begins to share that with others.
Gay – A word describing a man or a woman who is emotionally, romantically, sexually and relationally attracted to members of the same sex.
Gender expression – How a person behaves, appears or presents him- or herself with regard to societal expectations of gender.
Gender identity – The gender role that a person claims for his or her self — which may or may not align with his or her physical gender.
Genderqueer – A word people use to describe their own nonstandard gender identity, or by those who do not conform to traditional gender norms.
GLBT – An acronym for “gay, lesbian, bisexual and transgender.”
Homophobia – The fear and hatred of or discomfort with people who love and are sexually attracted to members of the same sex.
Internalized homophobia – Self-identification of societal stereotypes by a GLBT person, causing them to dislike and resent their sexual orientation or gender identity.
Lesbian – A woman who is emotionally, romantically, sexually and relationally attracted to other women.
Living openly – A state in which GLBT people are open with others about being GLBT how and when they choose to be.
Outing – Exposing someone’s sexual orientation or gender identity as being gay, lesbian, bisexual or transgender to others, usually without their permission; in essence “outing” them from the closet.
Queer – A term that is inclusive of people who are not heterosexual. For many GLBT people, the word has a negative connotation; however, many younger GLBT people are comfortable using it.
Same-gender loving – A term some prefer to use instead of “gay” or “lesbian” to express attraction to and love of people of the same gender.
Sexual orientation – An enduring emotional, romantic, sexual and relational attraction to another person; may be a same-sex orientation, opposite-sex orientation or bisexual orientation.
Sexual preference – What a person likes or prefers to do sexually; a conscious recognition or choice not to be confused with sexual orientation.
Straight supporter – A person who supports and honors sexual diversity, acts accordingly to challenge homophobic remarks and behaviors and explores and understands these forms of bias within him- or herself.
Transgender – A term describing a broad range of people who experience and/or express their gender differently from what most people expect. It is an umbrella term that includes people who are transsexual, cross-dressers or otherwise gender non-conforming.
Transphobia – The fear and hatred of, or discomfort with, people whose gender identity or gender expression do not conform to cultural gender norms.
Transsexual – A medical term describing people whose gender and sex do not line up, and who often seek medical treatment to bring their body and gender identity into alignment. Sexual orientation is the affectional or loving attraction to another person. It can be considered as ranging along a continuum from same-sex attraction only at one end of the continuum to opposite-sex attraction only at the other end.

Heterosexuality is the attraction to persons of the opposite sex; homosexuality, to persons of the same sex; bisexuality, to both sexes. Sexual orientation can be seen as part of a continuum ranging from same-sex attraction only (at one end of the continuum) to opposite-sex attraction only (at the other end of the continuum).
Sexual behavior, or sexual activity, differs from sexual orientation and alone does not define someone as an LGBT individual. Any person may be capable of sexual behavior with a person of the same or opposite sex, but an individual knows his or her longings—erotic and affectional—and which sex is more likely to satisfy those needs.
It is necessary to draw a distinction between sexual orientation and sexual behavior. Not every person with a homosexual or bisexual orientation is sexually active. A person’s sexual orientation does not tell us if she/he is sexually active nor does it define her/his specific sexual behaviors.
Similarly, sexual behavior alone does not define orientation. A personal awareness of having a sexual orientation that is not exclusively heterosexual is one way a person identifies herself or himself as an LGBT person. Or a person may have a sexual identity that differs from his or her biological sex—that is, a person may have been born a male but identifies and feels more comfortable as a female.
Sexual orientation and gender identity are two independent variables in an individual’s definition of himself or herself. Sexual identity is the personal and unique way that a person perceives his or her own sexual desires and sexual expressions. Biological sex is the biological distinction between men and women.
Gender is the concept of maleness and masculinity or femaleness and femininity. One’s gender identity is the sense of one’s self as male or female and does not refer to one’s sexual orientation or gender role.
Sex refers to the biological characteristics of a person at birth, while gender relates to his or her perception of being male or female and is known as the gender role.
Gender role refers to the behaviors and desires to act in certain ways that are viewed as masculine or feminine by a particular culture.
A culture usually labels behaviors as masculine or feminine, but these behaviors are not necessarily a direct component of gender or gender identity. It is common in our culture to call the behaviors, styles, or interests shown by males that are usually associated with women “effeminate” and to call the boys who behave this way “sissies.” Women or girls who have interests usually associated with men are labeled “masculine” or “butch,” and the girls are often called “tomboys.”

Transgender is a general term that is used by individuals that do not conform to the gender role expectations of their biological sex. It is also used by persons who may clearly identify their gender as the opposite of their biological sex. Transgender can also be used as a general term to include transsexual people.

Transsexuals are people with the biological characteristics of one sex who identify themselves as the opposite gender and have had some type of surgical alteration and/or hormone treatments that changes their bodies’ appearance in alignment with their identity.

