M.Sc. Nursing 1st year Student Specialty: - Psychiatric
1
SYLLABUS OF ADVANCED NURSING PRACTICE Placement: 1ST Year
Hours of Instruction Theory 150 Hours. Practical 200 Hours. Total: 350 Hours.
Course Description: The course is designed to develop an understanding of concepts and constructs of theoretical basis of advance nursing practice and critically analyze different theories of nursing and other disciplines. Objectives: At the end of the course the students will be able to: 1. Appreciate and analyze the development of nursing as a profession. 2. Describe ethical, legal, political and economic aspects of health care delivery and nursing practice. 3. Explain bio- psycho- social dynamics of health, life style and health care delivery system. 4. Discuss concepts, principles, theories, models, approaches relevant to nursing and their application. 5. Describe scope of nursing practice. 6. Provide holistic and competent nursing care following nursing process approach. 7. Identify latest trends in nursing and the basis of advance nursing practice. 8. Perform extended and expanded role of nurse. 9. Describe alternative modalities of nursing care. 10. Describe the concept of quality control in nursing. 11. Identify the scope of nursing research. 12. Use computer in patient care delivery system and nursing practice. 13. Appreciate importance of self development and professional advancement.
2
Course Content: Unit
Hours
Content
I
10
II
5
III
10
Nursing as a Profession: � History of development of nursing profession, characteristics, criteria of the profession, perspective of nursing profession-national, global � Code of ethics(INC), code of professional conduct(INC), autonomy and accountability, assertiveness, visibility of nurses, legal considerations, �Role of regulatory bodies. � Professional organizations and unions-self defense, individual and collective bargaining. � Educational preparations, continuing education, career opportunities, professional advancement & role and scope of nursing education. �Role of research, leadership and management. �Quality assurance in nursing (INC). �Futuristic nursing. Health care delivery: � Health care environment, economics, constraints, planning process, policies, political process vis a vis nursing profession. �Health care delivery system- national, state, district and local level. � Major stakeholders in the health care system-Government, non-govt, Industry and other professionals. �Patterns of nursing care delivery in India. � Health care delivery concerns, national health and family welfare programs, inter-sectoral coordination, role of non-governmental agencies. �Information, education and communication (IEC). �Tele-medicine. Genetics: � Review of cellular division, mutation and law of inheritance, human genome project, The Genomic era. �Basic concepts of Genes, Chromosomes & DNA. �Approaches to common genetic disorders. � Genetic testing – basis of genetic diagnosis, Pre symptomatic and predisposition testing, Prenatal diagnosis & screening, Ethical, legal & psychosocial issues in genetic testing. �Genetic counseling. �Practical application of genetics in nursing.
3
Unit
Hours
Content
IV
10
V
20
VI
20
VII
10
Epidemiology: �Scope, epidemiological approach and methods, �Morbidity, mortality, �Concepts of causation of diseases and their screening, � Application of epidemiology in health care delivery, Health surveillance and health informatics. �Role of nurse. Bio-Psycho social pathology: �Path physiology and Psychodynamics of disease causation. � Life processes, homeostatic mechanism, biological and psycho-social dynamics in causation of disease, life style. � Common problems: Oxygen insufficiency, fluid and electrolyte imbalance, nutritional problems, hemorrhage] and shock, altered body temperature, unconsciousness, sleep pattern and its disturbances, pain, sensory deprivation. �Treatment aspects: pharmacological and pre- post operative care aspects, �Cardio pulmonary resuscitation. �End of life Care. � Infection prevention (including HIV) and standard safety measures, bio-medical waste management. �Role of nurse- Evidence based nursing practice; Best practices. �Innovations in nursing. Philosophy and Theories of Nursing: �Values, Conceptual models, approaches. � Nursing theories: Nightingale‘s, Hendersons‘s, Roger‘s, Peplau‘s, Abdella‘s, Lewine‘s, Orem‘s, Johnson‘s, King‘s, Neuman‘s, Roy‘s, Watson parsce, etc and their applications, �Health belief models, communication and management, etc. �Concept of Self health. �Evidence based practice model. Nursing process approach: � Health Assessment- illness status of patients/clients (Individuals, family, community), Identification of healthillnes problems, health behaviors, signs and symptoms of clients. � Methods of collection, analysis and utilization of data relevant to nursing process. � Formulation of nursing care plans, health goals, Implementation, modification and evaluation of care.
