LEARNING MODULE

NCM 103 A

FUNDAMENTALS IN NURSING PRACTICE

Second Semester
Academic Year 2022-2023

Lecturers:

Mrs. Cerina Joy M. Alarca RN MAN

and
NCM 103 A TEAM
VISION: A community of dynamic and proactive scholars and learners within the Asia Pacific Region, upholding
the highest standards of excellence in community service, education, and research towards attainment of better
quality of life

MISSION: To purposively link quality education, training and research with community service in pursuing the
holistic development of individuals through innovative programs and productive activities attuned to the needs
of the global community.

GOALS
St. Dominic College of Asia, a private non-sectarian HEI, aims to:
1. Prepare the students to become competent, productive, and socially responsible professional.
2. Actively promote research and the utilization of new technology for the enhancement of individual
competencies.
3. Assume leadership role in addressing the concerns of the academic community towards improving their
quality of life.

CORE VALUES: Service Dynamism

Competence Accountability

QUALITY POLICY
SDCA commits to providing excellent academic and academic support services that
exceed the expectations of all stakeholders as the College continuously develops and sustains
the effectiveness of its quality management system.

Quality Objectives
1. To achieve excellence in academic programs and projects guided by the College vision
– mission, and in compliance with the CHED, DepEd, and TESDA requirements as well
as those standards observed by duly accredited educational institutions.
2. To establish, implement and maintain effective and efficient quality management
system.
3. To assume leadership role in improving the quality of life of the people by engaging
SDCA stakeholders in meaningful community services.
4. To focus on its task of revolutionizing education by instilling creativity and innovation
among the faculty members, students and administrative staff working collaboratively
on enhancing the culture of research in the College.
5. To identify, nurture, and enhance human, physical and financial resources for
productivity and sustainability.

SDCA QUALITY LIFE FORMULA

1. Research & Product Development: Research & Product Development: Demonstrate ability to develop
researches and to produce scientific and entrepreneurial outputs.
 2. Moral and Spiritual Accountability: Embrace moral/ spiritual values in living one’s life. Apply moral/
spiritual practices in all aspects of life.
3. Multicultural Advocacy: Demonstrate knowledge of values and beliefs of various cultures; effectively
engage in a multicultural society; interact with others; develop a global perspective.
4. Understanding the Discipline: Demonstrate a systematic and coherent understanding of an academic
field of study.
5. Self- Directed Learning: work independently; identify appropriate resource; take initiative; take a lead in
managing a project or an activity through completion.
6. Information and Technology Literacy: Access, evaluate, use variety of relevant sources and produce
materials of the same.
7. Critical Thinking: Identify relevant assumptions or implication; evaluate arguments; apply analytic thought
to analyze coherent arguments.
8. Communication Skills: Express ideas clearly in unity; speak articulately; use media as appropriate in
order to communicate effectively.
9. Creativity and Innovation: Demonstrate ability to work creatively and innovatively in any setting that result
in a productive output.
10. Collaboration and Community Engagement: Demonstrate responsible participation; engage in
meaningful activities in the academe, in the community, and beyond.
PROGRAM OUTCOMES (PO):
1. Apply knowledge of physical, social, natural and health sciences and humanities in the practice
of nursing.
a. Integrated relevant principles of social, physical, natural and health sciences and humanities in the
given health nursing situation.
b. Apply appropriate nursing concepts and actions holistically and comprehensive.
2. Perform safe, appropriate and holistic care to individuals, families, population groups and
community utilizing nursing process.
a. Assess with the client (individual, family, population group, and / or community) one’s health status /
competence.
b. Formulate with the client a plan of care to address the health conditions, needs, problem and issues.
c. Implement safe and quality intervention with the clients to address the health needs problems and
issues.
d. Provide health education using selected planning models to targeted clientele (individual, family,
population group, and / or community).
e. Evaluate with the client the health status / competence and / or process / expected outcomes of
nurse-client working relationship.
f. Institute appropriate corrective actions to prevent or minimize harm arising from adverse effects.
3. Apply guidelines and principles of evidence - based practice in the delivery care.
a. Provide appropriate evidence based nursing care using a participatory approach based on:
• variety of theories and standards relevant to health and healing,
• Research
• Clinical practice
• Client reference
 • Client and staff safety
• Customers care standards
4. Practice nursing in accordance with the existing laws, legal ethical and moral principles.
a. Adhere to ethico–legal considerations when providing safe, quality and professional nursing care.
b. Apply ethical reasoning and decision making process to address situations of ethical distress and
moral dilemma.
c. Adhere to established norms of conduct based on the Philippine Nursing Law and other legal,
regulatory and institutional requirements relevant to safe nursing practice.
d. Protect clients right based on the “Patient’s Bill of Rights and Obligations.”
e. Implements strategies / policies related informed consent as it applies in multiple context
5. Communicate effectively in speaking writing and presenting using culturally appropriate
language.
a. Ensure a working relationship with the client and / or support system base on trust, respect and
shared and decision – making using appropriate communication / interpersonal techniques / strategies.
6. Report / document client care accurately comprehensively.
a. Document client’s response / nursing care services rendered and process / outcomes of the nurse
clients working relationship.
b. Ensure completeness, integrity’s safety, accessibility and security of information.
c. Adhere to protocol and principles of confidentiality in safekeeping and releasing of records and other
information.
7. Collaborate effectively with inter – intra and multi - disciplinary and multi cultural teams.
a. Ensure intra- agency, inter-agency, multidisciplinary and sectoral collaboration in the delivery of
health care.
b. Implement strategies/approaches to enhance/support the capability of the client and care providers
to participate in decision making by the inter-professional team.
c. Maintain a harmonious and collegial relationship among members of the health team for effective,
efficient and safe client care.
d. Coordinate the tasks/functions of other nursing personnel (midwife.BHW and utility worker)
e. Collaborate with other members of the health team in the implementation of programs and services.
f. Apply principles of partnership and collaboration to improve delivery of health services.
g. Collaborates with NGOs and other socio-civic agencies to improve health care services, support
environment protection policies and strategies, and safety and security mechanisms in the
community.
h. Participates as a member of a quality team in implementing the appropriate quality improvement
process on identified improvement opportunities.
8. Practice beginning management and leadership skills using systems approach in the delivery
of client care.
a. Participate in the development and improvement policies and standards and regarding safe nursing
practice and relevant to human resources management.
b. Manage resources (human, physical, financial, time) efficiency and effectively.
c. Apply management and leadership principle in providing direction to manage a community /village-
based.
 d. Use appropriate strategies/approaches to plan community health programs and nursing service.
e. Supervise the implementation of the nursing component of the health services/programs.
f. Ensure that all nursing personnel adhere to standards of safety, bioethical principles and evidence
based nursing practice.
g. Evaluate specific components of health programs and nursing services based on parameters/criteria.
h. Maintain a positive practice environment.
i. Participate in planning and implementation of staff development activities to enhance performance of
nursing support staff.
j. Evaluate performance of nursing support staff using a standard evaluation tool.
9. Conduct research with an experiences researcher.
a. Participate in preparing a research proposal complying with the ethical principles in the nursing
research.
b. Conduct a research study as a member of a research team.
c. Determine if the research problems/questions, learning outcomes and/or hypotheses are clearly and
logically linked to the research purpose, concept and relationship, and propositions generated from
the study framework.
d. Analyze if the conceptual framework the summary of review of related literature, research design,
and data analysis procedure are logically linked with the research purpose, problems/questions, and
hypotheses.
e. Established if the interpretation, implications and recommendations are consistent with the result
considering the limitations of the study.
f. Analyze the research study/report for adherence to standards of writing mechanics, ethical principle
and guidelines in all phases of the research study.
g. Present the research study conducted in partnership with the research team.
10. Engage in lifelong learning with a passion to keep current with national and global
developments in general, and nursing and health developments in particular.
a. Assume responsible for the lifelong learning, own personal development and maintenance of
competence.
b. Demonstrate continued competence and professional growth.
c. Engage in advocacy activities to influence health and social care service policies and access to
services.
d. Model professional behavior.
e. Engage in advocacy activities to deal with the health related concerns and adopts policy that offers
the growth and development of the nursing profession.
11. Demonstrate responsible citizenship and pride in being a Filipino.
a. Exemplify love for country in the service of the Filipinos.
b. Customize nursing intervention based on the Phil culture and values.
12. Apply techno-intelligent care systems and processes in health care delivery.
a. Use appropriate technology to perform safe and efficient nursing activities.
b. Implement system of informatics to support the deliver of health care.
13. Uphold the nursing core values in the practice of the professions.
 a. Demonstrate caring as the core of nursing, love God, love of country and love of people.
b. Manifest professionalism integrity and excellence.
c. Project the positive professional image of Filipino nurses.
14. Apply entrepreneurial skills in the delivery of nursing care.
a. Identify appropriate financial strategies to adhere health related concerns.
b. Apply appropriate financial strategies to address health related concerns and employ financial
policies foster growth and development of the nursing profession.

COURSE INFORMATION
Course Code NCM 103A
Course Title Fundamentals of Nursing Practice
Number of Units 3 units lecture
Number of Contact Hours 54 hours lecture
Pre-requisite/s Theoretical Foundations of Nursing, Anatomy and Physiology and
Biochemistry
Instructor NCM 103 TEAM
Textbook Potter and Perry Fundamentals of Nursing 11th ed. 2022
Other Resource Material/s Kozier & Erb's Fundamentals of Nursing, 10th Edition. (n.d.). ( 2018)
Fundamentals of Nursing Checklist; 10th Edition. Pearson Education
Inc.
I. Specific Course Information
A. Levelof Competency Introduce
B. Course Description This course provides the students with the overview of nursing
as a science, an art and a profession. It deals with the concept
of man as a holistic being comprised of bio- psycho- socio and
spiritual dimensions. It includes a discussion on the different
roles of a nurse emphasizing health promotion, maintenance of
health as well as prevention of illness utilizing the nursing
process. It includes the basic nursing skills needed in the care
of individual clients.