UNIT XI

Role Conflict
Definition: Role conflict occurs when people are confronted with incompatible role expectations in the various social statuses they occupy. Role conflict can take several different forms. When the roles are associated with two different statuses, the result is known as status strain. When the conflicting roles are both associated with the same status, the result is known as role strain. Conflict may also occur when people disagree about what the expectations are for a particular role or when someone simply has difficulty satisfying expectations because their duties are unclear, too difficult, or disagreeable.
Examples:
A parent may feel conflicting obligations to employers who demand full devotion to the job and children who need to be cared for when they are sick (status strain).
Role Ambiguity - norms for a specific position are vague, unclear and ill-defined. Actors disagree on role expectations, not because there is role conflict but because role expectations are unclear. Examples: job descriptions, clinical objectives.
Assessment is focused on the person's roles in the world and relationships with others. Satisfaction with roles, role strain, or dysfunctional relationships may be further evaluated. Patterns of relationships, role responsibilities, satisfaction with relationships and responsibilities. Inquire about – Communication, family, loss, parenting, socialization, violence, responsibilities.
Associated Nursing Diagnoses:
Breast-feeding: effective: mother-baby dyad exhibits adequate proficiency and satisfaction with the breast-feeding process. Includes mother's ability to facilitate successful latch-on, infant is content after feeding, regular and sustained suckling, infant cues and maternal interpretation are in sync.
Breast-feeding: ineffective: The state in which a mother-infant dyad experience or is at risk for dissatisfaction or difficulty with the breast-feeding process. Includes: actual or perceived inadequate milk supply, inability of infant to latch on correctly and sustain suckling, sore or cracked nipples, fussy and crying infant. Can be related to maternal fatigue, anxiety, ambivalence, inadequate nutrition, history of unsuccessful breast-feeding, non supportive partner/family, lack of knowledge, mother or infant is ill, barriers in the work environment.
Caregiver role strain: A state in which a person is experiencing physical, emotional, social and/or financial burdens in the process of caregiving. Related to insufficient energy, conflicts in caregiving responsibilities, or unrealistic expectations of self.
Communication, Verbal, Impaired: Decreased, delayed, or absent ability to receive, process, transmit, and use a system of symbols.
Family Processes, Interrupted: change in family relationships and/or functioning.
Family Processes, Alcoholism, dysfunctional: The state in which the psychosocial, spiritual and physiological functions of the family unit are chronically disorganized, leading to conflict, denial of problems, resistance to change, ineffective problem solving, and a series of self-perpetuating crises.
Grieving, Anticipatory: Intellectual and emotional responses and behaviors by which individuals, families, and communities work through the process of modifying self-concept based on the perception of potential loss.
Loneliness, Risk for: At risk for experiencing vague dysphoria.
Parenting, Impaired: Inability of primary caretaker to create, maintain, or regain an environment that promotes optimum growth and development of the child.
Parenting: Readiness for Enhanced: A pattern of providing an environment for children or other dependent person(s) that is sufficient to nurture growth and development and can be strengthened.
Role performance, Ineffective: Patterns of behavior and self-expression that do not match the environmental context, norms, and expectations.
Social Interaction, Impaired: Insufficient or excessive quantity or ineffective quality of social exchange.
Social Isolation: Aloneness experience by the individual and perceived as imposed by others and as a negative or threatened state

XII COGNITIVE PERCEPTION PATTERN

Cognitive perception pattern assesses the ability of the individual to understand and follow directions, retain information, make decisions, and solve problems
Perception - acquiring information regarding environment
Cognition - process of knowing, thinking, remembering, reasoning
Perceptual functions - sensory organs and structures for vision, hearing, taste, touch, smell, position sense
Cognitive functions - learning style, language or communication capabilities, thought processes
Sensory-perceptual experiences - pain, hallucinations, altered thought processes
Cognitive-Perceptual Pattern. * Acute confusion * Acute pain * Chronic confusion * Chronic pain * Decisional conflict * Deficient knowledge * Disturbed sensory perception * Disturbed thought processes * Impaired environmental interpretation syndrome * Impaired memory * Readiness for enhanced comfort * Readiness for enhanced decision making * Readiness for enhanced knowledge * Risk for acute confusion * Unilateral neglect

