Introduction of medical surgical nursing

Mr.A.Sanjaikumar M.Sc Nursing,
PhD Fellow
Medical Surgical Nursing
Critical Care Department
Associate Professor
School of Health Sciences
Madda Walabu University
Bale Goba.
by SANJAIKUMAR.A 1

Unit I:Introduction to Medical Surgical
Nursing
Unit II: Nursing interventions of patients with
respiratory disorders.
03/04/19 by SANJAIKUMAR.A 2

Definition and Scope of medical surgical nursing
Concepts of health and illness
Nursing process

At the end of this session, you will be able to:
Define medical surgical nursing
Discuss about the scope of medical surgical nursing
Discuss about the concept of health and illness
Discuss about Nursing process

Medical-surgical nursing involves the nursing
care of adult patients
whose conditions or disorders are treated medically/pharmac
ologically, or surgically
It is also defined as the diagnosis and treatment of
human responses of individuals and groups to actual or
potential health problems

 The goal of medical-surgical nursing is to assist the
individual or group in promoting, restoring, or
maintaining optimal health
 The medical-surgical nurse is skilled in assessing,
diagnosing, and treating actual or potential alterations in
functional ability and lifestyle
 Medical-surgical nursing services are provided to clients
from adolescence throughout the life span

• Medical-surgical nursing is practiced in a variety of settings
across the continuum of care; these settings include, but are
not limited to:
Acute And Sub Acute Care Facilities,
Home Care Agencies,
Ambulatory Care Clinics,
Outpatient Services,
Residential Facilities,
Skilled Nursing Facilities,
Private Practice,
Adult Day Care Agencies,
Primary Care And Specialty Practices,
Schools, Insurance Companies, And Private Companies

Health concept
Biomedical concepts: Health has been traditionally defined as
"absence of disease", and disease as deviation from a biochemical
concept" was based on the germ theory of disease, which
dominated medical thought at the turn of the 20th
century.
Ecological concept
Health is a dynamic equilibrium between man & his
environment, and disease is maladjustment of the human
organisms to the environment.

Health concept…
The Nightingale definition of health
Nightingale defined health as a state of “being well and using every
power the individual possesses to the fullest extent” (Nightingale, 1969
[1860], p.334)
The World Health Organization (WHO) definition
Health is a “state of complete physical, mental, and social well-being and
it is not merely the absence of disease and infirmity” (Hood & Leddy,
2002).

Host- agent-environment model
Health and illness depends on
interaction of host, agent and
environmental factors.
When the agent, host and
environment variables are in
equilibrium health is maintained.

The Health illness continuum
model
According to this model, health is
a constantly changing state, with
high level wellness and death being
in the opposite ends of a graduated
scale, or continuum.

High-level wellness model
The function of one's maximum potential while maintaining
balance and purposeful direction in the environment.
The concept of high level of wellness can be applied to the
individual, family, community, environment, and society.
High-level wellness model viewed human beings in
five aspects
1. Each individual is functioning as a total personality.
2. Each person possess dynamic energy.

High-level wellness model ….
3. Each person is at peace with inner and outer worlds.
4.Each person has a relationship between energy use and self
integration.
5. Each person has an inner world and an outer world.

Health Belief Model
The health belief model is based on what people perceive,
or believe, to be true about them in relation to health.
This model is based on three components: perceived
susceptibility to a disease, perceived seriousness of a disease
and perceived value of action.

At the end of this session, students will be able
to:
Define nursing process
List out purpose of nursing process
List out characteristics of nursing process
Discuss about component of nursing process
2003/04/19 by SANJAIKUMAR.A

Common definitions
• Nursing process is an organised, systematic and
deliberate approach to nursing in partnership with the
patient and their family with the aim of improving standards
in nursing care (Rush et al, 1996)
• It is a holistic and interactive approach through which
nursing care provision is organised to achieve patient
centred nursing interventions (Arnold and Boggs, 1999 and
Heaven and Maguire, 1996).
N.B. Linda Hall first introduces the term nursing process in 1965

Common definitions...
• It is a systematic problem solving approach to client care.
• It is a series of planned steps and actions directed toward
meeting the need and solving problems of people and their
significant others
• It is an organised, systematic method of giving goal
oriented, humanistic care that is both effective and efficient.
Nursing process is the cornerstone of the nursing profession

1. To identify clients health care needs
2. To establish nursing care plan so as to meet those needs
3.To give scientific based, holistic, individualized care for the patient;
4. An opportunity to work collaboratively with patients and others;
5. Achieve continuity of care and;
6. Encourages the health care team to observe and interact with the
patient, and not just the task they are performing such as a
administering an injection, dressing change, or a bed bath.
7. The process provides a roadmap that ensures good nursing care and
improves patient outcomes.