C. Course Objectives At the end of the course and given actual or simulated
situations/condition, the students will be able to:
1. Utilize the nursing process in the holistic care of client for the
promotion and maintenance of health.
1.1. Assess with the client his/her health status and risk factor
affecting health.
1.2. Identify actual wellness/ at risk nursing diagnosis.
1.3. Plan with client appropriate interventions for the promotion
and maintenance of health.
 1.4. Implement with the client appropriate interventions for the
promotion and maintenance of health.
1.5. Evaluate with client outcome of a healthy status.
2. Ensure a well organized recording and reporting system.
3. Observe bioethical principles and the core values (love of
God, caring, love of country and of people)
4. Relate effectively with clients, members of the health team
and others in work situations related to nursing and health, and
5. Observe bioethical concepts/principles and core values and
nursing standards in the care of clients

13 Differentiate health care services based on primary,Health, Wellness

secondary, andand Lecture-prevention
tertiary disease Discussion Class work quiz
categories. Kozier & Erb's
Illness discussio and assignment Fundamentals of
Describe the functions and purposes of the health carea.agencies
Recall outlined in thisnchapter. Nursing, 10th
Identify the roles of various health care professionals. concepts Edition
learned about Journal Potter and Perry
Describe the factors that affect health care delivery. man as an Reading Fundamentals of
Differentiate health, wellness, and well-being. individual and /Video Nursing 11th ed.
as a member and 2022
Compare various models of health of the family. reflection
b. Define SDL#5
Differentiate illness from disease and acute illness from chronic
Health,illness VLOG
Wellness, Podcast
Identify nursing theories focusing on caring
Illness
Analyze the importance of different types of knowledgec.in nursing.
Explain the
dimension of
Describe how nurses demonstrate caring in practice wellness
d. Discuss
Health-Illness
Continuum
e. Enumerate
the stages of
wellness and
Illness
 ➢ Describe the
three levels
of prevention
14 Explain the functions and the physiology of sleep. Lecture- Discussion Class work quiz Kozier & Erb's
- discussio and assignment Fundamentals of
Identify factors that affect normal sleep. Promoting
16 n Nursing, 10th
Explain the role and function of the respiratory system a. Healthy oxygen and carbon dioxide to and from body
in transporting Edition
tissues lifestyle / Potter and Perry
Promoting
Identify common manifestations of impaired respiratory function. Journal Fundamentals of
Physiological
Reading Nursing 11th ed.
Identify essential nutrients and their dietary sources. Health /Video 2022
b. Sleep and
Discuss body weight and body mass standards. c. Oxygenation
reflection
d. Fluid and
Identify factors influencing nutrition SDL#6
Electrolyte VLOG
Identify factors affecting normal body fluid, electrolyte, and balance
acid–base balance. Podcast
e. Nutrition
Discuss the function, distribution, movement, and regulation of fluids and electrolytes in the body.
f. Elimination
Explain the functions and the physiology of sleep. g. Temperature
regulation
Understand the physiology of defecation. h. Mobility and
Identify factors that influence fecal elimination and patternsexercise
of defecation.
i. Hygiene and
Distinguish normal from abnormal characteristics and constituentscomfort of feces.
j.
Describe the process of urination, from urine formation through Pain micturition.
Management
Identify factors that influence urinary elimination. k. Circulation
l. Safety,
Identify common causes of selected urinary problems
security and
Describe four basic elements of normal movement. privacy
Psychosocial and
Differentiate isotonic, isometric, isokinetic, aerobic,Spiritual
and anaerobic
concernsexercise.
Compare the effects of exercise and immobility on body systems.
17 Identify factors influencing cardiovascular function. Lecture- Discussion Class work quiz Kozier & Erb's
Identify major risk factors for the development of coronary heart disease. discussio and assignment Fundamentals of
Promoting Health n Nursing, 10th
List signs of alterations in cardiovascular function. a. Sexuality Edition
b. Spirituality Potter and Perry
Define sexual health.
c. Stress and Fundamentals of
Discuss the varieties of sexuality. Coping. Nursing 11th ed.
d. Concept of response cycle. 2022
Describe physiologic changes in males and females during the sexual
death and
Identify common potential hazards throughout the lifespan.dying/grief
and grieving
Explain measures to prevent injuries e. Care of the
Define the concepts of spirituality and religion as they relateterminally ill and health care.
to nursing
patients and
Describe the spiritual development of the individual across their
the life span.
family
Post mortem care
Differentiate the concepts of stress as a stimulus, as a response, and as a transaction.
Identify physiologic, psychologic, and cognitive indicators of stress.
Differentiate four levels of anxiety.
Discuss types of coping and coping strategies.
Describe interventions to help clients minimize and manage stress.
Describe types and sources of losses.

Identify clinical symptoms of grief

Identify measures that facilitate the grieving process
Describe helping clients die with dignity.
Describe the role of the nurse in working with families or caregivers of dying clients.

WKS 13-17 CONCEPTS OF PROMOTING HEALTH

Objectives:
1. Explain the functions and the physiology of sleep.
2. Identify factors that affect normal sleep.
3. Explain the role and function of the respiratory system in transporting oxygen and carbon
dioxide to and from body tissues
4. Identify common manifestations of impaired respiratory function.
5. Identify essential nutrients and their dietary sources.
6. Discuss body weight and body mass standards.
7. Identify factors influencing nutrition
8. Identify factors affecting normal body fluid, electrolyte, and acid–base balance.
9. Discuss the function, distribution, movement, and regulation of fluids and electrolytes in the
body.
10. Explain the functions and the physiology of sleep.
11. Understand the physiology of defecation.
12. Identify factors that influence fecal elimination and patterns of defecation.
13. Distinguish normal from abnormal characteristics and constituents of feces.
14. Describe the process of urination, from urine formation through micturition.
15. Identify factors that influence urinary elimination.
16. Identify common causes of selected urinary problems
17. Describe four basic elements of normal movement.
 18. Differentiate isotonic, isometric, isokinetic, aerobic, and anaerobic exercise.
19. Compare the effects of exercise and immobility on body systems.
20. Identify factors influencing cardiovascular function.
21. Identify major risk factors for the development of coronary heart disease.
22. List signs of alterations in cardiovascular function.
23. Define sexual health.
24. Discuss the varieties of sexuality.
25. Describe physiologic changes in males and females during the sexual response cycle.
26. Identify common potential hazards throughout the lifespan.
27. Explain measures to prevent injuries
28. Define the concepts of spirituality and religion as they relate to nursing and health care.
29. Describe the spiritual development of the individual across the life span.
30. Differentiate the concepts of stress as a stimulus, as a response, and as a transaction.
31. Identify physiologic, psychologic, and cognitive indicators of stress.
32. Differentiate four levels of anxiety.
33. Discuss types of coping and coping strategies.
34. Describe interventions to help clients minimize and manage stress.
35. Describe types and sources of losses.
36. Identify clinical symptoms of grief
37. Identify measures that facilitate the grieving process

HEALTH PROMOTION
Enhanced when nurses understand:
➢ Individuality
➢ Holism
➢ Homeostasis
➢ Human needs
Individuality
➢ Each individual is a unique being
➢ Focus on total care and individualized care context
➢ Total care context considers all the principles that apply when taking care of any client
➢ Individualized care context means using the total care principles that apply to the
person at this time
Holism
➢ Concerned with the individual as a whole, not as an assembly of parts
 ➢ Strive to understand how one area of concern relates to the whole person
➢ Consider the relationship of individuals to the environment and to others
Characteristics of Homeostatic Mechanisms
➢ Self-regulatory
➢ Compensatory
➢ Regulated by negative feedback systems
➢ Feedback mechanisms

Maslow’s Hierarchy of Needs

➢ Maslow’s Characteristics of the Self-actualized Person
➢ Realistic, sees life clearly, and is objective
➢ Judges people correctly
➢ Has superior perception, is more decisive
➢ Has clear notion of right and wrong
➢ Is usually accurate in predicting future events
➢ Understands art, music, politics, and philosophy
➢ Maslow’s Characteristics of the Self-actualized Person
➢ Possesses humility, listens to others carefully
➢ Is highly creative, flexible, spontaneous, courageous, and willing to make mistakes
➢ Is open to new ideas
➢ Is self-confident and has self respect
➢ Has low degree of self-conflict; personality is integrated
➢ Respects self, does not need fame, possesses a feeling of self control
➢ Is highly independent, desires privacy
➢ Can appear remote and detached
➢ Is friendly, loving, and governed more by inner directives than by society
➢ Can make decisions contrary to popular opinion
➢ Is problem-centered rather than self-centered
➢ Accepts the world for what it is

Health Promotion and Health Protection/Illness Prevention

The difference is the individual’s motivation for behavior
Health Promotion
➢ Not disease oriented
➢ Motivated by personal, positive approach to wellness
➢ Seeks to expand positive potential for health
Health Protection/Illness Prevention
➢ Illness or injury specific
 ➢ Motivated by avoidance of illness
➢ Seeks to thwart the occurrence of insults to health and well-being
Types of Health Promotion Programs
➢ Health promotion
➢ Specific protection
➢ Screening for early detection of disease
➢ Sites of Health Promotion Programs
➢ Various settings for programs:
o In home
o Community
o Schools
o Health care organizations
o Worksites

Health Promotion Model (HPM)

• Competence or approach-oriented model
• Motivational source for behavior changes based on individual’s subjective value of the change
• Variables of HPM
• Individual characteristics and experiences
– Prior related behaviors
– Personal factors
• Behavior-specific cognitions and affect
– Perceived benefits of action
– Perceived barriers to action
– Perceived self-efficacy
– Activity-related affect
– Interpersonal factors
– Situational influences
• Variables of HPM
• Stages of Health
• Commitment to a plan of action
• Immediate competing demands and preferences
• Behavioral outcome
• Stages of Health Behavior Change
Behavior Change
1. Precontemplation
2. Contemplation
3. Preparation
4. Action
5. Maintenance
6. Termination

Nurse’s Role in Health Promotion

1. Model healthy lifestyle
2. Facilitate client involvement
3. Teach self-care strategies
4. Assist clients to increase levels of health
5. Educate clients to be effective health care consumers
6. Assist clients to develop and choose health-promoting options
7. Guide development of effective problem-solving and decision-making
8. Reinforce clients’ personal and family health-promoting behaviors
9. Advocate in the community for changes that promote a healthy environment

Assessment of Health
• Health history
• Physical examination
• Physical fitness assessment
• Lifestyle assessment
• Spiritual health assessment
• Social support system review
• Health risk assessment
• Health beliefs review
• Life-stress review
• Developing Health Promotion Plans
• Based on health needs, desires, and priorities of the client
• Client decides on:
– Goals
– Activities or interventions to achieve these goals
– Frequency and duration of activities
– Method of evaluation

• Implementing Health Promotion Plans

• Emphasis on self responsibility
• Nursing interventions include:
– Supporting
– Counseling
– Facilitating
– Teaching
 – Consulting
– Enhancing the behavior change
– Modeling
–
• Evaluating Health Promotion Plans
• Ongoing
• Collaborative effort
• Client actions may include:
– Continue the plan
– Reorder priorities
– Change strategies
– Revise the contract

ACTIVITIES

1. Health Teaching
2. Classwork Quiz and Assignments
 BASIC CONCEPT OF SLEEP
Physiology of Sleep
➢ Sleep is altered state of consciousness where perception of and reaction to
environment decreased
➢ Cyclic nature of sleep thought to be controlled by lower part of brain
o Neurons in reticular formation integrate sensory information from peripheral
nervous system(PNS) and relay to cerebral cortex
o RAS involved in sleep-wake cycle (reticular activating system (RAS) is a complex
bundle of nerves in the brain that's responsible for regulating wakefulness and
sleep-wake transitions).
➢ Neurotransmitters
- Affect sleep-wake cycle
Serotonin
o Thought to lessen response to sensory stimulation
GABA
o Thought to shut off activity in neurons of RAS
o Gamma aminobutyric acid (GABA) is a naturally occurring amino acid that
works as a neurotransmitter in your brain. Neurotransmitters function as chemical
messengers. GABA is considered an inhibitory neurotransmitter because it
blocks, or inhibits, certain brain signals and decreases activity in your nervous
system.
Acetylcholine, dopamine, noradrenalin associated with cerebral cortical arousal
➢ Exposure to Darkness
➢ Darkness and preparing for sleep cause decrease in stimulation of RAS
➢ Pineal gland begins to secrete melatonin and person feels less alert
➢ During sleep GH secreted and cortisol inhibited
➢ Circadian Rhythm
➢ Circadian synchronization when biological clock coincides with sleep-wake cycle
o Person awake when body temp highest and asleep when body temp lowest
➢ By 3-6 months of age have regular sleep-wake cycle