NURSING DIAGNOSIS: Confusion
Nursing Interventions & Rationale Nursing Interventions | Rationale | Observe for changes in behavior and mentation, e.g., lethargy, confusion, drowsiness, slowing/slurring of speech, and irritability (may be intermittent). Arouse patient at intervals as indicated. | Ongoing assessment of behavior and mental status is important because of fluctuating nature of impending hepatic coma. | Review current medication regimen/schedules. | Adverse drug reactions or interactions (e.g., cimetidine plus antacids) may potentiate/exacerbate confusion. | Evaluate sleep/rest schedule. | Difficulty falling/staying asleep leads to sleep deprivation, resulting in diminished cognition and lethargy. | Note development/presence of asterixis, fetor hepaticus, seizure activity. | Suggests elevating serum ammonia levels; increased risk of progression to encephalopathy. | Consult with SO about patient’s usual behavior and mentation. | Provides baseline for comparison of current status. | Have patient write name periodically and keep this record for comparison. Report deterioration of ability. Have patient do simple arithmetic computations. | Easy test of neurological status and muscle coordination. | Reorient to time, place, person as needed. | Assists in maintaining reality orientation, reducing confusion/anxiety. | Maintain a pleasant, quiet environment and approach in a slow, calm manner. Encourage uninterrupted rest periods. | Reduces excessive stimulation/sensory overload, promotes relaxation, and may enhance coping. | Provide continuity of care. If possible, assign same nurse over a period of time. | Familiarity provides reassurance, aids in reducing anxiety, and provides a more accurate documentation of subtle changes. | Reduce provocative stimuli, confrontation. Refrain from forcing activities. Assess potential for violent behavior. | Avoids triggering agitated, violent responses; promotes patient safety. | Discuss current situation, future expectation. | Patient/SO may be reassured that intellectual (as well as emotional) function may improve as liver involvement resolves. | Maintain bedrest, assist with self-care activities. | Reduces metabolic demands on liver, prevents fatigue, and promotes healing, lowering risk of ammonia buildup. | Identify/provide safety needs, e.g., supervision during smoking, bed in low position, side rails up and pad if necessary. Provide close supervision. | Reduces risk of injury when confusion, seizures, or violent behavior occurs. | Investigate temperature elevations. Monitor for signs of infection. | Infection may precipitate hepatic encephalopathy caused by tissue catabolism and release of nitrogen. | Recommend avoidance of narcotics or sedatives, antianxiety agents, and limiting/restricting use of medications metabolized by the liver. | Certain drugs are toxic to the liver, whereas other drugs may not be metabolized because of cirrhosis, causing cumulative effects that affect mentation, mask signs of developing encephalopathy, or precipitate coma. | Eliminate or restrict protein in diet. Provide glucose supplements, adequate hydration. | Ammonia (product of the breakdown of protein in the GI tract) is responsible for mental changes in hepatic encephalopathy. Dietary changes may result in constipation,which also increases bacterial action and formation of ammonia. Glucose provides a source of energy, reducing need for protein catabolism. Note: Vegetable protein may be better tolerated than meat protein. | Assist with procedures as indicated, e.g., dialysis, plasmapheresis, or extracorporeal liver perfusion. | May be used to reduce serum ammonia levels if encephalopathy develops/other measures are not successful. |

Care Plan: Nursing Interventions for Acute Pain ursing interventions for acute pain * Explore the need for both opioid and non-opioid pain medicine * Determine the clients current medication is effective for the pain relief especially if the patient has taken the pain medicine all day with no relief. * It is okay as a nurse, to suggest to the doctor a patient controlled analgesia (PCA) but most the time these are standard for acute pain that develops after surgery. * If you can avoid it, try not to give pain medication intramuscularly due to pain from needle stick. * Be clear to the patient about how the doctors and nurses are going to provide pain management, such as therapies, type medications to be given, to include side effects and complications. * · Plan nursing care such as dressing changes, showers, ambulation when the patient is comfortable and has been given a pain medication about 30 min. before care is to be given. This will promote patient cooperation. * · Sometimes patients have fears of taking medications they are not used to, find out if the patient has any fear of overdose or addiction to pain medication, whether ibuprofen or morphine. You would be surprised the amount of patients that are hesitant to even take aspirin at home. * · When giving pain medication determine on a scale 0 to 10 what the patient's pain is before the pain medication is given, and 30 min. to an hour after pain medication to see if there has been a change. * · When giving opioids check respiratory status and how often the patient is sedated about every two hours for the first 24 hours. Especially if the drug is new to them. It may be appropriate to awaken a patient that is sleeping if their respirations' are irregular, shallow, or they are snoring. If the patient exhibits excessive sedation notify the physician. * · If more than one pain medication is ordered by the doctor, try to pepper the day with those medications to make it possible to treat breakthrough pain. * · Determine if the client would like to use nonpharmacological methods to help control their pain such as distraction, imagery, relaxation, and heat application as well as cold. * · Only attempt to teach non-medication interventions when the pain is well controlled with medication inventions. * · It may be necessary to get a prescription from the doctor for a stool softener if not already ordered, narcotic medication can slow bowel function.