4
Unit
Hours
Content
VIII
30
IX
10
X
25
Psychological aspects and Human relations: � Human behavior, Life processes & growth and development, personality development, defense mechanisms, � Communication, interpersonal relationships, individual and group, group dynamics, and organizational behavior, � Basic human need, Growth and development, (Conception through preschool, School age through adolescence, Young & middle adult, and Older adult). �Sexuality and sexual health. �Stress and adaptation, crisis and its intervention, �Coping with loss, death and grieving, �Principles and techniques of Counseling. Nursing practice: �Framework, scope and trends. � Alternative modalities of care, alternative systems of health and complimentary therapies. � Extended and expanded role of the nurse, in promotive, preventive, curative and restorative health care delivery system in community and institutions. �Health promotion and primary health care. � Independent practice issues, - Independent nurse midwifery practitioner. �Collaboration issues and models-within and outside nursing. �Models of Prevention, �Family nursing, Home nursing, �Gender sensitive issues and women empowerment. �Disaster nursing. �Geriatric considerations in nursing. �Evidence based nursing practice- Best practices �Trans-cultural nursing. Computer applications for patient care delivery system and nursing practice: �Use of computers in teaching, learning, research and nursing practice. �Windows, MS office: Word, Excel, Power Point, �Internet, literature search, �Statistical packages, �Hospital management information system: soft ware‘s.
5
Practical: Clinical posting in the following areas: Specialty area- in-patient unit - 2 weeks Community health center/PHC - 2 weeks Emergency/ICU - 2 weeks Activities: Prepare Case studies with nursing process approach and theoretical basis. Presentation of comparative picture of theories. Family case- work using model of prevention. Annotated bibliography. Report of field visits (5). Methods of Teaching: Lecture cum discussion. Seminar. Panel discussion. Debate. Case Presentations. Exposure to scientific conferences. Field visits. Methods of evaluation: Tests. Presentation. Seminar. Written assignments. Advance nursing Procedures: Definition, Indication and nursing implications; CPR, TPN, Hemodynamic monitoring, Endotrcheal intubation, Tracheotomy, mechanical ventilation, Pacemaker, Hemodialysis, Peritoneal dialysis, LP, BT Pleural and abdominal parecentasis OT Techniques, Health assessment, Triage, Pulse oxymetry. Internal Assessment: Techniques
Weight age
Test- (2 tests) Assignment Seminar/presentation
50 25 25 ---------------------100 ----------------------
6
UNIT-I 7
SYLLABUS Unit
Hours
Content
I
10
Nursing as a Profession: � History of development of nursing profession, characteristics, criteria of the profession, perspective of nursing profession-national, global � Code of ethics(INC), code of professional conduct(INC), autonomy and accountability, assertiveness, visibility of nurses, legal considerations, �Role of regulatory bodies. � Professional organizations and unions-self defense, individual and collective bargaining. � Educational preparations, continuing education, career opportunities, professional advancement & role and scope of nursing education. �Role of research, leadership and management. �Quality assurance in nursing (INC). �Futuristic nursing.