Functions of Sleep
1. Restores normal levels of activity
2. Restores normal balance among parts of the nervous system
3. Necessary for protein synthesis
4. Psychological well-being
5. Sleep Architecture
6. Refers to basic organization of sleep
Two types that alternate in cycles during sleep
1. NREM - non-rapid eye movement
2. REM - rapid eye movement

1.NREM Sleep
▪ Occurs when activity in RAS inhibited
▪ Constitutes 75% - 80% of sleep
▪ Consists of 4 stages
a. Stage I
➢ Very light sleep and lasts only a few minutes
➢ Feels drowsy and relaxed
➢ Eyes roll from side to side
➢ HR and RR drop slightly
➢ Can be readily awakened and may deny sleeping
b. Stage II
➢ Light sleep lasts only about 10 to 15 minutes
➢ Body processes continue to slow down
➢ Eyes are generally still
➢ HR and RR decrease slightly
➢ Body temperature falls
➢ 44% to 55% of total sleep
➢ Requires more intense stimuli to awaken
c. Stage III and IV
➢ Deepest stages of sleep (delta sleep or deep sleep)
➢ HR and RR drop 20% to 30% below waking hours
➢ Difficult to arouse
➢ Not disturbed by sensory stimuli
➢ Skeletal muscles very relaxed
➢ Reflexes are diminished
➢ Snoring is likely to occur
➢ Swallowing and saliva production reduced
➢ Essential for restoring energy and releasing important growth hormones
d. Physiologic Changes in NREM Sleep
➢ BP falls
➢ Pulse rate decreases
➢ Peripheral blood vessels dilate
➢ CO decreases
➢ Skeletal muscles relax
➢ BMR decreases 10% - 30%
 ➢ GH levels peak
➢ Intracranial pressure decreases

Characteristics of REM Sleep

➢ Occurs every 90 minute
➢ Lasts 5 to 10 minutes
➢ Acetylcholine and dopamine increase
➢ Most dreams take place
➢ Brain is highly active
➢ Brain metabolism increases as much as 20%
➢ Distinctive eye movements occur
➢ Characteristics of REM Sleep
➢ Voluntary muscle tone dramatically decreased
➢ Deep tendon reflexes absent
➢ May be difficult to arouse or may wake spontaneously
➢ Gastric secretions increase
➢ HR and RR often are irregular
➢ Regions of brain associated with learning, thinking, organizing information stimulated

Sleep Patterns: Newborns

➢ Sleep 16 to 18 hours a day
➢ Periods of 1 to 3 hours spent awake
➢ Enter REM sleep immediately
➢ 50% NREM and 50% REM
➢ Sleep cycle ~ 50 minutes

Sleep Patterns:Infants
➢ Awaken every 3 to 4 hours, eat, and then go back to sleep
➢ Periods of wakefulness gradually increase
➢ By 6 months, most infants sleep through the night and establish a pattern
➢ Establish a pattern of daytime naps
➢ Sleep Patterns:
Toddlers
➢ 12 to 14 hours are recommended
➢ Most still need an afternoon nap
➢ Nighttime fears and nightmares are also common
 Sleep Patterns:Preschool and School-age
➢ Preschool child (3-5 years) requires 11 to 13 hours of sleep
➢ Sleep needs fluctuate in relation to activity and growth spurts
➢ School-age child (aged 5 to 12) needs 10-11 hours of sleep
➢ Most receive less

Sleep Patterns: Adolescents

➢ Require 9-10 hours of sleep each night
➢ Few actually get that much sleep
➢ Circadian rhythms tend to shift
➢ Tendency to stay up later and wake later

Sleep Patterns:Adults and Elders

Adults
➢ Most healthy adults need 7-9 hours of sleep
➢ Individual variations
Elders
➢ Tendency toward earlier bedtime and wake times
➢ May show an increase in disturbed sleep
➢ Need to sleep does not decrease with age

Factors the Affect Sleep

1. Illness
2. Environment
3. Lifestyle
4. Emotional stress
5. Stimulants and alcohol
6. Diet
7. Smoking
8. Motivation
9. Medications

Common Sleep Disorders

1. Insomnia
2. Excessive daytime sleepiness
3. Parasomnias
4. Insomnia
5. Difficulty falling asleep
 6. Waking up frequently
7. Difficulty staying asleep
8. Daytime sleepiness
9. Difficulty concentrating
10. Irritability

Risk factors
1. Older age
2. Female

Excessive Daytime Sleepiness

Hypersomnia
- Sufficient sleep at night but cannot stay awake during day
- Caused by medial or psychological disorders
Narcolepsy
- Caused by lack of hypocretin in CNS that regulates sleep
- Clients have sleep attacks
- Sleep at night usually begins with sleep-onset REM period
Sleep Apnea
- Frequent short breathing pauses during night
- More than 5 apneic episodes > 10 sec/hr considered abnormal
- Symptoms include snoring, frequent awakenings, difficulty falling asleep, morning
headaches, memory and cognitive problems, irritability
- Types include obstructive, central, mixed
Parasomnia
- Behavior that may interfere with or occur during sleep
- Arousal disorders
i.e., Sleepwalking ( somnambulism ), sleep terrors
- Sleep-wake transition disorders
i.e., Sleep talking ( somniloquy)
- Associated with REM sleep
i.e., Nightmares
- Others
i.e., Bruxism- a condition in which you grind, gnash or clench your teeth. If you have
bruxism, you may unconsciously clench your teeth when you're awake (awake bruxism)
or clench or grind them during sleep (sleep bruxism). Sleep bruxism is considered a
sleep-related movement disorder.
ACTIVITIES

1. Discussion
2. Journal and Reflection
3. Classwork Quiz and Assignment
 BASIC CONCEPT OF OXYGENATION

Function of the Respiratory System

➢ The function of the respiratory system is gas exchange
➢ Oxygen from inspired air diffuses from alveoli in the lung into the blood in the pulmonary
capillaries
➢ Carbon dioxide produced during cell metabolism diffuses from the blood into the alveoli and
is exhaled.
The Respiratory System
➢ Structures of the Respiratory System

Upper Respiratory Tract

➢ Mouth
➢ Nose
➢ Pharynx
➢ Larynx

Lower Respiratory Tract

• Trachea
• Bronchi
• Bronchioles
• Alveoli
• Pulmonary capillary network
• Pleural membranes

Process of Breathing
1. Inspiration
• Air flows into lungs
2. Expiration
• Air flows out of lungs

• Inspiration
➢ Diaphragm and intercostals contact
➢ Thoracic cavity size increases
➢ Volume of lungs increases
➢ Intrapulmonary pressure decreases
➢ Air rushes into the lungs to equalize pressure
• Exhalation

➢ Diaphragm and intercostals relax

➢ Volume of the lungs decreases
➢ Intrapulmonary pressure rises
➢ Air is expelled

• Gas Exchange
➢ Occurs after the alveoli are ventilated
➢ Pressure differences on each side of the respiratory membranes affect diffusion
➢ Diffusion of oxygen from the alveoli into the pulmonary blood vessels
➢ Diffusion of carbon dioxide from pulmonary blood vessels into alveoli.

• Oxygen Transport
➢ Transported from the lungs to the tissues
➢ 97% of oxygen combines with hemoglobin in red blood cells and carried to tissues as
oxyhemoglobin
➢ Remaining oxygen is dissolved and transported in plasma and cells

• Carbon Dioxide Transport

➢ Must be transported from the tissues to the lungs
➢ Continually produced in the process of cell metabolism
➢ 65% is carried inside the red blood cells as bicarbonate
➢ 30% combines with hemoglobin as carbhemoglobin
➢ 5% transported in solution in plasma and as carbonic acid

Factors that Influence Respiratory Function

1. Age
2. Environment
3. Lifestyle
4. Health status
5. Medications
6. Stress

Common Manifestations of Impaired Respiratory Function

• Hypoxia
• Altered breathing patterns
• Obstructed or partially obstructed airway
Hypoxia
• Condition of insufficient oxygen anywhere in the body
• Rapid pulse
• Rapid, shallow respirations and dyspnea
• Increased restlessness or lightheadedness
Flaring of nares
Substernal or intercostal retractions
• Cyanosis

Altered Breathing Patterns

• Tachypnea (rapid rate) is an increase in the respiratory rate above normal; hyperventilation is
increased minute ventilation relative to metabolic need, and hyperpnea is a disproportionate
rise in minute ventilation relative to an increase in metabolic level. These conditions may not
always be associated with dyspnea.
• Bradypnea (abnormally slow rate) This is when you’re breathing more slowly than normal. It
can mean your body isn’t getting enough oxygen. Bradypnea can be a sign of a condition that
affects your metabolism or another problem, like sleep apnea, carbon monoxide poisoning, or
a drug overdose. Bradypnea can be a sign of a condition that affects your metabolism or
another problem, like sleep apnea, carbon monoxide poisoning, or a drug overdose.
• Apnea (cessation of breathing) potentially serious sleep disorder in which breathing repeatedly
stops and starts. If you snore loudly and feel tired even after a full night's sleep, you might
have sleep apnea.
Types:
• Obstructive sleep apnea (OSA), which is the more common form that occurs when throat
muscles relax and block the flow of air into the lungs
• Central sleep apnea (CSA), which occurs when the brain doesn't send proper signals to the
muscles that control breathing
• Treatment-emergent central sleep apnea, also known as complex sleep apnea, which happens
when someone has OSA — diagnosed with a sleep study — that converts to CSA when
receiving therapy for OSA
• Kussmaul’s breathing an abnormal breathing pattern characterized by rapid, deep breathing
at a consistent pace. It's a sign of a medical emergency — usually diabetes-related
ketoacidosis (DKA), which can affect people with diabetes and people with undiagnosed Type
1 diabetes. This is when you’re breathing more slowly than normal. It can mean your body isn’t
getting enough oxygen.
• Cheyne-Stokes respirations or periodic respiration, involves an atypical pattern of breathing.
It consists of cycles of deep breathing followed by shallow breathing. It can be a sign of lung or
circulatory problems.
Causes: 1. Unstable feedback in the respiratory control system; 2.delayed circulation;
3.Reduced blood gas buffering capacity. As those with Cheyne-Stokes respiration
 hyperventilate, their total carbon dioxide stores are likely to reduce. This interferes with the
carbon dioxide buffering capacity of the body.
• Biot’s respirations also called cluster respiration, is an abnormal pattern of breathing
characterized by groups of quick, shallow inspirations followed by regular or irregular periods
of apnea. It is distinguished from ataxic respiration by having more regularity and similar-sized
inspirations, whereas ataxic respirations are characterized by completely irregular breaths and
pauses. As the breathing pattern deteriorates, it merges with ataxic respirations.
Cause: damage to the medulla oblongata due to strokes or trauma or by pressure on the
medulla due to uncal or tentorial herniation. It generally indicates a poor prognosis.