IMPAIRED MEMOR NURSING CARE
Inability to recall bits of information or behavioral.
CHARACTERISTICS
* Inability to determine whether a behavior was performed * Inability to learn to new skills or information or to perform previous learned skills * Inability to recall factual information and recent or past events * Incidence of forgetting including forgetting to perform a behavior at a schedule time

* Know / oriented towards people's time and place. * Perform daily activities optimally.

Nursing Intervention

* Give an opportunity for patients to know their personal belongings such as beds, cupboards, clothes etc.. * Give the opportunity for patients to know the time by using a large clock, a calendar that has a large sheet of paper per day with. * Give the opportunity for patients to mention his name and closest family members * Give the opportunity for clients to know where it is located. * Give praise if the patient when the patient can answer correctly. * Observation of the patient's ability to perform daily activities * Give the opportunity for patients to choose the activities that can be done. * Help the patient to perform activities that have been chosen * Give praise if the patient can perform activities. * Ask if the patient feel able to perform its activities. * With patients to schedule their daily activities.

Interventions and Evaluation Nursing Care Plans For Dementia NO | DIAGNOSIS | OUTCOME | INTERVENTION | EVALUATION | 1 | Impaired Communication related to cerebral impairment as demonstrated by altered memory, judgment, and word finding | Demonstrate congruent verbal and nonverbal communication. | * Speak slowly and use short, simple words and phrases. * Consistently identify yourself, and address the person by name at each meeting. * Focus on one piece of information at a time. Review what has been discussed with patient. * If patient has vision or hearing disturbances, have him wear prescriptioneyeglasses and/or a hearing device. * Keep environment well lit. * Use clocks,calendars, and familiar personal effects in the patient’s view. * If patient becomes verbally aggressive, identify and acknowledge feelings. * If patient becomes aggressive, shift the topic to a safer, more familiar one. * If patient becomes delusional, acknowledge feelings and reinforce reality. Do not attempt to challenge the content of the delusion. | * Demonstrates decreased anxiety and increased feelings of security in supportive environment | 2 | Bathing or Hygiene Self-Care Deficit related to cognitive impairment as demonstrated by inattention and inability to complete ADLs | Independence in Self-Care | * Assess and monitor patient’s ability to perform ADLs. * Encourage decision making regarding ADLs as much as possible. * Label clothes with patient’s name, address, and telephone number. * Use clothing with elastic and Velcro for fastenings rather than buttons or zippers, which may be too difficult for patient to manipulate. * Monitor food and fluid intake. * Weigh patient weekly. * Provide food that patient can eat while moving. * Sit with patient during meals and assist by cueing. * Initiate a bowel andbladder program early in the diseaseprocess to maintain continence and preventconstipation or urine retention | Maintains maximum degree of orientation and self-care within level of ability | 3 | Risk for Injury related to cognitive impairment and wandering behavior | Safety appears | * Discuss restriction of driving when recommended. * Assess patient’s home for safety: remove throw rugs, label rooms, and keep the house well lit. * Assess community for safety. * Alert neighbors about the patient’s wandering behavior. * Alert police and have current pictures taken. * Provide patient with a MedicAlert bracelet. * Install complex safety locks on doors to outside orbasement. * Install safety bars inbathroom. * Closely observe patient while he is smoking. * Encourage physical activity during the daytime. * Give patient a card with simple instructions (address andphone number) should the patient get lost. * Use night-lights. * Install alarm and sensor devices on doors. | Safety precautions and close surveillance maintained; no injury | 4 | Impaired Social Interaction related to cognitive impairment | Socialization increase | * Provide magazines with pictures as reading and language abilities diminish. * Encourage participation in simple, familiar group activities, such as singing, reminiscing, doing puzzles, andpainting. * Encourage participation in simple activities that promote the exercise of large muscle groups. | Attends group activities; sings, exercises with group | 5 | Risk for Violence: Self-directed or Other-directed related to suspicion and inability to recognize people or places | Risk for violence is not appears | * Respond calmly and do not raise your voice. * Remove objects that might be used to harm self or others. * Identify stressors that increase agitation. * Distract patient when an upsetting situation develops. | |

PAIN MANAGEMENT
Pain may be caused by medical conditions, injury or surgery. Management strategies include pain-relieving medicines, physical or occupational therapy, complementary therapies (such as acupuncture and massage) and cognitive behaviour therapy (CBT). The incidence of pain rises as people get older and women are more likely to be in pain than men. Pain management strategies include pain-relieving medications, physical or occupational therapy and complementary therapies (such as acupuncture and massage).

Studies suggest that a person’s outlook and the way they emotionally cope with long-term (chronic) pain can influence their quality of life. Counselling can help support you to manage the emotional and psychological effects of chronic pain. Understanding the causes of your pain can help reduce your fear and anxiety.

The Basic Concept of Pain

1. Definition of Pain

Pain is a subjective sensory and emotional experience unpleasant tissue damage associated with actual or potential or perceived in the events where the damage occurred.