Problem-oriented
Goal-oriented
Orderly, planned, systematic
Open to accepting new information during its application
Interpersonal
Permits creativity among nurses and clients
Universal;
 It is applicable to individuals, families, and communities

Access to quality nursing care
Continuity of care
Reduces the incidence of hospital stay
Patient participation reflects respect for human
dignity

 Consistent and systematic nursing education and care
provision
 Job satisfaction
 Professional development
 Avoidance of legal action
 Meeting code of ethics and professional nursing standards
• Speed up diagnosis and treatment of actual and potential
health problems
• Promotes flexibility and independent thinking

Components of the
NP
Components of the Nursing Process
‘ADPIE’

Promote
Prevent
Maintain
Restore
Promote
Prevent
Maintain
Restore
29

• Assessment is the systematic collection of data
(subjective and objective data) to determine the
patient’s health status and to identify any actual or
potential health problem .
• It is the first step in the Nursing Process and includes:
Collection of data
Validation of data
Organizing data
Recording data

Data collection
• Nursing History from client as a primary source
• A comprehensive physical examination that helps to identify the
client’s response to disease; to establish an initial data base for later
comparison, and to validate subjective data presented by the client
during the interview- Not toward identification of disease;
• Laboratory
• Nursing Records
• Relevant Literature
• Input from family and significant others

Ways of Designing Assessment Tool
• Use the Nursing Model– Functional Health Pattern
 This model changes from medical model (disease oriented)
to Nursing model (holistic, human response oriented –Bio-
psycho-social human being)

34
• Sources of information:
Primary Source –
information of assessment comes from
the client
Secondary Source
includes family members, significant
other health care professionals, health records,
and literature review

35
Two categories of data collected:
Subjective data – consists of client’s opinions,
feelings about what is happening. Only the client
can tell you that he/she is afraid or in pain.
Sometimes the client can communicate through
body language: gesture, facial expressions and
body posture. To obtain subjective data you need
sharp interviewing, listening and observation skills
Objective data (precise, accurate
measurements or clears descriptions) – include
all the measurable and observable pieces of
information about the client and his or her overall
state of health.

• Subjective data: consists the client’s opinions, feelings
about what is happening.
• To obtain subjective data you need sharp interviewing,
listening, and observation skills.
E.g. "I feel sick to my stomach."
"I have a stabbing pain in my side."
"I feel like nobody likes me."

• Objective data: include all the measurable and observable pieces of
information about the client and his or her overall state of health.
 Objective data are concrete, observable information such as:
- vital signs, laboratory studies, and changes in physical appearance
Example: Blood pressure of 110/70 mmHg.
Rash on right arm
Urinated 150 ml clear urine
• The term objective means that only precise, accurate measurements
or clear descriptions are used.
N.B. S- S = Subjective data are Stated.
O-O = Objective data are Observable.

Method of data collection
1. Observation: is an assessment tool that relies on the use of
the five senses (sight, touch, hearing, smell and taste) to
discover information about client.
2. Health interview: the health interview is a way of
soliciting information from the client.
 This interview may also be called a nursing history.
3. Physical examination: done from head to toe or on
particular body area depending on the clients condition

• Nursing diagnosis is a clinical judgment about an individual, family
or community response to actual or potential health problems.
• It tells us the health care needs of the patient
• Nursing diagnosis are those problems for which nurses can legally
prescribe definitive interventions independently.
Type of Nursing Diagnosis:
Actual Nursing Diagnosis
Potential Nursing Diagnosis
Wellness Nursing Diagnosis

41
Types of Nursing diagnosis
Actual diagnosis - present at the time of nursing assessment
Risk Nursing Diagnosis – problem does not exist, but the
presence of risk factors indicates that a problem is likely to
develop unless nurses intervene
Wellness diagnosis – describes human responses to levels of
wellness in an individual, family or community that have
readiness for enhancement
Possible nursing diagnosis - one in which evidence about a
health problem is incomplete or unclear; requires more data
either to support or to refute it.
Syndrome diagnosis – a diagnosis that is associated with a
cluster of other diagnoses