Alterations in Ease of Breathing

• Orthopnea is the sensation of breathlessness in the recumbent position, relieved by sitting or
standing. Paroxysmal nocturnal dyspnea (PND) is a sensation of shortness of breath that
awakens the patient, often after 1 or 2 hours of sleep, and is usually relieved in the upright
position.
• Dyspnea refers to the sensation of difficult or uncomfortable breathing. It is a subjective
experience perceived and reported by an affected patient. Dyspnea on exertion (DOE) may
occur normally, but is considered indicative of disease when it occurs at a level of activity that
is usually well tolerated.
when you feel “short of breath,” like your body can’t get enough air. It’s a common symptom of
many heart and lung problems, and it can be a sign of something serious, like an asthma
attack or heart attack.

• Obstructed or Partially Obstructed Airway

• Partial indicated by low-pitched snoring during inhalation
• Complete indicated by extreme inspiratory effort with no chest movement

ACTIVITIES
1. Discussion
2. Journal and Reflection
3. Classwork Quiz and Assignment
 BASIC CONCEPT OF FLUIDS AND ELECTROLYTES
Distribution of Body Fluids

Composition of Body Fluids

Movement of Body Fluids

1. Osmosis
2. Diffusion
3. Filtration
4. Active transport
Regulating Body Fluids
• Fluid intake
1. Thirst
• Fluid output
1. Urine
2. Insensible loss
3. Feces
• Maintaining homeostasis
1. Kidneys
2. ADH
3. Renin-angiotensin-aldosterone system
4. Atrial natriuretic system

Regulating Electrolytes
1. Sodium
2. Potassium
3. Calcium
4. Magnesium
5. Chloride
6. Phosphate
7. Bicarbonate

Regulation Acid-Base Balance

1. Regulation of Acid-Base
Balance
2. Low pH = acidic
3. High pH = alkalinic
4. Body fluids maintained between pH of 7.35 and 7.45 by
• Buffers
• Respiratory system
• Renal system

Buffers
• Prevent excessive changes in pH
• Major buffer in ECF is HCO3 and H2CO3
• Other buffers include:
• Plasma proteins
• Hemoglobin
• Phosphates
 Lungs
• Regulate acid-base balance by eliminating or retaining carbon dioxide
• Does this by altering rate/depth of respirations
• Faster rate/more depth = get rid of more CO2 and pH rises
• Slower rate/less depth = retain CO2 and pH lowers

Kidneys
• Regulate by selectively excreting or conserving bicarbonate and hydrogen ions
• Slower to respond to change

Factors Affecting Body Fluid, Electrolyte, and Acid-Base Balance

1. Age
2. Gender
3. Body size
4. Environmental temperature
5. Lifestyle
6. Risk Factors for Fluid, Electrolyte, and Acid-Base Imbalances
7. Chronic diseases
8. Acute conditions
9. Medications
10. Treatments
11. Extremes of age
12. Inability to access food and fluids

Fluid Imbalances
1. Isotonic loss of water and electrolytes (fluid volume deficit)
2. Isotonic gain of water and electrolytes (fluid volume excess)
3. Hyperosmolar loss of only water (dehydration)
4. Hypo-osmolar gain of only water (overhydration)
5. Fluid Balance

Electrolyte Imbalance

1. Hyponatremia
2. Hypernatremia
3. Hypokalemia
4. Hyperkalemia
5. Hypocalcemia
6. Hypercalcemia
7. Hypomagnesemia
8. Hypermagnesemia
9. Hypochloremia
10. Hyperchloremia
11. Hypophosphatemia
12. Hyperphosphatemia

ACTIVITIES

1. Discussion
2. Journal and Reflection
3. Classwork Quiz and Assignment
 BASIC CONCEPTS OF NUTRITION

Essential Nutrients
and
Sources
• Water
• Carbohydrates
• Protein
• Fats
• Micronutrients
• Vitamins
• Minerals

Digestion,
Absorption, and
Metabolism:
Carbohydrates
• Major enzymes include
ptyalin (salivary
amylase), pancreatic amylase, and the disaccharidases
• End products are monosaccharides
• Absorbed by the small intestine in healthy people
• Body breaks carbohydrates into glucose
• Maintain blood levels
• Provide a readily available source of energy

Digestion, Absorption, and Metabolism: Protein

• Digestion begins in the mouth with enzyme pepsin
• Most protein digested in the small intestine
• Pancreas secretes the proteolytic enzymes trypsin, chymotrypsin, and carboxypeptidase
• Glands in intestinal wall secrete aminopeptidase and dipeptidase which break protein into
amino acids
• Amino acids absorbed by active transport through small intestines
• Anabolism, catabolism, nitrogen balance.
 Digestion, Absorption, and Metabolism: Lipids/Fats
• Digestion begins in the stomach, but mainly digested in the small intestine
• Digestion primarily by bile, pancreatic lipase, and enteric lipase
• End products of lipid digestion are glycerol, fatty acids, and cholesterol
• Reassembled inside the intestinal cells into triglycerides and cholesterol esters
• Small intestine and the liver convert these into soluble compounds called lipoprotein
• Converting fat into useable energy occurs through lipase that breaks down triglycerides in
adipose cells releasing glycerol and fatty acids into the blood

Energy Balance
• Relationship between the energy derived from food and the energy used by the body
• Caloric value is the amount of energy that nutrients or foods supply to the body
• Basal metabolic rate (BMR) is the rate at which the body metabolizes food to maintain the
energy requirements of a person who is awake and at rest
• Resting energy expenditure (REE) is the amount of energy required to maintain basic body
functions (calories required to maintain life)

Healthy Body Weight

• Balance between the expenditure of energy and the intake of nutrients
• Ideal body weight (IBW) is the optimal weight recommended for optimal health ; defined as
weight for height at the lowest risk of mortality.( https://www.calculator.net/ideal-weight-
calculator.html?ctype=metric&cage=51&csex=f&cheightfeet=5&cheightinch=10&cheightmeter=
170.688&printit=0&x=42&y=21)

• Body mass index (BMI) is considered to be the more reliable indicator by health professionals
BMI ranges
For most adults, an ideal BMI is in the 18.5 to 24.9 range.
For children and young people aged 2 to 18, the BMI calculation takes into account age and gender
as well as height and weight.
If your BMI is:
below 18.5 – you're in the underweight range
between 18.5 and 24.9 – you're in the healthy weight range
between 25 and 29.9 – you're in the overweight range
30 or over – you're in the obese range
• Other indirect body mass measures
• Percent body fat
• Waist circumference
• Skinfold testing
 • Near-infrared interactance is one of many measures of body composition, which uses
a computerized spectrophotometer, which has a single, rapid scanning monochromator
and fiber optic probe. This method uses the principles of light absorption and reflection
to measure body fat.
• Bioelectrical impedance analysis (BIA) measures body composition based on the
rate at which an electrical current travels through the body.

Factors Influencing Nutrition

• Developmental considerations
• Gender
• Ethnicity and culture
• Beliefs about food
• Personal preferences
• Religious practices
• Lifestyle
• Economics
• Medications and therapy
• Health
• Alcohol consumption
• Advertising
• Psychologic factors

Developmental Nutritional Considerations

• Neonate to 1 year
• Fluid and nutritional needs are met by breast milk or formula
• Addition of solid food to the diet between 4 and 6 months of age
• By the age of 1, most infants can be completely fed on table food, and milk intake is
about 20 ounces per day
Developmental Nutritional Considerations
• Toddler
• Can eat most foods and adjust to three meals each day
• By the age of 3 is able to bite and chew adult table food
• Caloric requirement is 900 to 1800 Kcal/day
• Need for adequate iron, calcium, and vitamins C and A are common deficiencies
Developmental Nutritional Considerations
• Preschooler
• Eat adult foods
• Very active and often require snacks between meals
 • Cheese, fruits, yogurt, raw vegetables, and milk are good choices
Developmental Nutritional Considerations
• School-aged
• Require a balanced diet including 2400 Kcal/day
• Eat three meals a day and one or two nutritious snacks
• Need a protein-rich food at breakfast to sustain the prolonged physical and mental effort
required at school
• Developmental Nutritional Considerations
• Adolescent
• Increased need for nutrient and calories during growth spurts
• Adequate calcium intake (1200 to 1500 mg/day)
• Health snacks and limits on junk foods
• Anorexia nervosa and bulimia may occur
• Developmental Nutritional Considerations
• Adults
• Continue to eat a healthy diet, with special attention to protein, calcium, and limiting
cholesterol and caloric intake
• Two or three liters of fluid should be included in the daily diet
• Postmenopausal women need to ingest sufficient calcium and vitamin D to reduce
osteoporosis
• Antioxidants such as vitamin A, C, and E may be helpful in reducing the risks of heart
disease in women
• Elders
• Require the same basic nutrition as the younger adult
• Fewer calories are needed by elders because of the lower metabolic rate and the
decrease in physical activity
• Some may need more carbohydrates for fiber and bulk, but most nutrient requirements
remain relatively unchanged
• Developmental Nutritional Considerations
• Physical changes as tooth loss and impaired sense of taste and smell may affect eating
habits
• Decreased saliva and gastric juice secretion may also affect nutrition
• Psychosocial factors may also contribute to nutritional problems

• 1. Discussion
• 2.Classwork Quiz and Assignments
ACTIVITIES 3. Computation BMI
 BASIC CONCEPTS OF ELIMINATION

➢ The act of elimination is a fundamental human process essential to life.

➢ Being able to meet clients’ elimination needs is therefore an essential nursing function and can
help to both maintain and/or restore a client’s wellbeing and preserve life.
➢ The skills involved do, however, need to be applied sensitively, as many clients despair at the
thought of being unable to manage their own toilet requirements

The factors that affect elimination :

• Physical - arising from alteration in the structure, function or processes of the urinary, gastro-
intestinal or associated bodily systems
• Psychological - such as intellect, anxiety and stress
• Sociocultural -for example different words used for elimination and products of elimination,
different rituals surrounding elimination (such as clean hand for eating/dirty hand for
cleansing), fasting and other dietary restrictions
• Environmental - including poor food storage, personal hygiene and toileting facilities
• Politico-economic - for example lack of finances for a healthy high-fibre diet, political
influences on availability of certain foods and genetically modified products.

Monitoring urinary output

➢ Normal urinary output is approximately 1.5 litres in 24 hours and the usual frequency of
micturition is between 5 and 10 times in that period.

➢ However, this can be influenced significantly by the amount of fluid a person drinks and how
much fluid they are losing through sweating, mental state and lifestyle.

➢ Urine normally consists of:

96% water
2% urea
2% uric acid, creatinine, sodium, potassium, chlorides, phosphates,sulphates, oxalates.