8
HISTORY OF DEVELOPMENT OF NURSING PROFESSION
Introduction: Knowledge of the profession‘s history increases the nurse‘s awareness and promotes an understanding of the social and intellectual origins of the discipline. From its earliest history nursing was a form of community service to protect and preserve the family. Historically men and women held the role of nurse. In Prehistoric Period, women were responsible for gathering herbs, roots and plants that were used to heal the sick. History of nursing: Christianity: The entry of women into nursing can be traced to approximately 300 AD. Christians taught that men and women are equal before God and appealed to carry on His work in the behalf of all who were in distress. The founding of Benedictine Order in sixth century increased the number of men in nursing. Middle Ages: During the middle Ages (1100-1200 AD) charitable institutions were started to care for the aged, sick and poor. Nurses delivered custodial care and depended on physicians or priests for direction. Nurse Midwifery flourished during middle ages. Fifteenth To Nineteenth Century: The Crusades expanded health care by establishing hospitals and nursing orders for men. Christianity greatly influenced the development of nursing. One of the earliest records of Christian nursing was the formation of the order of Deaconesses, a group of public health or visiting nurses. Deaconesses‘ appointments by the bishops were highly valued and given only to women of high social standing. The need for nurses and increasing nursing responsibilities were due to the economic growth of eighteenth century, the smallpox epidemics and the Revolutionary War. The Sisters of Charity, founded in 1633 by St. Vincet de Paul, cared for people in hospitals, asylums and poor houses. The sisters became widely known as visiting nurses because they cared for sick people in their homes. The first Supervisor of the Sisters of Charity was Louise de Gras and was later known as Sr. Louise de Marillac. She established perhaps the first educational program to be associated with a nursing order. In 1809 the Sisters of Charity was introduced in America by Mother Elizabeth Senton, later their name was changed to Daughters of Charity. In the eighteenth century the further growth of cities brought an increase in the number of hospitals and expanded role of nurses. Smallpox epidemics in the French Colonies and during the Revolutionary war the English colonies increased the need of nursing services. Because there was little formal nursing education, nursing knowledge and skills were generally passed by experienced nurses. During the nineteenth century Protestant churches revived the Deaconess Order. The Deaconess Institute at Kaiserwerth, Germany was established in 1836 by Pastor Theodore Flieder. Florence Nightingale: The founder of modern nursing, Florence Nightingale, established the first nursing philosophy based on health maintenance and restoration in Notes of Nursing: What it is and what it is not. Her views on nursing were derived from
9
a spiritual philosophy, developed in her adolescence and adulthood and reflecting the changing needs of society. In 1853 Nightingale went to Paris to study with the Sisters of Charity and was appointed superintendent of The English General Hospitals in Turkey. During this Crimean War period she brought about major reforms in hygiene, sanitation and nursing practice and reduced the mortality rate at the Barracks Hospital, Turkey. The Civil War: The civil war stimulated the growth of nursing in United States. Clara Barton, founder of American Red Cross, tended soldiers on the battle field, cleansing the wounds, meeting their basic needs and comforting them in death. Dorothea Leynde Dix, Mary Ann Ball and Harriet Tubman also influenced nursing during Civil War. After the Civil War, nursing schools in the United States and Canada began to pattern their curricula after the Nightingale School. St. Catherine‘s in Ontario, was founded in 1874.The first African-American professional nurse was Mary Mahoney. Isabel Hampton Robb, a graduate of St. Catherine‘s in Ontario was the first superintendent of Johns Hopkins training school in Baltimore, Maryland in 1894.Nursing in hospitals expanded in the late nineteenth century. However, nursing in the community did not increase significantly until 1893, when Lillian Wald and Mary Brewster opened the Henry Street Settlement which focused on the health needs of poor people who lived in the tent aments in New York City. Wald described her activities with the Henry Settlement in the textbooks The House on Henry Street and Windows on Henry Street. Twentieth Century: In the early twentieth century, a movement toward a scientific, research-based defined body of nursing knowledge and practice was seen. Nurses began to assume expanded and advance practice roles. Mary Adelaide Nutting, a member of the first graduating class at Johns Hopkins Hospital and successor to Isabel Hampton Robb as superintendent of the Johns Hopkins Training School, was instrumental in the affiliation of nurse‘s education with university. She became the first professor of nursing at Columbia University Teachers College in 1907. In 1923 the Rockfeller foundation funded a survey of nursing education, The Goldmark Report. The report concluded that the nursing education needed Increased financial support and suggested that the money be given to university schools of nursing. As education developed, nursing practice also expanded. In 1901 the Army Nurse Corps was established. By the year 1908 Navy Corps established. By the year 1920s nursing specialization was developing. Graduate nurse midwifery programs were initiated and beginning in 1950s specialty nursing organizations such as Association of Operating Room Nurses (1949), American Association of Critical Care Nurses and Oncology Nursing Society were formed. Today, the profession is faced with multiple challenges. Nurses and Nurse Educators are revising nursing practice and curricula to meeting the ever changing needs of society.