42
Nursing Diagnosis Example
Actual diagnosis -Deficient Fluid Volume related to
nausea and vomiting as manifested by dry skin and
mucous membranes and decreased oral intake of fluids
Risk diagnosis -Risk for Infection related to presence
of invasive lines (intravenous line and indwelling
bladder catheter)
Possible diagnosis -Possible Imbalanced Nutrition:
Less Than Body Requirements related to insufficient
oral intake
Wellness diagnosis -Readiness for Enhanced Spiritual
Well-Being

43
• Formulating Diagnostic Statement
A. Formulating Diagnostic statements
 Problem (P): statement of the client’s response
(NANDA label)
 Etiology (E): factors contributing to or probable cause
of the responses
 The two parts are joined by the words related to rather
than due to. The phrase due to implies that one part
causes or is responsible for the other part. By contrast,
the phrase related to merely implies a relationship

Problem Related to Etiology
Constipation Related to
Prolonged
laxative use
Ineffective
Breastfeeding
Related to
Breast
engorgement
44

45
B. Basic three-part statements
 PES format and includes the following:
 Problem (P): statement of the client’s
response (NANDA label)
 Etiology (E): factors contributing to or
probable cause of the response
 Signs and Symptoms (S): defining
characteristics manifested by the client

Problem Related to Etiology As manifested
Signs and
Symptoms
ineffective
airway
clearance
Related to (r/t) incisional
pain as
manifested
by
As manifested by
(a.m.b.)
poor cough
effort”
46

47
C. One-part statements
Some diagnostic statements such as
wellness diagnoses and syndrome nursing
diagnoses consist of a NANDA label only. As
the diagnostic labels are refined they tend to
become more specific, so that nursing
interventions can be derived from the label
itself. Therefore, an etiology may not be
needed.
Example: Rape-Trauma Syndrome

Actual nursing diagnosis should be written as a three-part statement(s)
which includes:
• The problem (P), its cause or etiology (E), Signs and symptoms
(S) (defining characteristics or evident) (the ‘PES’ format)
Therefore, the diagnostic statement should have
 Problem (Health Problem)
 Etiology
 Sign and symptom
Examples:
 “ineffective airway clearance related to incisional pain as manifested by poor
cough effort”

Summary of a 3-part statement for actual nursing diagnosis
1. Health Problem: Ineffective Airway Clearance
N.B. Use one of the NANDA- approved nursing diagnostic labels to
state the problem
(NANDA- North American Nursing Diagnosis Association)
2. Etiology: related to weak cough and incisional pain
3. Signs and symptoms as manifested by poor or no cough (defining
characteristics)

PES Format:
 The PES format describes the problem and its causes(etiology),
together with data(signs and symptoms) that validate the chosen
diagnosis.
 To write the nursing diagnostic statement, you link the problem
and its cause by using “ related to” then add “as manifested
by” or “as evidenced by” and state the major signs and
symptoms that validate the diagnosis

Writing Diagnostic Statements for Potential Nursing Diagnoses
• If you assess a patient and note there are some high-risk factors present
that may cause him to have a certain nursing diagnosis, then you have
identified a potential nursing diagnosis.
• Use a two part format using “related to” to link the potential
problem with the risk factor present

Example:
You were caring for an elderly woman who was very thin, immobile, and
bedridden. She may have had excellent care at home, and as a result, has
beautiful, healthy-looking skin. However, you should be aware that her
age, weight, immobility, and confinement to bed can be contributing or
etiological factors for Impaired Skin Integrity.

• Document the potential nursing diagnosis by writing a two-part
statement that describes both the problem and its cause
E.g. Potential Impaired Skin Integrity related to advanced age,
immobility, and confinement to bed
• You would then establish a plan of care that would prevent irritated or
broken skin
E.g. establish a regimen of monitoring for pressure points and of turning,
repositioning, and massaging to promote circulation to the skin

Physician Vs Nursing Diagnosis
Physician diagnosis is disease focused, for e.g.
 “Ato Yidnek has pain and swelling in all joints. Diagnostic studies
indicate that he has rheumatoid arthritis”.
Nursing diagnosis is holistic, considering both the problem and its
effect on the patient and family, for e.g.
 “Ato Yidnek has pain and swelling in all joints, making it difficult to
feed and dress himself. He has voiced that it's difficult to feel
worthwhile when he can't even feed himself”.