Another definition of pain is a subjective experience, greatly influenced by private educational, cultural, and cognitive meaning of the situation.

2. Type of pain based on the duration and length

Pain is usually divided into two major types are acute and chronic pain. Both can be distinguished from the onset, duration and cause pain.

a) Acute pain

Acute pain occurs after an acute injury, illness or surgical intervention and has a rapid onset, with varying intensity (mild to severe) and lasts for a short time (Meinhart and Mc Caffery, 1983, NIH 1986 in Potter and Perry, 1997).

By Bonica in 1987, acute pain as a collection of unpleasant experiences associated with sensory, perceptual and emotional responses related to the autonomic, emotional and behavioral.

Acute pain is usually a new event, a sudden and short duration. It is associated with acute illness, surgery or medical procedures or trauma and pain can help to determine its location. Another characteristic is the sense of pain can usually be identified, the pain was quickly reduced / lost, are clear and likely to end up / missing.

b) Chronic Pain

Chronic pain is pain that lasts a long, varied in intensity and usually lasts more than six months (Mc Caffery, 1986 in Potter and Perry, 1997). On clients with chronic pain often experience periods of remission (partial or complete loss of symptoms) and exacerbation (increased severity). The nature of this chronic pain can not be predicted which makes the client often leads to frustration and psychological depression.

Chronic pain is a situation or circumstance that experience persistent pain / continuously for several months / years after the healing phase of an acute illness / injury. Characteristics of chronic pain is not easily identifiable area of pain, reduced pain intensity difficult, the pain usually increases, its nature is less obvious and less likely to heal / disappear.

Chronic pain can be categorized into two: chronic pain of malignant and non malignant. Malignant chronic pain can be described as pain associated with cancer or other progressive diseases. Non-malignant chronic pain is usually associated with pain due to non-progressive tissue damage, or have experienced healing.

3. Type of pain based on the intensity

The intensity of pain a person can be known from the assessment tools used. In the verbal descriptions of pain, the individual is the best assessor of the pain they experienced and should therefore be asked to describe and make level. Obtained pain intensity was measured using a scale of them; simple descriptive pain intensity scale, a scale of 0-10 numerical pain intensity and visual analogue scale (VAS). Scale used to describe the intensity / severity of pain.

a. Simple descriptive pain intensity scale
Pain intensity scale of this simple descriptive pain using six images of different facial expressions, showing a happy face to sad face, which is used to express pain. This scale can be used from children age 3 (three) years.

b. Numeric pain intensity scale: 0 -10
Severity of pain or pain made into measurable with subjective pain make objective opinion. Numerical scale, was used from 0 to 10, zero (0) is a state with no or a pain-free, while ten (10), a very great pain.

c. Visual analog scale (VAS)
Similar scale is a straight line, without figures. Be free to express pain, to the left to no pain, unbearable pain in the right direction, with the center about which pain is. Clients asked to indicate the position of pain on the line between these two extreme values.

NANDA Nursing Care Plan for Pain

Pain Definition - Nanda

Feeling and an unpleasant emotional experience arising from tissue damage or a description of actual and potential damage. It can occur suddenly or slowly, the intensity of light or heavy. With predictions of healing time is approximately less than 6 months.

Defining characteristics:
Reports of verbal and nonverbal
Observation reports
Position the patient to be careful to avoid the pain
Movement to protect themselves
Cautious behavior
Face mask
Sleep disturbances (glazed eyes, looked tired, which is difficult or chaotic movement, smirk)
Focus on self-
The focus narrows (decreasing the perception of time, damage fikir process, decreasing the interaction with people and the environment)
Distracting activity (a walk, meet other people or activities, repetitive activities)
Response autonomy (diaphoresis, changes in blood pressure, changes in breathing, pulse and dilated pupils).
Autonomy in response to changes in muscle tone (visible from the weak to stiff)
Expressive behavior (restlessness, moaning, crying, alert, iritabel, deep breath, sigh)
Changes in appetite, drinking
Interventions and Rational:

* Perform a comprehensive assessment * Observation of nonverbal reactions and discomfort * Use therapeutic communication to know the experience of pain * Assess the culture that affect the pain response * Evaluation of past experience of pain * Assist patients and families to seek and find support * Environmental control * Reduce the Pain of precipitation factor * Select and doing pain management (pharmacologic, non-pharmacological and interpersonal) * Assess the source and type of pain to determine intervention * Teach about non-pharmacological techniques * Give analgesics for pain relief * Increase breaks * Collaboration with a physician if there are complaints of pain and the action does not work * Monitor the patient acceptance of pain management.