10
CHARACTERISTICS OF PROFESSION Although nursing has been called a profession for many years, an assessment of characteristics of a profession indicates that it should more accurately be considered as ―emerging profession‖. Characteristics of a profession have been defined as: Authority to control its own work. Exclusive body of specialized knowledge. Extensive period of formal training. Specialized competence. Control over work performance. Service to society. Self-regulation. Credentialing system to certify competence. Legal reinforcement of professional standards. Ethical practice. Creation of a collegial subculture. Intrinsic rewards. Public acceptance. Apart from this the characteristics of a profession can be categorized as following: Intellectual: This character is reflecting commitment to serve society. This category has three components: a) Body of knowledge: professional practice is based on body of knowledge derived from experience (leading to expertise) and research (leading to theoretical foundation for knowledge).This knowledge base contributes to judgment and rationale for modifying actions according to specific situation. However, the education has often emphasized proven methods for responding to particular kinds of situations e.g. clients may be discharged without self care teaching because the doctor did not write an order. b) Specialized education: Nursing transmits knowledge through specialized education. However, there are five levels of basic education for registered nurses, all of which prepare for one licensure examination. Three of five levels (diploma, associate degree and baccalaureate degree) accept high school graduation where as other two (master‘s degree and doctoral degree) accept college with liberal arts majors. c) Critical and Creative Thinking: A logical and critical thinking process is one essential component of professional practice. The nursing process is a problem solving approach. It includes: Collect and organize information derived from multiple sources. Decide what is needed, based on that information. Select and implement one approach from among many possible approaches. Evaluate the results of the process. Personal: This category emphasizes on autonomy. Autonomy means the practitioners have control over their own functions in a work setting. Autonomy involves independence, a willingness to take risks and responsibility and accountability for one‘s 11
own actions as well as self-determination and self-regulation. The autonomous practitioners are also obligated to collaborate with others for the benefit of the patient. Interpersonal: Nursing is a significant therapeutic interpersonal process. It functions cooperatively with other human processes that make health possible for individuals in the communities. The nurse collaborates with the patient, significant others and health care providers in the formulation of overall goals and plan of care and in the decisions related to care and delivery of services. CRITERIA OF PROFESSION Bixler and Bixler Criteria for Profession: Genevieve and Roy Bixler who were against the status of ‗Nursing as a Profession 1945, appraised nursing according to their original seven criteria as follows:1. A profession utilizes in its practice a well defined and well organized body of knowledge, which is on the intellectual level of the higher training. 2. A profession constantly enlarges the body of knowledge its uses and improves its techniques of education and service by the use of the scientific method. 3. A profession entrusts the education of its practitioners to institutions of higher education. 4. A profession applies its body of knowledge in practical service, which is vital to human beings and social welfare. 5. A profession functions autonomously in the formulation of professional policy and in control of professional activities there by. 6. A profession attracts individuals of intellectual and personal qualities who exalt service above personal gain and who can recognize their chosen profession as life long. 7. A profession strives to compensate its practitioners by providing freedom of action, opportunity for continuous professional growth and economic security. After examining all the criteria of profession and other related concepts and aspects ―world health organization‖ has already recognized ‗Nursing as a Profession‘. PRESPECTIVE OF NURSING PROFESSION: At National Level: During the Post Independence period there has been enormous change and development in the field of medicine, medical technology, health care and nursing. Some vital recommendations to the Bohre Committee relevant to nursing profession are given below: 1. Stipends to the nursing students: In order to prevent economic barriers in the way of suitable persons entering the nursing profession, the committee suggested the provision of Rs.60 per month for pupil nurses. 2.Nurses, Midwives and Dais: The committee suggested that by 1971, the number of trained nurses available in country should be raised to 7, 40,000. As essential step towards the achievement of this objective was the removal of the existing unsatisfactory conditions of training and service. The committee made proposals to improve the situations. 3. Training of Nurses and Midwives: In view of the extreme shortage of nursing personnel the committee recommended that the first group of 100 training centers, each taking 50 pupils, should be started two years before the Health Organization began to be established, that another set of 100 training centers should be created during the first two 12