Monitoring Bowel Movement

➢ Bowel habits are variable between individuals and are influenced by lifestyle, eating habits and
mental state.
➢ The average adult will pass 100–150 g of faeces once per day; change in this pattern and
change in the nature of faeces passed can indicate disease.
➢ The health care professional will therefore need to monitor the bowel action of clients where
actual or potential problems are indicated.
 ➢ Normal faeces is made up of 75 per cent water and 25 per cent solid constituents
(cellulose, dead epithelial cells, bacteria, mucus and bile pigments).
➢ Skatole and indole arise from bacterial decomposition and give faeces it characteristic odour.
➢ Faecal matter is normally brown in colour, soft in consistency and cylindrical in form.

Monitoring vomitus
➢ Monitoring a client’s vomiting pattern along with the amount and consistency of the vomit can
help in determining the nature of their condition as well as assisting in helping us determine a
client’s potential for malnutrition and dehydration, and subsequently their replacement needs.
➢ It is therefore essential that this be documented accurately on the client’s fluid balance chart.

• 1. Discussion
ACTIVITIES
• 2.Classwork Quiz and Assignments
3. I and O monitoring
 BASIC CONCEPT ON TEMPERATURE REGULATION

➢ Most of the time adults are unaware of their body temperature because it usually remains at a
constant, comfortable level.
➢ A special regulating centre in the brain, the hypothalamus, carefully balances the amount of
heat produced and the amount lost by the body by, for example, making us sweat or shiver.
Control of temperature in this way is part of maintaining homeostasis of the body.

The factors that may affect body temperature include:

➢ physical, for example illness, infection, gender, age, metabolic rate

➢ psychological such as emotion, stress and anxiety
➢ sociocultural including exercise, activity, recreational drugs
➢ environmental, for example time of day, severe heat or cold
➢ politico-economic, for instance lack of finances for heating or occupation.

Normal body temperature

➢ The following levels may vary slightly in different textbooks, but the following is intended to
offer a simple, useful guide:
Normal range = 36–37oC
Pyrexia = 38–40oC
Hyperpyrexia = 40.1oC and above
Heat stroke = Usually occurs around 41–42oC
Death = 43oC and above
Hypothermia = 35oC and below
Death = 20oC

• 1. Discussion
• 2.Classwork Quiz and Assignments
ACTIVITIES 3. I and O monitoring
 BASIC CONCEPTS ON ACTIVITY AND EXERCISE
.
Four Basic Elements of Normal Movement
1. Body alignment (posture)
2. Joint mobility
3. Balance
4. Coordinated movement

Body Alignment/Posture
• Brings body parts into position that promotes optimal balance and body function
• Person maintains balance as long as line of gravity passes through center of gravity and base
of support

Joint Mobility
• ROM is maximum movement possible for joint
• ROM varies and determined by:
– Genetic makeup
– Developmental patterns
– Presence or absence of disease
– Physical activity
• Elbow Flexion/Extension Animation
• Elbow Pronation/Supination Animation
• Foot Dorsiflexion/Extension Animation
• Ankle Inversion/Eversion Animation
• Hand Opposition Animation
• Humerus Adduction /
Abduction Animation
• Humerus Circumduction Animation

Balance
• Smooth, purposeful movement
• Result of proper functioning of:
– Cerebral cortex
• Initiates voluntary movement
– Cerebellum
• Coordinates motor activity
– Basal ganglia
• Maintains posture
 Coordinated Movement
• Complex mechanisms
• Proprioception
– Awareness of posture, movement, changes in equilibrium
– Knowledge of position, weight, resistance of objects in relation to body

Isotonic (Dynamic) Exercise

• Muscle shortens to produce muscle contraction and active movement
• Increase muscle tone, mass, and strength
• Maintain joint flexibility and circulation
• HR and CO quicken increase

Isometric (Static or Setting) Exercise

• Muscle contraction without moving the joint (muscle length does not change)
• Involve exerting pressure against a solid object
• Produce a mild increase in HR and CO
• No apparent increase in blood flow to other parts of the body

Isokinetic (Resistive) Exercise

• Muscle contraction or tension against resistance
• Can either be isotonic or isometric
• Person moves (isotonic) or tenses (isometric) against resistance
• An increase in blood pressure and blood flow to muscles occurs

Aerobic Exercise
• Activity during which the amount of oxygen taken in the body is greater than that used to
perform the activity
• Improve cardiovascular conditioning and physical fitness
• Activity in which the muscles cannot draw enough oxygen from the bloodstream
• Anaerobic pathways are used to provide additional energy for a short time
• Used in endurance training for athletes

Effect on Musculoskeletal System

• Exercise
– Maintain size, shape, tone, and strength of muscles (including the heart muscle)
– Nourish joints
– Increase joint flexibility, stability, and ROM
– Maintain bone density and strength
• Immobility
 – Disuse osteoporosis
– Disuse atrophy
– Contractures
– Stiffness and pain in the joints
– Effects on the Cardiovascular System
• Exercise
– Increases HR, strength of contraction, and blood supply to the heart and muscles
– Mediates harmful effects of stress
• Immobility
– Diminished cardiac reserve
– Increased use of the Valsalva maneuver
– Orthostatic hypotension
– Venous vasodilation and stasis
– Dependent edema
– Thrombus formation
• Leg Veins

Effect on the Respiratory System

• Exercise
– Increase ventilation and oxygen intake improving gas exchange
– Prevents pooling of secretions in the bronchi and bronchioles
• Immobility
– Decreased respiratory movement
– Pooling of respiratory secretions
– Atelectasis
– Hypostatic pneumonia
• Pooling of Secretions:
Immobile Person

Effects on the Metabolic/Endocrine System

• Exercise
– Elevates the metabolic rate
– Decreases serum triglycerides and cholesterol
– Stabilizes blood sugar and make cells more responsive to insulin
– Immobility
– Decreased metabolic rate
– Negative nitrogen balance
– Anorexia
– Negative calcium balance
 Effects on the GI System
• Exercise
– Improves the appetite
– Increases GI tract tone
– Facilitates peristalsis
– Immobility
– Constipation

Effect on the Urinary System

• Exercise
– Promotes blood flow to the kidneys causing body wastes to be excreted more effectively
– Prevents stasis (stagnation) of urine in the bladder
– Immobility
– Urinary stasis
– Renal calculi
– Urinary retention
– Urinary infection
• Pooling of Urine

Effect on the Immune System

• Exercise
– Pumps lymph fluid from tissues into lymph capillaries and vessels
– Increases circulation through lymph nodes
– Strenuous exercise may reduce immune function
• Leaving window of opportunity for infection during recovery phase

Effect on the Psychoneurologic System

• Exercise
– Elevates mood
– Relieves stress and anxiety
– Improves quality of sleep for most individuals
• Immobility
– Decline in mood elevating substances
– Perception of time intervals deteriorates
– Problem-solving and decision-making abilities may deteriorate
– Loss of control over events can cause anxiety
 Effect on Cognitive Function
• Exercise
– Positive effects on decision-making and problem solving processes, planning, and
paying attention
– Induces cells in the brain to strengthen and build neuronal connections

Other Effects of Exercise and Immobility

• Evidence that certain types of exercise increase spiritual health
• Immobility causes reduced skin turgor and skin breakdown
• Factors Affecting Body Alignment, Mobility, and DAL
• Growth and development
• Nutrition, personal values and attitudes

• External factors
– i.e., Temperature, humidity, availability of recreational facilities, safety of the
neighborhood
• Prescribed limitations
– i.e., Casts, braces, traction, activity restrictions including bed rest

1. Discussion
2. Journal and Reflection
ACTIVITIE 3. Classwork Quiz and Assignment
 BASIC CONCEPTS ON HYGIENE AND COMFORT

Hygienic Care

• Involves care of:

– Skin
– Hair
– Nails
– Teeth
– Oral and nasal cavities
– Eyes
– Ears
– Perineal-genital area

Types of Hygienic Care

• Early morning
• Morning
• Hours of sleep (HS) or PM
• As needed (prn)
• Factors Influencing Personal Hygiene
• Culture
• Religion
• Environment
• Developmental level
• Health and energy

1. Discussion
2. Journal and Reflection
ACTIVITIE 3. Classwork Quiz and Assignment
 BASIC CONCEPT ON PAIN MANAGEMENT

Factors affecting dying may be:

Pain Management
Physiologic Pain
• Experienced when an intact, properly functioning nervous system signals that tissues are
damaged, requiring attention and proper care
• Transient
• Persistent

Subcategories
1. Somatic
2. Visceral
3. Neuropathic Pain- Experienced by people who have damaged or malfunctioning nerves

Types
1. Peripheral
2. Central
3. Sympathetically maintained

Four Processes Involved in Nociception

1. Transduction
2. Transmission
3. Perception
4. Modulation

Transmission of Pain
• Gate Control Theory
• Small diameter (a-delta or C) peripheral nerve fibers carry signals of noxious stimuli to the
dorsal horn
• Signals are modified when they are exposed to the substantia gelatinosa
• Ion channels on the pre- and postsynaptic membranes serve as gates
• When open, permit positively charged ions to rush into the second order neurons, sparking an
electrical impulse and sending signals of pain to the thalamus
 • Large diameter (A-delta) fibers have inhibitor effect
• May activate descending mechanism that can inhibit transmission of pain

Gate Control Theory

Clinical Application of Gate Control Theory

• Stop nociceptor firing
• Apply topical therapies
• Address client’s mood
• Address client’s goals
• Factors Affecting
Perception of Pain
• Ethnic and cultural values
• Developmental stage
• Environment and support people
• Past pain experiences
• Meaning of pain
– Spiritual
– Social
• Pain Assessment
Subjective Data
• Comprehensive pain history includes COLDERR
– Character
– Onset
– Location
– Duration
– Exacerbation
– Relief
– Radiation
• Additional Data to Obtain
• Associated symptoms
• Effect on ADLs
• Past pain experiences
• Meaning of the pain to the person
 • Coping resources
• Affective response

1. Discussion
2. Journal and Reflection
ACTIVITIE 3. Classwork Quiz and Assignment
 BASIC CONCEPTS ON CIRCULATION

THE CARDIOVASCULAR SYSTEM

• Heart
• Blood vessels
• Blood
• The Heart
• The Heart
• Blood Vessels
• Arterial System
– Arteries
– Arterioles
– Capillaries
• Venous System
– Venules
– Veins

The Heart and Blood Vessels

Blood Flow Through Heart
• Coronary Arteries
• Blood
• Blood cells
• Plasma
• Transports oxygen, nutrients, hormones to cells
• Transports wastes from tissues
• Regulates body temperature, pH, fluid volume
• Prevents infection, blood loss
• Factors Influencing
Cardiovascular Function
• Cardiac output (CO)
– Amount of blood ejected from the heart each minute
• Stroke volume (SV)
– Amount of blood ejected from the heart with each beat
 • Heart rate (HR)
– Number of beats per minute

Factors Influencing Cardiovascular Function

• Contractility
– Inotropic state of the myocardium, strength of contraction
• Preload
– Left ventricular end diastolic volume, stretch of the myocardium
• Afterload
– Resistance against which the heart muscle must pump.