Terms
Parenting: Impaired: State in which one or more caregivers demonstrate a real or potential inability to provide a constructive environment that nurtures the growth and development of the child (children).
Social isolation: State in which a person or group experiences or perceives a need or desire for increased involvement with others but is unable to make contact.
Comfort, Impaired: State in which an individual experiences an uncomfortable sensation in response to a noxious stimulus. Related to uterine contractions during labor, trauma to perineum during labor, involution of uterus or engorged breasts.
Fear: related to: lack of knowledge, pain, failure, invasive procedures, financial
Acute Pain: Pain is whatever the experiencing person says it is, existing whenever the person says it does; unpleasant sensory and emotional experience arising from actual or potential tissue damage or describe in terms of such damage; sudden or slow onset of pain of any intensity from mild to severe with anticipated or predictable end. The discomfort of normal labor or abnormal conditions such as prolonged latent phase, abnormal fetal position, CPD, or side effects of sedation or analgesia
Chronic Pain: Pain is whatever the experiencing person says it is, existing whenever the person says it does ; unpleasant sensory and emotional experience arising from actual or potential tissue damage or describe in terms of such damage (International Association for the Study of Pain); sudden or slow onset of pain of any intensity from mild to severe, constant or recurring, without anticipated or predictable end; state in which the individual experiences pain that persists for a period of time beyond the expected course or reasonable duration.
Confusion, Acute: Abrupt onset of a cluster of global, transient changes and disturbances in attention, cognition, psychomotor activity level, consciousness or sleep-wake cycle.
Confusion, Chronic: Irreversible, long-standing, and/or progressive deterioration of intellect and personality characterized by decreased ability to interpret environmental stimuli and decreased capacity for intellectual thought processes, and manifested by disturbances of memory, orientation and behavior.
Decisional Conflict (specify) – Uncertainty about course of action to be taken when choice among competing actions involves risk, loss or challenge to personal life values.
Impaired verbal communication: The state in which a person experiences a decreased ability to speak and understand others. Related to: inability to speak or understand English.
Knowledge Deficit: (Specify) Absence of deficiency of cognitive information related to a specific topic.
Sensory-Perception, Disturbed: (Specify) (Visual, Auditory, Kinesthetic, Gustatory, Tactile, Olfactory) Change in the amount or patterning of incoming stimuli accompanied by a diminished, exaggerated, distorted, or impaired response to such stimuli.
Thought Processes, Altered: Disruption in cognitive operations and activities.
Readiness for enhanced knowledge: Related to interest in acquiring cognitive information. Expresses interest in learning, explains knowledge of topic, previous experience.

UNIT XIII
Self-Perception, Self-concept Pattern
Assessment is focused on the person's attitudes toward self, including identity, body image, and sense of self-worth. The person's level of self-esteem and response to threats to his or her self-concept may be identified. Attitudes about self, sense of worth, perception of abilities, emotional patterns, body image, identity. Inquire about - Anxiety, fear, control, self concept.
Self-Perception-Self-Concept Pattern

Its focused on the person’s attitudes toward self, including identity, body image, and sense of self-worth. * Anxiety * disturbed Body image * Chronic low self-esteem * Death anxiety * Disturbed personal identity * Fear * Hopelessness * Powerlessness * Readiness for enhanced hope * Readiness for enhanced power * Readiness for enhanced self-concept * Risk for compromised human dignity * Risk for loneliness * Risk for powerlessness * Risk for situational low self-esteem * Risk for [/actual] other-directed violence * Risk for [actual/] self-directed violence * Situational low self-esteem

Nanda Care Plan for Anxiety Anxiety

Anxiety is a signal to awaken; warned of the danger and allows one to take action and tackle the threat.

Anxiety related to feeling uncertain / helplessness, emotional state does not have a specific object.

Panic disorder experienced by approximately 1.7% of the adult population. Lifetime incidence of panic disorder was reported 1.5% to 5%, while the panic attacks as much as 3% to 5.6%.

Panic disorder is often chronic occurred, vary widely among individuals. In the long term, 30% - 40% of patients no longer have panic attacks, 50% experience mild symptoms that do not affect his life, while the rest are still experiencing significant symptoms (Elvira, 2008).

Anxiety is different from Fear

Fear is the man dreams of a clear source, or where the person is the object which can identify and explain the object. Involves the interpretation of intellectual fear of the threatening stimulus, whereas anxiety involves the emotional response to the interpretation.

Criteria for panic attacks, obsessions and compulsions

Panic * Palpitations, heart beating hard * Sweat * Shaky or unsteady * Feeling choked * Chest pain * Nausea * Feeling dizzy
Obsession
* Thoughts, impulses or images over and over and settle * Thoughts, impulses with excessive worries * Individuals attempt to suppress the irrational thoughts * Individuals recognize the mind's obsession
Compulsive
* Repetitive behavior (such as hand washing) or mental acts (eg praying, counting, muttering words without sound) so that individuals feel compelled to do in response to an obsession.