• Don’t state the nursing diagnoses using the medical
terminology; focus on the person’s response to the medical
problems;
• Don’t state two problems at the same time;
e.g. anxiety and pain
• Don’t state the nursing diagnosis based on a value judgment

• Planning: development of goals and a plan of care designed to
assist the patient in resolving the diagnosed problems.
• It includes: Setting priorities, establishing expected outcomes,
and selecting nursing interventions & recording the plan of care
• Nursing care plan: is a record of nursing interventions that
will address the identified problems; it’s a legal document that
identifies the care to be given, and it shows who planned and
gave that care, it aids continuity of care, it is a logical and
systematic flow of ideas through from the initial assessment to
the final evaluation (Rush and Fergy, 1996).

• Types of Planning
Initial planning
Usually developed by the admitting nurse who performs the
assessment
Planning should be initiated as soon as possible after the
initial assessment, especially because of the trend toward
shorter hospital stay
Ongoing planning
Is done by all nurses who work with the client
Also occurs at the beginning of a shift as the nurse plans the
care to be given that day
Discharge planning
The process of anticipating and planning for needs after
discharge 58

59
• Developing a Nursing Care Plan
Informal nursing care plan – is a strategy for action
that exist in the nurse’s mind
Formal nursing care plan – written or computerized
guide that organizes information about the client’s
care
Standardized care plan – a formal plan that specifies
the nursing care for groups of clients with common
needs
Individualized care plan – tailored to meet the unique
needs of a specific client

In writing the nursing care plan, the nurse should think about:
 Who is it for?
 What are the short term and long term goals?
 How can you determine that you have reached the goals?
(measurable)
 How will the patient know he/she has achieved the goals?
(realistic)

In writing the nursing care plan, the nurse should think about..
• Who is involved in the delivery of the care? (The patient (and family),
yourself, the nursing team, medical staff, multidisciplinary team, labs,
investigations, procedures etc)
 nursing centred, and it identifies the scope and depth of the nursing
practice
• How quickly is the problem likely to change?
• How soon will you need to re-evaluate the plan?
• How many problems are there?
• Which order of priority?

Priority setting
• Nursing diagnoses are ranked in order of importance.
• Survival needs or imminent life threatening situations takes the
highest priority.
• For example, the needs for air, water and food are survival needs.
Nursing diagnostic categories that reflect these high-priorities
needs include Ineffective Airway Clearance and deficient fluid
volume.

Priority setting …
During setting criteria, consider the following points:
• Actual problems take precedence over potential concerns.
• Airway should always be given highest priority.
• Clients with unstable condition should be given priority over those with
stable conditions.

• Priority setting is based on
Maslow's hierarchy of human
needs

• Priority 1. - Life threatening problems and those interfering with
physiologic needs. (Ex. Problems with respiration, circulation,
nutrition, hydration, elimination, temperature regulation, physical
comfort);
• Priority 2. - Problems interfering with safety and security (ex.
Environmental hazards, fear)
• Priority 3. - Problems interfering with love and belonging (ex.
Isolation or loss of a loved one)

• Priority 4. - Problems interfering with self esteem (ex. Inability
to wash hair, perform normal activities)
• Priority 5. - Problems interfering with the ability to achieve
personal goals.
Exercise-
Q. If you had someone with the following problems, which problem
would you need to treat immediately?
A. diarrhea B. severe dyspnea C. High risk for fluid volume deficit

Setting client centered goals (Outcomes)
• Writing client-centered goals (what the client is expected to
achieve) instead of nursing goals (what the nurse aims to
achieve) has been recognized as an effective method of writing goal
statements.
• This is because client centered goals focus on the desired result of
the plan of care, which is that the client benefit from nursing care.


Outcome Identification
Outcome criteria should be specific, measurable, attainable,
realistic and time-bound
Example 1
Goal(Outcome):
The patient will report a decreased anxiety level regarding surgery
Possible outcome criteria:
• During patient teaching, the patient discusses fears and concerns
regarding surgical procedure.
• After patient teaching, the patient verbalizes decreased anxiety.
• The patient identifies a support system and strategies to use to reduce
stress and anxiety related to the surgical experience.