Risk Factors for Coronary Heart Disease

• Nonmodifiable risks
– Heredity
– Age
– Gender
• Modifiable risks
– Elevated serum lipid levels
– Hypertension
– Cigarette smoking
– Diabetes
– Obesity
– Sedentary lifestyle
• Other Risk Factors
– Heat and cold
– Previous health status
– Stress and coping
– Dietary factors
– Alcohol intake
– Elevated homocysteine level

Cardiovascular Function
• Can be altered by conditions that affect:
– The function of the heart as a pump
 – Blood flow to organs and peripheral tissues
– The composition of the blood and its ability to transport oxygen and carbon dioxide

Alterations in Cardiovascular Function

• Decreased cardiac output
• Impaired tissue perfusion
• Disorders that affect composition or amount of blood available for transport of gases

Conditions that Affect Cardiac Output

• Myocardial infarction
• Heart failure
• Irregular heart rhythms
• Structural heart conditions
• Myocardial Infarction
• Chest pain
• Substernal and/or radiating to left arm or jaw
• Nausea
• Shortness of breath
• Diaphoresis
• Heart Failure
• Can develop if heart not able to keep up with body’s need for oxygen and nutrients
• Usually occurs because of MI
• May result from chronic overwork of heart
• Left-sided heart failure can result in pulmonary edema
Heart Failure
• Pulmonary congestion
• Adventitious breath sounds
• Shortness of breath
• Increased HR
• Increased RR
• Peripheral vasoconstriction
• Cold, pale extremities
• Distended neck veins
Irregular Heart Rhythms : dysrhythmias.
• Structural Heart Conditions Animation
• Structural Heart Conditions
Congenital Heart Defects.

Conditions that Affect Tissue Perfusion

• Atherosclerosis
– Coronary arteries
– Brain
– Peripheral arteries
• Vessel inflammation
• Arterial spasms
• Blood clots
• Incompetent valves of veins
• Pulmonary emboli
• Atherosclerosis
• Most common cause of impaired blood flow to organs and tissues
• Vessels narrow and become constricted
• Distal tissues receive less oxygen and nutrients
• Coronary arteries most affected
• Obstruction of coronary arteries leads to myocardial ischemia leads to angina pectoris
• Obstruction in vessels supplying brain results in TIA or stroke
• Incompetent Venous Valves
• May allow blood to pool in veins
– Edema
– Decreased venous return to heart
• Veins become inflamed
– Reduce blood flow
– Increased risk of thrombus formation
• Thrombi may break loose
– Emboli
– Occlude blood supply A/C membrane
– Acute pulmonary embolism
Impaired Peripheral Arterial Circulation
• Decreased peripheral pulses
• Pale skin color
• Cool extremities
• Decreased hair distribution
• Acute
Pulmonary Embolism
• Sudden onset of shortness of breath
• Pleuritic chest pain

Conditions that Affect Composition of Blood

• Anemia
– Chronic fatigue
– Pallor
– Shortness of breath
– Hypotension

Conditions that Affect Blood Volume

• Hemorrhage
• Dehydration
• Fluid retention
• Kidney failure

Problems With Oxygen Transport

• Inadequate RBCs
• Low hemoglobin
• Abnormal hemoglobin
• Maintaining Vascular Function
• Elevate the client’s legs
• Avoid placing pillows under the knees or providing more than 15° knee flexion
• Encourage leg exercises for a client on bedrest
• Promote ambulation as soon as possible
• Encourage or provide frequent position changes
• Maintaining Cardiac Function
 • Position the client in high Fowler’s position
• Monitor intake and output
• Fluid restriction

Importance of Cardiopulmonary Resuscitation

• Within 20 to 40 seconds of a cardiac arrest the victim is clinically dead
• After 4 to 6 minutes the lack of oxygen supply to the brain causes permanent and extensive
damage
• Must initiate CPR immediately

1. Discussion
2. Journal and Reflection
ACTIVITIE 3. Classwork Quiz and Assignment
 BASIC CONCEPTS ON SEXUALITY

Sexual Development:
Birth to 18 Months
• From birth, infants assigned gender of male or female
• Infant gradually differentiates self from others
• External genitals are sensitive to touch
• Males have penile erections
• Females have vaginal lubrication

Sexual Development:
Toddler (1-3 Years)
• Continues to develop gender identity
• Can identify own gender

Sexual Development:
Preschooler (4-5 Years)
• Becomes increasingly aware of self
• Explores own and classmates’ body parts
• Learns correct name for body parts
• Learns to control feelings and behaviors
• Focuses love on parent of opposite sex

Sexual Development:
School Age (6-12 Years)
• Strong identification with parent of same gender
• Friends of same gender
• Increasing awareness of self
• Increased modesty, desire for privacy
• Continues self-stimulating behavior
• Learns roles and concepts of own gender as part of self-concept
• Age 8 or 9 often have specific concerns about sexuality and reproduction
Sexual Development:
Adolescence (12-18 Years)
• Primary and secondary sexual characteristics develop
• Menarche
• Develops relationships with interested partners
• Masturbation common
• May participate in sexual activity
• May experiment with homosexuality
• At risk for pregnancy and STDs

Sexual Development:
Young Adulthood
• Sexual activity common
• Establishes own lifestyle and values
• Homosexual identity established in mid-20s
• Couples may share financial and household responsibilities

Sexual Development:
Middle Adulthood
• Decreased hormone production
• Menopause in women between 40-55 years
• Climacteric occurs gradually in men
• Quality rather than number of occurrences becomes important
• Individuals establish independent moral and ethical standards

Sexual Development:
Late Adulthood
• Interest in sexual activity continues but may be less frequent
• Women
– Vaginal secretions diminish
– Breasts atrophy
• Men
– Produce fewer sperm
– Need more time to achieve erection and ejaculate
 • Sexual Health
• WHO (1975) definition:
“integration of the somatic, emotional, intellectual, and social aspects of sexual being, in ways
that are positively enriching and that enhance personality, communication, and love.”

Characteristics of Sexual Health

• Knowledge about sexuality and sexual behavior
• Ability to express one’s full sexual potential
• Ability to make autonomous decisions about one’s sexual life
• Experience of sexual pleasure as a source of physical, psychologic, cognitive, and spiritual
well-being
• Capability to express sexuality through communication, touch, emotional expression, and love
• Right to make reproductive choice
• Ability to access sexual health care
• Varieties of Sexuality
• Sexual Orientation
• Gender Identity
• Erotic Preferences
• Sexual Orientation
• Same gender
• Opposite gender
• Both genders
• Gender Identity
• Transgenderism
• Intersexuality
• Transsexuality
• Cross-dressers
• Erotic Preferences
• Sexual fantasies
• Masturbation
• Cunnilingus
• Fellatio
• Anal stimulation
 • Genital intercourse
• Anal intercourse
• Others

Influences on Sexuality
• Family
• Culture
• Religion
• Personal expectations and ethics

Male and Female Sexual Response Cycle

1. Excitement/Plateau
2. Orgasmic
3. Resolution
4. Desire Phase

• Men and women

– Response cycle starts in brain
– Sexually erotic stimuli may be real or symbolic
• Excitement/Plateau
• Both
– Muscle tension increases as excitement increases
– Sex flush (chest)
– Nipple erection
• Male
– Penile erection
– Increase in glans size
– Few drops lubricant
• Female
– Erection of clitoris
– Vaginal lubrication
– Labia increase 2-3 times in size
– Breasts enlarge
– Inner 2/3 of vagina widens
 – Outer 1/3 of vagina narrows
– Uterus elevates
• Orgasmic Phase
• Both
– RR up to 40 bpm
– Involuntary muscle spasms
– Diminished sensory awareness
– Involuntary contractions anal sphincter
– Peak HR 110-180 bpm
– SBP 30-80 mm Hg above normal
– DBP 20-50 mm Hg above normal
– Orgasmic Phase
• Men
– Rhythmic, expulsive contractions of penis
– Emission of seminal fluid
– Closing of internal bladder sphincter before ejaculation
– May occur without ejaculation
– Force varies but diminishes after first 2-3 contractions
• Female
– 5-12 contractions of muscles of pelvic floor and uterine muscles
– Varied patterns
• Minor
• Multiple
• Simple intense
• Resolution
• Both
– Reversal of vasocongestion in 20-30 min.
– Disappearance of myotonia within 5 min.
– Genitals and breasts return to preexcitement state
– Sex flush disappears in reverse order
– HR, RR, BP return to normal
– Sleepiness, relaxation, emotional outbursts
• Resolution
• Male
 – Refractory period during which body will not respond to sexual stimulation
– Varies from moments to days

Sexual Dysfunction
• May be related to:
– Past and current factors
– Sexual desire disorder
– Sexual arousal disorder
– Orgasmic disorder
– Sexual pain disorder
– Problem with satisfaction

Influence of Past and Current Factors

• Sociocultural
• Psychological
• Cognitive
• Relationship problems
• Health
• Medications or street drugs

Sexual Desire and Arousal Disorders

1. Sexual Desire Disorders
a. Hypoactive sexual desire
b. Sexual aversion disorders
2. Sexual Arousal Disorders
a. Female sexual arousal disorder
b. Male erectile dysfunction or erectile dysfunction (ED)
3. Orgasmic Disorders
• Female orgasmic disorder
– Preorgasmic women
• Male orgasmic disorder
– Retarded ejaculation
– Rapid ejaculation
Sexual Pain Disorders
• Dyspareunia
• Vaginismus
• Vulvodynia
• Vestibulitis
• Problems with Satisfaction
• Some people experience sexual desire, arousal, and orgasm yet feel dissatisfied with their
sexual relationship

1. Discussion
2. Journal and Reflection
ACTIVITIE 3. Classwork Quiz and Assignment
 BASIC CONCEPTS ON STRESS AND COPING

Disorders Caused by Stress

Concepts of Stress
1. Stimulus-based models
2. Response-based models
3. Transaction-based models

Stimulus-based Models
➢ Stress defined as a stimulus, a life event, or set of circumstances that arouses
physiologic/psychologic reaction
➢ This stress may increase vulnerability to illness
➢ Both positive and negative events considered stressful

Response-based Models
➢ Stress may be considered a response
➢ Selye (1956, 1976) defined as nonspecific response of body to any kind of demand made upon
it.
 Transaction-based Models
➢ Based on work of Lazarus (1966)
➢ Set of cognitive, affective, and adaptive (coping) responses that arise out of person-
environment transactions
➢ Person and environment are inseparable – each affects and affected by the other
➢ Stress refers to any event in which environmental and/or internal demands tax adaptive
resources of individual, social system, or tissue system

Selye’s General Adaptation Syndrome

Indicators for Stress

• May be:
1. Physiologic
2. Psychologic
3. Cognitive

Physiologic Indicators of Stress

• Pupils dilate
• Sweat production increases
• Heart rate and cardiac output increase
• Skin is pallid
• Sodium and water retained
• Rate and depth of respiration increase
• Urinary output decreases
• Mouth may be dry
• Peristalsis of the intestines decrease for serious threats
• Mental alertness improves
• Blood sugar increases

Psychologic Indicators of Stress

• Anxiety
• Fear
• Anger
• Depression
• Unconscious ego defense mechanisms

Cognitive Indicators of Stress

• Problem solving
• Structuring
• Self-control or self-discipline
• Suppression
• Fantasy