years of the schemes and that a third group of the same number of training centers should be established before the third year of the second puperium. 4. Male Nurses: Male nurses should be trained and employed in large numbers in the Male wards and Male Out Patient Departments of Public hospitals, thus releasing women workers for other work. 5.Public Health Nurses: The committee also made specific proposals with regard to the training of Public Health Nurses. These should be fully qualified nurses with training in midwifery as well. 6.Midwives: The number of midwives actually available for midwifery duties in the country was probably 5000.The committee laid down certain fundamental requirements which should be met before an institution could be organized as a training centre for Midwives. 7.Dais: The continued employment of women as dais was inevitable. The committee advocated the training of dais as an in trim measure until an adequate number of midwives would become available. 8.Nursing Staff: The report recommended to produce another category of Nursing Health Personnel called Auxiliary Personnel. Auxiliary Nurse Midwife training was started to meet the health needs of the country. Establishment of Indian Nursing Council: As a result of Bohre Committee recommendations, Indian Nursing Council was established in 1947 to regulate the standards of Nursing Education. Nursing Council made three important decisions: a) There should be only two standards of training of General Nursing and Midwifery: i. The full course of General nursing to be for three years followed by a minimum of nine months of midwifery. ii. A course of Auxiliary Nurse Midwife for two years. b) The minimum entrance requirement of General Nursing Course to be Matriculation and for Auxiliary Nurse Midwife to be 7th or 8th standard of education. c) The Auxiliary Nurse Midwife Course to replace various courses like Junior Grade Nursing Certificate and courses other than for nurses. Development of nursing education in India: The Auxiliary Nurse Midwife/ General Nurse Midwife Programmed: a) The Indian Nursing Council at its meeting in 1950 came out with some important decisions relating to future patterns of Nursing Training in India. One of the important decision was that there should be two standards of training of Nursing and Midwifery: A full course of 3 yrs in Nursing and minimum of 6 months of Midwifery. A course of Auxiliary Nurse Midwives of 2 yrs which would replace various courses for Junior Grade Certificate. The first course of A.N.M was started at St.Mary‘s Hospital Taran Taran, Punjab in 1951.Initially a very few training centers undertook to give this course but the financial aid was given by Govt. Of India under the scheme for preparing personnel for Primary Health Centers gave a great impetus to the training program. The entrance qualification was raised from 7th class passed to matriculation. UNIVERSITY LEVEL PROGRAMMES: Basic B.Sc. Nursing: The need for providing basic training in nursing at University Level was felt by the members of TNAI from 1940 onwards. B.Sc. Nursing (Hones.) was 13
started at Delhi in July 1946 in School Of Hospital Administration which was started in 1943.This school was renamed as College Of Nursing which is now called Rajkumari Amrit Kaur College OF Nursing in1972.This college is located at Lajpat Nagar, New Delhi. A similar course in B.Sc. Nursing was started at CMC Vellore, Madras University, and Tamil Nadu in 1946 by the Joint Church Society of England, U.S.A and Canada. Post Basic/ Post Certificate B.Sc. Nursing: The need for higher training for certificate nurses was also stressed by the Mudaliar Committee in 1962.For up gradation of professional standard, two year Post Basic Certificate B.Sc. Degree Programmed for nurses with Diploma in General nursing and Midwifery was started in Dec.1962 by the School of Nursing, University of Thiruvananthpuram. POST-GRADUATION EDUCATION: M.Sc. Nursing Education: Two year course in Master of Nursing was started at Rajkumari Amrit Kaur College of Nursing, New Delhi in 1959.In 1969; M.SC Nursing was started at CMC Vellore affiliated to Madras