Outcome Identification…
Example 2
Goal (Outcome)
The patient will bring out pulmonary secretions.
Possible outcome criteria:
• After the teaching session, the patient demonstrates proper coughing
techniques.
• The client drinks at least 6 glasses of water per day while in the
hospital.
• The caregiver demonstrates proper techniques of chest
physiotherapy including percussion and postural drainage, before
discharge

Group exercise
Plan the Nursing Care for
• MS. MARICEL AZUCENA, 28 years of age with Medical Diagnosis
(upon admission) of Acute Gastroenteritis
Subjective data: States…
• “I am weak and worried about my condition.”, “My stool is very watery and
frequent” and “I’m feeling very feverish”
Objective data:
• Temp = 38.0 C (oral), Pulse = 110 per minute
• Respiration rate = 32 per minute,
• Decreased PA O2 , the nurse observed
• that the patient had diarrhoea
• x 2-3 times of ½ cup per bout following admission

– Carrying out the planned nursing
interventions
• Implementing skills include the
following:
•Cognitive skills/intellectual skills
•Interpersonal skills
•Technical skills
73

•Implementing skills include the following:
Cognitive skills/intellectual skills –include problem
solving, decision-making, critical thinking, and creativity.
They are crucial to safe intelligent nursing care
Interpersonal skills – all of the activities, verbal and
non-verbal, that people use when interacting directly with
one another
Technical skills – “hands-on” skills such as
manipulating equipment , giving injections and
bandaging, moving, lifting and repositioning clients. These
skills are also called tasks procedures, or psychomotor
skills. The psychomotor includes the interpersonal
component, for example, the need to communicate with
the client 74

• Implementation of established plan of care is putting
the plan into action and it includes the following activities:
1.Carrying out the Nursing Interventions and
Activities prescribed in the nursing care plan during the
planning phase
2.Ongoing collection of information to determine how
the patient is responding to nurses’ actions and to identify
new problems
3.Recording (Charting) and Communicating patient's
health status and response to nursing interventions

Nurses function during Intervention
Independent Interventions
Dependent Interventions
Collaborative or Interdependent Interventions

Types of Nursing Interventions
Independent interventions (nurse-initiated
treatments) – activities that nurses are licensed to
initiate on the basis of their knowledge and skills
Dependent interventions (physician-initiated
treatments) – activities carried out under the
physician’s order or supervision, according to
specified routines.
Collaborative interventions – actions the nurse
carries out in collaboration with other health team
members, such as physical therapists, social workers,
dietitians and physicians

 Nurses should use a wide range of interventions designed to
(RMP): Restore, Maintain and Promote
Nursing interventions should be:
 Evidenced based info. On relevant Rx modalities
 Selected based on the needs and/or desires of the patient and
accepted practice
 Selected according the nurse’s level of practice, education, and
certification implemented within established plan of care
 Adapted to changing patient needs and situations
 Reviewed in order to understand the progress or lack of
progress toward identified goals

• Nursing evaluation is the regular review of the effect of nursing
interventions and the treatment regimen on the patient’s health status
and expected health outcomes.
• During this phase
Collect data regarding your client progress
Measure goal attainment
Revise or modify care plan if necessary

The following questions should be considered:
 Have the goals of the nursing care plan been achieved? If not, why
not?
 Were the goals realistic?
 Was the patient committed to the goals?
 Was there enough time to achieve the goals?
 Did other problems arise that impeded progress?
 Were interventions consistently performed as prescribed?

The following questions should be considered...
 Have any new problems developed that have not been addressed?
 Could more have been achieved than originally hoped for?
 Should new goals be set?

• Follow a SOAP format including SOAPE, SOAPIE, and
SOAPIER notes.
• These are acronyms for subjective data (S), objective data (O),
assessment (A) and plan (P).
• Some also use intervention (I), evaluation (E), and response (R).

SOAPE…
S- Includes subjective data from the client.
O- Objective data that can be observed or measured.
A- is a conclusion from the subjective and objective data.
 Assessment is an interpretation of the client’s condition or level of
progress.
 It is a statement of the status of the diagnosis or problem.
 It determines whether the problem has been resolved or if further
care is required.

SOAPE…
P- Depending on the assessment of the situation, the health care member
maintains or revises the previous plan of care.
• Plans may include specific orders or interventions designed to manage
the client’s problem and goals and expected outcomes of care.

Thank you !

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