Signs and symptoms of anxiety

Patients come to the health or psychiatric services typically complain of triad-anxiety, namely; * the anxiety of uncertain future, * over the activity, and * a feeling of tension and fear.

Nanda Nursing Diagnosis for Anxiety 1. Breathing pattern, ineffective 2. Individual coping, ineffective 3. Verbal communication, Impaired 4. Anxiety 5. Powerlessness 6. Fear

Nursing Interventions, Implementation and Evaluation :

Interventions :

1. Protect clients from harm
Construct the therapeutic relationship: first thank his will and give clients the support of the fight.
Recommend the reality of pain-related coping mechanisms Do not focus on phobias, rituals or physical complaints.
Feedback on: the behavior of stress, assessment of stressors and coping resources
Reinforce the idea that physical health Dealing with emotional health.
Then begin to limit maladaptive behavior by supporting clients.

2. Environmental modifications that can reduce anxiety
Perform a calm manner to the client.
Reduce the environmental stimulation.
Limit patient interaction with others, to minimize the spread of anxiety in others.
Identification and modification of situations that affect anxiety.
Provide measures to support the physical, such as a warm bath, massage.

3. Encourage clients to do the activities that have been scheduled
Support clients to share their activities with activities such as cleaning the room, then take care garden reinforcement given socially productive behavior.
Give some kind of physical exercise such as gymnastics, relaxation.
Together with the client to create a schedule of activities.
Involve the family or other support systems that allow.

4. Collaboration for the administration of antianxiety drugs to reduce the symptoms of severe anxiety.
Collaboration of antianxiety drugs,
Observe the side effects of drugs.

Nursing Care Plan for Low Self-Esteem

Low self-esteem is a person rejects as something precious and is not responsible for their own lives. If the individual often fails it tends to lower self-esteem. Low self-esteem if it loses the love and appreciation of others. Self-esteem derived from self and others, the main aspect is to be accepted and received awards from other people.

Low self-esteem disturbance described as negative feelings about themselves, including the loss of confidence and self esteem, sense of failure to reach the desire, self-criticism, reduced productivity, which is directed destructive to others, feelings of inadequacy, irritable and withdrawnsocially.