Four Levels of Anxiety

• Mild
• Moderate
• Severe
• Panic

Indicators of Mild Anxiety

• Increased questioning
• Mild restlessness
• Sleeplessness
• Feelings of increased arousal and alertness
• Use of learning to adapt

Indicators of Moderate Anxiety

• Voice tremors and pitch changes
• Tremors
• Facial twitches
• Shakiness
• Increased muscle tension
• Narrowed focus of attention
• Ability to focus but selectively inattentive
• Slightly impaired learning
• Slight increased RR and HR
• Mild gastric symptoms

Indicators of Severe Anxiety

• Communication that is difficult to understand
• Increased motor activity
• Inability to relax
• Fearful facial expression
• Inability to focus or concentrate
• Easily distracted

Severely impaired learning

• Tachycardia
• Hyperventilation
• Headache
• Dizziness
• Nausea

Indicators of Panic
• Communication not understandable
• Increased motor activity
• Agitation
• Unpredictable responses
• Trembling
• Poor motor coordination
• Perception distorted or exaggerated
• Inability to learn or function
• Dyspnea, palpitations, choking
• Chest pain/pressure
• Feeling of impending doom
• Paresthesia, sweating

Defense Mechanisms
• Compensation
• Denial
• Displacement
• Identification
• Intellectualization
• Introjection
• Minimization
• Projection
• Rationalization
• Reaction formation
• Regression
• Repression
• Sublimation
• Substitution
• Undoing

Coping
• Dealing with change (either successfully or unsuccessfully)
• Coping strategy is natural or learned way of responding to changing environment or specific
problem or situation

Types of Coping
• Problem-focused
– Efforts to improve situation by making changes or taking action
• Emotion-focused coping
– Thoughts and actions that relieve emotional distress
– Doesn’t improve situation but person feels better
• Both types usually occur together

Coping Strategies
• Long term
– Can be constructive and realistic
• Short-term
– Reduce stress temporarily but ineffective to deal with reality
– May be destructive or detrimental
• Adaptive
– Can be effective
– Result of effective coping
• Maladaptive
– Results in unnecessary distress
– Results from ineffective coping
Assessing Stress and Coping Patterns
• Nursing History
– Client-perceived stressors or stressful incidents
– Manifestations of stress
– Past and present coping strategies
– Developmental transitions
• Assessing Stress and Coping Patterns
• Assessment interview
– Scale to rate specific stressors
– Duration of stressful situation
– Usual strategy for handling stressful situations
– Effectiveness of these strategies
• Assessing Stress and Coping Patterns
• Physical Examination
– Verbal
– Motor
– Cognitive
– Other physical manifestations of stress

Nursing Diagnoses Related to Stress

• Anxiety
• Caregiver Role Strain
• Compromised Family Coping
• Decisional Conflict (Specify)
• Defensive Coping
• Disabled Family Coping
• Fear
• Impaired Adjustment
• Ineffective Coping
• Ineffective Denial
• Post-Trauma Syndrome
• Relocation Stress Syndrome
• Interventions to Minimize and Manage Stress
• Physical Exercise
• Optimal Nutrition
• Adequate Rest and Sleep
• Time Management
• Interventions
• Physical exercise
 – Promotes physical and emotional health
– 30 minutes/day recommended
• Optimal nutrition
– Essential for health
– Increases resistance to stress
– Avoid excesses of caffeine, salt, sugar, fat
– Avoid vitamin deficiencies
• Interventions
• Sleep
– Restores body’s energy level
– May need to use relaxation techniques
• Time Management
– Must address what is important and achievable
– Reexamine “should do”, “ought to do”, “must do”
• Reducing Client Stress
• Other methods include:
– Listen attentively
– Provide atmosphere of warmth and trust
– Convey sense of caring and empathy
– Include client in plan of care
– Promote feeling of safety and security
– Minimize additional stressors
– Help with recognition of stressors and coping mechanisms

1. Discussion
2. Journal and Reflection
ACTIVITIES 3. Classwork Quiz and Assignment
S
 BASIC CONEPTS ON SPIRITUALITY
Concepts of Spirituality
• Religion
• Faith
• Hope
• Transcendence
• Forgiveness

Concepts of Religion
• Organized system of beliefs and practices
• Offers a way of spiritual expression
• Offer sense of community
• Collective study of scripture
• Performance of rituals

Characteristics of Spiritual Health

• Faith
• Hope
• Meaning and purpose of life
• Achievement of spiritual world
• Feelings of peacefulness
• Ability to love, to forgive, to pray, to worship

Characteristics of Spiritual Health

• Spiritual experiences
• Participation in spiritual rites and passages, in meditation, in spiritual reading
• Interaction with spiritual leaders, with other to share thoughts, feelings, and beliefs
• Expression through song/music, art, writing
• Connectedness with inner-self, with others

Factors Associated with Spiritual Distress

• Physiologic problems
• Treatment-related concerns
• Situational concerns

NANDA Defining Characteristics of Spiritual Distress

• Expresses lack of hope, meaning and purpose in life, forgiveness of self
• Expresses being abandoned by or having anger toward God
• Refuses interaction with friends, family
• Sudden changes in spiritual practices
• Requests to see a religious leader
• No interest in nature, reading spiritual literature

Spiritual Development
• 0-3 Years
– Acquiring qualities of trust, mutuality, courage, hope, love
• 3-7 Years
– Fantasy-filled, imitative phase
– Stories, images and fusion of facts and feelings
– Make-believe experienced as reality

Spiritual Development: 7-12 Years

• Demand proof or demonstrations of reality
• Accepts stories and beliefs literally
• Able to learn beliefs and practices of culture and religion
• Above can extend into adulthood

Spiritual Development:Adolescence
• Spiritual beliefs help understand extended environment
• Generally conform to beliefs of those around them
• Begin to examine beliefs objectively

Spiritual Development:Young Adulthood

• Differentiating beliefs from those of others
• Develop personal meaning for symbols of religion and faith

Spiritual Development: Mid-Adulthood

• Respect for past and one’s inner voice
• More awareness of differences because of social background
• Attempts to reconcile contradictions in mind and experience
• Remain open to others’ truths

Spiritual Development: Mid-to-Late Adulthood

• Believe in, live with, participate in community
• Works to resolve problems in society
• Embraces life, yet holds it loosely
 Influence of Spiritual and Religious Beliefs on Diet
• Proscriptions about foods and beverages permitted
• Fasting
• Provide diet plans specific to religious beliefs
• Influence of Spiritual and Religious Beliefs on Dress
• Conservative female dress
• Recognize desire to comply even when hospitalized

Influence on Prayer and Meditation

• Daily prayers or worship
• Provide uninterrupted quiet time
• Influence on Birth and Death
• Birth
– Rituals and ceremonies
– Assist families in fulfilling these obligations
• Death
– Observances and rituals
– Provide environment conducive to performance of rituals

Assessment of Spiritual Needs

• FICA
– F (faith or beliefs)
– I (implications or influence)
– C (community)
– A (address)

Clinical Assessment
• May find cues to spiritual and religious preferences
– Environment
– Behavior
– Verbalizations
– Affect and attitude
– Interpersonal relationships

Planning
• Overall Goal:
– Maintaining or restoring spiritual well-being so that spiritual strength, serenity, and
satisfaction are realized
• Help the client fulfill religious obligations
 • Help the client draw on and use inner resources more effectively
• Help the client maintain or establish a dynamic, personal relationship with a supreme being in
the face of unpleasant circumstances
• Help the client find meaning in existence and the present situation
• Promote a sense of hope
• Provide spiritual resources otherwise unavailable

Nursing Interventions
• Providing presence
• Supporting religious practices
• Assisting clients with prayer
• Referring clients for spiritual counseling
Evaluation
• Use measurable outcomes developed during the planning stage
• Collect data needed to judge whether client goals and outcomes have been achieved

1. Discussion
2. Journal and Reflection
ACTIVITIE 3. Classwork Quiz and Assignment
 BASIC CONCEPTS ON DEATH AND DYING
Types of Loss
1. Actual
a. Recognized by others
2. Perceived
a. Experienced by one person but cannot be verified by others
3. Anticipatory
a. Experienced before loss occurs
b. Can be actual or perceived
4. Situational
a. i.e., Loss of job, death of child
5. Developmental
a. i.e., Departure of children from home

Sources of Loss
1. Loss of an aspect of oneself
2. Loss of an object external to oneself
3. Separation from an accustomed environment
4. Loss of a loved one or valued person

Kübler-Ross Stages of Grieving

1. Denial
2. Anger
3. Bargaining
4. Depression
5. Acceptance

Engel Stages of Grieving

1. Shock and disbelief
2. Developing awareness
3. Restitution
4. Resolving the loss
5. Idealization
6. Outcome

Sanders Phases of Bereavement

1. Shock
2. Awareness of loss
3. Conservation/withdrawal
4. Healing: the turning point
5. Renewal
6. Martocchio Clusters of Grief
7. Shock and disbelief
8. Yearning and protest
9. Anguish, disorganization, and despair
10. Identification in bereavement
11. Reorganization and restitution
12. Rando Categories of Response
13. Avoidance
14. Confrontation
15. Accommodation

Clinical Symptoms of Grief

1. Signs and symptoms of stress reaction
2. Normal manifestations
a. Verbalization of the loss
b. Crying
c. Sleep disturbance
d. Loss of appetite
e. Difficulty concentrating
3. Complicated grieving
a. Extended time of denial
b. Depression
c. Severe physiologic symptoms
d. Suicidal thoughts

Factors Affecting Grief Response

1. Age
2. Significance of the loss
3. Culture
4. Spiritual beliefs
5. Gender
6. Socioeconomic status
7. Support systems
8. Cause of death
9. Measures that Facilitate the Grieving Process
10. Explore and respect ethnic, cultural, religious, and personal values
11. Teach what to expect in the grief process
12. Encourage the client to express and share grief with support people
13. Teach family members to encourage the client’s expression of grief
14. Encourage the client to resume activities on a schedule that promotes physical and
psychologic health

Manifestations of Impending Death

1. Loss of muscle tone
2. Slowing of the circulation
3. Changes in respiration
4. Sensory impairment

Traditional Clinical Signs of Death

1. Cessation of
➢ Apical pulse
➢ Respirations
➢ Blood pressure
2. World Medical Assembly
Guidelines for Death
3. Total lack of response to external stimuli
4. No muscular movement, especially during breathing
5. No reflexes
6. Flat encephalogram
7. In instances of artificial support, absence of brain waves for at least 24 hours

Cerebral Death
• Occurs when cerebral cortex is irreversibly destroyed
• Permanent loss of cerebral and brainstem function
– Absence of responsiveness to external stimuli
– Absence of cephalic reflexes
– Apnea
• Isoelectric EEG for at least 30 minutes in the absence of hypothermia and poisoning by CNS
depressants

Helping Clients Die with Dignity

• Introduce options available to the client and significant others to restore and support feelings of
control:
– Location of care
– Times of appointments with health professionals
– Activity schedule
 – Use of health resources
– Times of visits from relatives and friends

• Assist clients to manage the events preceding death so they can die peacefully
• Help clients to determine their own physical, psychologic, and social priorities
• Support the client’s will and hope

Strategies to Facilitate Discussions About Death

• Identify personal feelings about death
• Focus on client’s needs
• Determine client’s usual ways of coping
• Establish communication relationship
• Determine what client knows about illness
• Respond with honesty and directness
• Make time to be available

Factors affecting dying may be:

1. Physical arising from the nature of the terminal illness or cause of death such as pain,
nausea, breathlessness
2. Psychological such as fear and anxiety about death itself or the effects on those left to grieve
3. Sociocultural including personal beliefs about death and attitude towards death and dying
4. Environmental for example preferred place of death, quiet/noisy, private/open
5. Politico-economic such as lack of finances for funeral, outstanding debts.