University. The M.Sc. Nursing Curriculum was prepared and prescribed by Indian Nursing Council in 1986 which is implemented by all the colleges. M.Sc. in Psychiatric Nursing was also started in Sept. 1983 at NIMHANS, Bangalore. This college is affiliated to Bangalore University. M. Phil Programmed: The inspection committee constituted by INC under statute 30(4) for the inspection of the college, visited RAK College of Nursing, New Delhi on September 13, 1977 and advised the principal to form an M. Phil committee to assess all the requirements for the said Programmed. But due o some administrative reasons the M. Phil Programmed could be started only on Oct.15, 1986 after due approval of the M. Phil Committee members. The Programmed is of 1 yr for regular candidates and 2 yr for part time candidates. Ph. D Programmed: Ph. D Programmed was started in few colleges of nursing like College of Nursing PGI, College Of Nursing CMC Vellore, and College Of Nursing Affiliated to Mangalore University and at RAK College of Nursing, Delhi University etc. from 1990 onwards. Ph. D Programmed in Psychiatric Nursing is also there in NIMHANS, Bangalore, for their own faculty. AT GLOBAL LEVEL: Introduction: There are various educational routes for becoming a Professional Registered Nurse. Initially hospital Schools of nursing were developed to educate nurses to work within those institutions. Associate Degree Education: The associate degree program in the United States is a 2 yr program that is usually offered by a University or Junior College. This program focuses on the basic sciences, theoretical and clinical courses related to the practice of nursing. Diploma Education: The diploma program in the United States is a 2-3 yr hospital based program. Diploma programs focus on the basic sciences and on theoretical and clinical courses related to nursing practice, usually with a substantial clinical component. In U.S, diploma programs are declining in numbers. In Canada, diploma programs are offered in community colleges or hospitals and are 2 yr programs. Baccalaureate Education: The baccalaureate degree program usually encompasses 4 yr of study in a college or university. The program focuses on basic sciences and on theoretical and clinical courses, as well as courses in social sciences, arts and humanities 14
to support nursing theory. In Canada, the degree of Bachelor of sciences in Nursing (B.Sc. nursing) or Bachelor in Nursing (BN) is equivalent to the degree of Bachelor of Sciences in Nursing (BSN) in the United States. RN completion programs are available at many colleges and universities. These programs are designed to assist the practicing RN in obtaining a baccalaureate degree in Nursing. Accreditation: To be accredited, nursing programs must meet certain criteria established by the National League for Nursing Accrediting (NLNAC).This voluntary accreditation is available for basic nursing education programs and masters degree programs in nursing. Licensure: In the U.S, RN candidates must pass the National Council Licensure Examination for Registered Nurses (NCLEX-RN), which is administered by the individual State Board of Nursing. Regardless of educational preparation, the examination for RN licensure is exactly the same in every state in United States. Certification: Beyond the NELEX-RN, National Nursing Organizations such as ANA, have many types of certification that the nurse can work toward. After passing the initial examination, the nurse maintains certification by ongoing continuing education and clinical or administrative practice. Masters Degree Preparation: A person completing a graduate program can receive the degree of Masters in Arts (MA) in Nursing or Masters in Science in Nursing. This provides the advanced clinician with strong skills in nursing sciences and research based clinical practice. A Masters degree in nursing can be valuable for nurses seeking roles of nursing educator, clinical nurse specialist, nurse administrator or nurse practitioners. Doctoral Preparation: The first nursing doctorate program was opened in 1953 at University of Pittsburgh. Other programs emphasized on basic research and theory and award the degree of Doctor Of philosophy (Ph. D). Continuing and In-service Education: Continuing education involves formal, organized and educational programs preferred by state Nurses Associations and Educational and Health Care Institutions. Other goals include helping nurses become specialized in a particular area of practice and teaching nurses new skills and techniques. Licensed Practical Nurse Education: A licensed practical or vocational nurse is trained in basic nursing techniques and direct client care. The Licensed Practical Nurse (LPN) or Licensed Vocational Nurse (LVN) practices under the supervision of a Registered Nurse (RN) in a hospital or community health practice setting.