Nursing Interventions & Rationale Nursing Interventions | Rationale | Have patient draw picture of self. | Provides opportunity to discuss patient’s perception of self/body image and realities of individual situation. | Involve in personal development program, preferably in a group setting. Provide information about proper application of makeup and grooming. | Learning about methods to enhance personal appearance may be helpful to long-range sense of self-esteem/image. Feedback from others can promote feelings of self-worth. | Suggest disposing of “thin” clothes as weight gain occurs. Recommend consultation with an image consultant. | Provides incentive to at least maintain and not lose weight. Removes visual reminder of thinner self. Positive image enhances sense of self-esteem. | Assist patient to confront changes associated with puberty/sexual fears. Provide sex education as necessary. | Major physical/psychological changes in adolescence can contribute to development of eating disorders. Feelings of powerlessness and loss of control of feelings (in particular sexual sensations) lead to an unconscious desire to desexualize self. Patient often believes that these fears can be overcome by taking control of bodily appearance/development/function. | Establish a therapeutic nurse/patient relationship. | Within a helping relationship, patient can begin to trust and try out new thinking and behaviors. | Promote self-concept without moral judgment | Patient sees self as weak-willed, even though part of person may feel sense of power and control (e.g., dieting/weight loss). | States rules clearly regarding weighing schedule, remaining in sight during medication and eating times, and consequences of not following the rules. Without undue comment, be consistent in carrying out rules. | Consistency is important in establishing trust. As part of the behavior modification program, patient knows risks involved in not following established rules (e.g., decrease in privileges). Failure to follow rules is viewed as patient’s choice and accepted by staff in matter-of-fact manner so as not to provide reinforcement for the undesirable behavior. | Respond (confront) with reality when patient makes unrealistic statements such as “I’m gaining weight, so there’s nothing really wrong with me.” | Patient may be denying the psychological aspects of own situation and is often expressing a sense of inadequacy and depression. | Be aware of own reaction to patient’s behavior. Avoid arguing. | Feelings of disgust, hostility, and infuriation are not uncommon when caring for these patients. Prognosis often remains poor even with a gain in weight because other problems may remain. Many patients continue to see themselves as fat, and there is also a high incidence of affective disorders, social phobias, obsessive-compulsive symptoms, drug abuse, and psychosexual dysfunction. Nurse needs to deal with own response/feeling so they do not interfere with care of patient. | Assist patient to assume control in areas other than dieting/weight loss, e.g., management of own daily activities, work/leisure choices. | Feelings of personal ineffectiveness, low self-esteem, and perfectionism are often part of the problem. Patient feels helpless to change and requires assistance to problem-solve methods of control in life situations. | Help patient formulate goals for self (not related to eating) and create a manageable plan to reach those goals, one at a time, progressing from simple to more complex. | Patient needs to recognize ability to control other areas in life and may need to learn problem-solving skills to achieve this control. Setting realistic goals fosters success. | Note patient’s withdrawal from and/or discomfort in social settings. | May indicate feelings of isolation and fear of rejection/judgment by others. Avoidance of social situations and contact with others can compound feelings of worthlessness. | Encourage patient to take charge of own life in a more healthful way by making own decisions and accepting self as she or he is at this moment (including inadequacies and strengths). | Patient often does not know what she or he may want for self. Parents (mother) often make decisions for patient. Patient may also believe she or he has to be the best in everything and holds self responsible for being perfect. | Let patient know that is acceptable to be different from family, particularly mother. | Developing a sense of identity separate from family and maintaining sense of control in other ways besides dieting and weight loss is a desirable goal of therapy/program. | Use cognitive-behavioral or interpersonal psychotherapy approach, rather than interpretive therapy. | Although both therapies have similar results, cognitive-behavioral seems to work more quickly. Interaction between persons is more helpful for patient to discover feelings/impulses/needs from within own self. Patient has not learned this internal control as a child and may not be able to interpret or attach meaning to behavior. | Encourage patient to express anger and acknowledge when it is verbalized. | Important to know that anger is part of self and as such is acceptable. Expressing anger may need to be taught to patient because anger is generally considered unacceptable in the family, and therefore patient does not express it. | Assist patient to learn strategies other than eating for dealing with feelings. Have patient keep a diary of feelings, particularly when thinking about food. | Feelings are the underlying issue, and patient often uses food instead of dealing with feelings appropriately. Patient needs to learn to recognize feelings and how to express them clearly. | Assess feelings of helplessness/hopelessness. | Lack of control is a common/underlying problem for this patient and may be accompanied by more serious emotional disorders. Note: Fifty-four percent of patients with anorexia have a history of major affective disorder, and 33% have a history of minor affective disorder. | Be alert to suicidal ideation/behavior. | Intense anxiety/panic about weight gain, depression, hopeless feelings may lead to suicidal attempts, particularly if patient is impulsive. | Involve in group therapy. | Provides an opportunity to talk about feelings and try out new behaviors. | Refer to occupational/recreational therapy. | Can develop interest and skills to fill time that has been occupied by obsession with eating. Involvement in recreational activities encourages social interactions with others and promotes fun and relaxation. |

Terms

Self-Concept: Readiness for Enhanced: A pattern of perceptions or ideas about self that is sufficient for well-being and can be strengthened
Self-Concept: Disturbed: State in which a person experiences or is at risk of experiencing a negative state of change about the way she/he feels, thinks or views self. It may include a change in body image, self-esteem or personal identity.
Anxiety: A vague, uneasy feeling of discomfort or dread accompanied by an autonomic response, with the source often non-specific or unknown to the individual; a feeling of apprehension caused by anticipation of daTernger
Fatigue: An overwhelming, sustained sense of exhaustion and decreased capacity for physical and mental work at usual level.
Fear: Response to perceived threat that is consciously recognized as a danger.
Hopelessness: Subjective state in which individual sees limited or unavailable alternatives or personal choices and is unable to mobilize energy for problem solving on his or her own behalf.
Powerlessness: Perception that one’s own actions will not significantly affect an outcome; perceived lack of control over current situation or immediate happening.
Body image Disturbance: Confusion in mental picture of one’s physical self.
Chronic Low Self-Esteem: Long-standing negative self-evaluations/feelings about self or self-capabilities
Situational Low Self-Esteem: Development of a negative perception of self-worth in response to a current situation (specify)

XIV VALUE BELIEF PATTERN
Value-Belief Pattern

It’s focused on the person’s values and beliefs. * Impaired religiosity * Moral distress * Readiness for enhanced religiosity * Readiness for enhanced spiritual well-being * Risk for impaired religiosity * Risk for spiritual distress * Spiritual distress

Terms
SPIRITUAL STRESS
Impaired ability to experience and integrate meaning and purpose in life through the individual’s connectedness with self ,others ,art music ,literature ,nature or a power greater than oneself.
MORAL DISTRESS
Response to the inability to carry out one’s chosen ethical moral decision./ action

RELIGIOSITY ,IMPAIRED : impaired ability to exercise reliance on beliefs and or participate faith tradition .

Value-Belief Pattern

It’s focused on the person’s values and beliefs. * Impaired religiosity * Moral distress * Readiness for enhanced religiosity * Readiness for enhanced spiritual well-being * Risk for impaired religiosity * Risk for spiritual distress * Spiritual distress