Physical
• Is the client in any physical distress, for example nauseous, vomiting, dehydrated, breathless,
constipated, unable to sleep, immobile, in pain?
• Is everything possible being done to promote the client’s comfort?
• Could anything else be done?
• Do they have a ‘Do not resuscitate’ order and has this been discussed with the client and their
next of kin?
• Can any other members of the multidF isciplinary team offer help or guidance?
• Could any alternative therapies be of help?
• Are there any physical effects on family/friends?
• Is the client an actual or potential organ donor and are the family aware?
• Do the client/family wish sustained treatment?
• Remember, good symptom control is not just for clients but also for
• relatives, as they have to live with their memories.
Psychological
• Are the client/family aware of the diagnosis/prognosis?
• What are the client/family’s beliefs about death and dying?
• Are the client/relatives frightened, anxious, depressed?
• Do they have any concerns that can be addressed by you or others, for example a Macmillan
nurse, the palliative care team?
• Is everything possible being done to promote the client’s autonomy, privacy and dignity?
• Have they any outstanding or unfinished business they wish to address?
• What effect will the death have on family members?

Environmental
• Does the client wish to die in a clinical environment, hospice or at home?
• Can this be facilitated?
• What support mechanisms are required/available?
• Is the environment of care conducive to the client/visitors?
• Could it be improved?
• Are there any concerns about necessary environmental changes that might be incurred for
spouse/family following death?

Special considerations for different Cultural and Religious practices

• Whilst the needs of all clients must be considered, visitors are generally extremely important to
the dying and bereaved. Staff should therefore be sensitive to the needs of dying clients and
their visitors, who may wish to chant, sing or pray, and facilitate this as much as possible but
paying due regard to the needs of other clients.

Bahai
• Bahá'ís believe the crucial need facing humanity is to find a unifying vision of the future of
society and of the nature and purpose of life; the youngest of the world's independent religions
originating in Persia (Iran) in the year 1844.
• Relatives usually say prayers over the deceased prior to the performance of Last Offices, but it
is generally acceptable for nursing staff to carry out the procedure itself. There are usually
noobjections to the carrying out of a post-mortem or to organ donation.

Buddhism
• Buddhism is a religion that was founded by Siddhartha Gautama (“The Buddha”) more than
2500 years ago in India.
• The body should not be moved for one hour following death.
• Some clients or relatives may request the presence of a Buddhist nun or monk.
• There are usually no objections to the carrying out of a post-mortem or to organ donation
though some Far Eastern followers may object.

Christianity
• is an Abrahamic monotheistic religion based on the life and teachings of Jesus of Nazareth.
• Differing denominations follow differing customs but Last Offices as outlined in the text are
generally acceptable. The client or relatives may wish the hospital chaplain or priest to perform
the last rites, preferably prior to death. Sometimes relatives may wish to place a rosary, icon or
flowers with the deceased and/or place the hands in prayer.
• Staff should not do this as a matter of course as some relatives find it very distressing, whilst
others may consider it their personal right, responsibility or duty.
• Relatives may wish to undertake or participate in Last Offices.
• Post-mortem and organ donation are generally acceptable though some people may object
depending on their individual socialization processes.

Hinduism
• A major world religion originating on the Indian subcontinent and comprising several and
varied systems of philosophy, belief, and ritual. a religion with various Gods and Goddesses.
According to Hinduism, three Gods rule the world. Brahma: the creator; Vishnu: the preserver
and Shiva: the destroyer. Lord Vishnu did his job of preserving the world by incarnating himself
in different forms at times of crisis.
• Distress can be caused if non-Hindus touch the body. Gloves should therefore be worn at all
times. Relatives may wish to be informed of impending death to arrange performance of
religious rituals.
• They may also wish to read from the Bhagavad-Gita.
• The family will usually want to care for the body (preferably at home), and the eldest son is
required to remain present throughout

Islam (Muslim)
• Islam is the name of the religion that Muslims follow. People who practice Islam are called
Muslims, just like those who practice Christianity are called Christians. The literal and lexical
meaning of Islam means submission. Islam comes from the root Arabic letters s-l-m which are
the same root letters the word peace (salam) comes from. The term Islam itself does not mean
peace, but it implies that one finds peace (salam) through submission (islam). The term Arab is
often used interchangeably with Muslim, but this is incorrect. Arab is a race while Islam is a
religion. Not all Arabs are Muslim and most Muslims are actually not Arab. Arabs make up
about 13% of the Muslim population.
• Islam is named after the action of submitting to God’s commands and will and not a person.
Other religions are often named after a person or people.
• What do Muslims believe?
• Muslims believe in God the Creator of the universe. The Arabic term for God is Allah.
Sometimes Muslims prefer to use the name Allah over God because Allah linguistically does
not have a gender and cannot be made plural. The English name God could become goddess
or gods. The main message of the Qurʾān is that God is one. He has no partner, child, or
helper.
• Muslims believe in angels. There are many angels and that all obey God. Unlike humans,
angels do not have free will and must obey all the commands of God. Different angels have
different tasks. For example, the angel Gabriel was responsible of communicating the
message of God to human Prophets and Messengers. The Angel Michael (Mikaaeel) was
responsible for rain. Angels also help and assist believers in times of difficulty.
• Muslims believe in all Prophets and Messengers. A Muslim is required to believe in Adam,
Noah, Abraham, Moses, David, Joseph, Jesus, and Muhammad peace be upon all of them.
They all came with the same message, to worship one God and not associate any partners
with him.
• Muslims also believe in all previous scripture that God sent to His Prophets and Messengers.
Moses was given the Torah, Abraham was given the scrolls, David was given the Psalms, and
Jesus was given the Injeel. With the exception of the Qurʾān, no previous scripture is
completely preserved in its original form. With time, many of these scriptures were lost or
corrupted. The Qurʾān was sent as a the “final testament” and it functions as God’s final
message to mankind.
• Muslims believe in the afterlife. There will be a day of judgment where God will hold people
accountable for their actions in this world. Those who did good will enter paradise and those
who did evil will either be forgiven or punished in hell. Everyone will be compensated for their
actions in this world.
• Lastly, Muslims believe in God’s divine will and decree. God has knowledge of all things that
will happen. He does not force humans to make decisions, we choose what we want to do.
However, there are certain things that God decreed and are outside of our control. These
things include the time and place we were born, where and when we will die, and anything that
happens that is outside our control. Muslims submit to these things as part of God’s decree
and will.
• Family members will wish to be present at death to perform last rites and will request that the
client’s head be pointed towards Mecca (south-east in the UK).
• Relatives or religious leaders usually perform Last Offices as soon as possible after death
either at home or in the mosque.
• If there is no family present, staff wearing gloves should straighten the body, remove tubes,
catheters, cannulae, etc., turn the head towards the right shoulder, facing Mecca, and cover
the body with a clean white sheet.
• Under no circumstances should nails or hair be cut. Organ donation is only permitted with the
express permission of the imam (religious leader) and post-mortem only agreed if required by
law.
• Islam requires that the deceased be buried, preferably within 24 hours.

Jehovah’s witness
• millenarian restorationist Christian denomination with nontrinitarian beliefs distinct from
mainstream Christianity. The group reports a worldwide membership of approximately 8.5
million adherents involved in evangelism and an annual Memorial attendance of over 19.7
million.
• Relatives sometimes wish to stay during Last Offices to read prayers and will inform staff of
any particular requests. The church does not object to post-mortem or organ donation; this is
therefore a matter of individual choice. Both burial and cremation are acceptable.

Judaism
• the world's oldest monotheistic religion, dating back nearly 4,000 years. Followers of Judaism
believe in one God who revealed himself through ancient prophets. The history of Judaism is
essential to understanding the Jewish faith, which has a rich heritage of law, culture and
tradition.
• If at all possible a Jewish person or Holy Assembly should be present at death, and they will
perform ritual prayer and washing.
• The body must be left for eight minutes immediately following death before it is touched, and
the funeral must take place within 24 hours, though it cannot take place during the Sabbath
(Friday sunset until Saturday sunset).
• If strict orthodox the body should be handled as little as possible. If handling by non-Jews is
necessary, gloves must be worn.
• If relatives are not present staff should straighten the body with hands open and arms parallel
and close to the body, close the mouth and eyes, and remove cannulae, drains, etc
• The body should be dressed in a shroud and covered with a clean sheet. Relatives may
request that the body be laid on the floor with the feet projecting towards the door. It is
customary for someone to stay with the deceased from death until burial and prayers will be
recited during this time.
 Assisting Families or Caregivers of Dying Clients
• Use therapeutic communication
• Provide an empathetic and caring presence
• Explain what is happening and what to expect
• Have a calm and patient demeanor
• Encourage to participate in the physical care as they are able:
– Assist with bathing
– Speak or read to the client
– Hold hands
• Support those who feel unable to care for or be with the dying
– Show an appropriate waiting area if they wish to remain nearby
• May be therapeutic for the family to verbally give permission to the client to “let go” when ready

After Client Dies

• Encourage the family to view the body
• May wish to clip a lock of hair as a remembrance
• Children should be included in the events surrounding the death if they wish
• The Grieving Client

Care of the Body After Death

• Follow policy of the hospital or agency
• Check the client’s religion rituals and make every attempt to comply
• If family or friends wish to view the body:
– Make the environment as clean and as pleasant as possible
– Make the body appear natural and comfortable
– All equipment, soiled linen, and supplies should be removed from the bedside
– Follow agency policy when caring for tubes
• Place the body in a supine position
• Place arms either at sides, palm down, or across the abdomen
• Place one pillow under the head and shoulders
• Close the eyelids for a few seconds
• Insert dentures
• Close mouth
• Wash soiled areas of the body
• Place absorbent pads under the buttocks
• Place a clean gown on the client
• Brush and comb the hair
• Remove all jewelry except a wedding band which is taped to the finger
• Adjust the top bed linen to cover the client to the shoulders
 • Provide soft lighting and chairs for the family
• After Body Viewed by Family
• Leave wrist identification tag on
• Apply additional identification tags
• Wrap the body in a shroud
• Apply identification to the outside of the shroud
• Take the body to the morgue
• Or arrange to have a mortician pick it up from the client’s room
• Handle the deceased with dignity

1. Discussion
2. Journal and Reflection
ACTIVITIE 3. Classwork Quiz and Assignment