15
BIBLIOGRAPHY: 1.Basavanthappa B.T ‗Nursing Administration‘ Ed 3rd Published By Jaypee Publishers pp-1-17. 2.‗History and Trends in Nursing in India‘ Published By Trained Nurses Association of India pp-1-22. 3.Kay Kittrell Chitty ‗Professional Nursing Concepts and Challenges‘ Ed 4th Published by Elsevier Saunders pp-2-27. 4. Leddy Susen and Pepper J. Mac ‗Conceptual Bases Of Professional Nursing‘ Ed 4 th Published By Lippincott pp-4-11. 5.Potter and Perry ‗Fundamentals of Nursing‘ Ed 5th Vol. 1st Published By Mosby Harcourt India pp-376-380. 6. Sorensen and Luckman‘s ‗basic Nursing: a psycho physiological Approach‘ Ed 3rd Published by W.B Saunders pp-6-18. 7. ‗The Foundations of Nursing‘ Vol. 1st Published by B.I Publications Pvt. Ltd. pp-4571. 8.www.google.com.
16
DEVELOPMENT OF NURSING PRACTICE Int roduction: Nursing is a unique profession. It is in its simpler form existed from the beginning of human life and is essential to the maintenance of life. The first mother was the first nurse. From the time of the first mother down to the present day, we have found women protecting their children, and taking care of the elderly and sick members of the family. They also rendered their services to the neighbors during illness. Simple procedures for the sick were adopted, e.g., application of cold water over the forehead, to reduce fever, application of pressure over a bleeding injury. Individuals who possessed special gifts and aptitudes for caring and healing gradually collected a lot of healing knowledge through trial and error, and passed on from generation to generation. The word nursing comes from the Latin word ―Nutrix‖ meaning of ―Nourish or cherish‖. The word nourishes means to supply that which is necessary to life. When nursing perceived as a science, the term nursing becomes a noun signifying a body of abstract knowledge. Nursing is a fast developing profession. To attain this stage it has taken a longer time. In early days only orphan, widows and nuns took up this nursing, professional nursing is adopting to meet changing health needs and expectations. Nurses now receive advanced education in such specialties as intensive care, coronary care, respiratory care, ontological care, neonatal intensive care, renal dialysis care, trauma care, transplant care and other to fulfill the needs and expectation in contemporary period. For the development of the nursing profession in new era one must know the philosophy, goals, and development of nursing for the betterment of the profession. Historical development in nursing: Historical background is an important aspect of every discipline. The nursing history is not just the story of dates, conquests, discoveries or research in the field of nursing but it provides the basis for understanding the nursing today. Just as childhood shapes to adult hood, nursling‘s origins and development shape it‘s response to the present. Development of nursing helps us: -To understand and interpret the changes which have taken place in nursing. -To understand some of the problems of the past and how they have been solved.The study about those who have developed nursing to the present stage will stimulate the present generation. It helps to accept the share of responsibility for the future of nursing. Nursing has a fascinating history that parallels the history of human kind. For as long as there has been life so has there been the need to seek care and conform from illness and injury. From the dawn of civilization, evidence prevails to support the premise that nursing has been essential for the preservation of life. Survival of the human race, therefore, is inextricably intertwined with the development of nursing. Genesis of nursing: History of nursing as an episode in the history of women. The nurse is the mirror in which reflected the position of women through the ages‖. During that time women restricted to home. Nursing has its origins in the mother. Care of helpless influence and must have co existed with this type of case from earliest times. 17
As the evolution taken place in the world another diminution was added to its meaning women who cases for and tends young children particularly with respect to the training, training and general upbringing of the young. The word nurse maid and governess thus reargued and became titles for the young girls. Stewart and Austin hesitated 2 kinds of helpers: Born Nurses: The women of their maternal instincts. Child Nurses: With the teaching and training of children so nurse became more closely associated the healing arts. Time progressed love and caring along were not sufficient to nature health or overcome disease. The development of nursing thus developed on the additional essential ingredients, such as SKILL EXPERTNESS AND KNOWLEDGE: Male and females have a tendency to respond to helplessness. Threat to life, disease and injury. So they functioned as nurses. The role of nurse gradually enlarged with much broad scope for care of sick. The aged, the helpless and the handicapped as health promotion of vital components of nursing. The head, heart and the hand become truly the strong foundation for modern day nursing. Nursing: the seed of early community service: This service was related to preservation and protection of the tribe and its members during this period community was influenced by waves of religious awakening ideas of chivalry. Patriotism and democracy social and humanitarian efforts. As more civilization developed the nursing care extended to poor people, prevention of disease. For longer period Nursing could be done only by those who renounced the world. Religious motive, self scarification provides an excellent qualification for assuming the Nursing role. Because of continued civilization all tribes followed some type of sanitary practice. Elementary practices become more sophisticated as technical advances. Such as improvement in water drainage system, disease and communicability that is over all emphasis on health. During these period medicine men, priests, wise women and midwives serve to the community as well as to the individual. The basic concept that included in nursing is health and illness. Thus the early roots of public health become a prominent aspect of the nursing role. Care of the sick among primitive people: No records of nursing in the prehistoric times what we know about the nurse of the sick in primitive times has been discovered through myths, songs, and the findings at archaeologists. Primitive man was much closer to nature and animals. The first trace of parental love, tendons and natural aid were elicited by birds and other animals. They were nature worshippers. This belief is known as ―animism and the period as called as Stone Age or age of hunters‖. He believed that thing in nature like a tree or river had a sprit or soul. Water and trees were friends while storms and poisonous plants were enemies. Natural colonies were attributed to the anger of god. Beliefs: The primitive people believed that sickness comes due to the following reasons: 1. Anger of the offended gods, devils and evil spirits. 2. Displeasure of the dead.
18
3. Breaking a taboo. 4. Bodily invasion by a sprit to get rid of evil spirits dwelling in the body, the body had to be made unpleasant for them. 5. Loss of soul - A soul catching ceremony was required for its return. 6. Dreams – It was believed that soul leaves the body during the period of dreaming. Preventive measure and treatment: Starving, beating, loud noises, magic treatise and ceremonies and sudden fright were also tried. Starting the evil spirit with a frightening mask and deafening noises. Using noxious body. Giving noxious medicines. Trephening the skull with stone. White magic was used to attract good or helpful spirits. While black magic was used to drive away evil spirits or bring harm to one‘s enemies.\ Hot and cold baths. Faith of the person. The above treatment was done by medicine man or priest physician. The heritage of nursing, initial image of the nurse: The role of the Nurse is mother. The concept of Nursing as a feminine occupation Nursing started to keep healthy full environment and keep the people healthy, and to provide comfort care and assurance to the sick. They were capable, concerned and compassionate persons whose practice encompassed ―a wellness‖ in addition to an illness component. They used problem solving skills as well as intuition in assessment of human needs. They developed body knowledge and utilized intellectual interpersonal and psychomotor skills in meeting human needs. They shared their knowledge and skills beyond family and neighborhood bonds by teaching individuals, families, communities and their own successors. They possessed a role and function separately and distinct from those of medical practitioners. Role of the nurse in the care of the sick: From the time of the first mother down to the present time we find women protecting and caring for their children aged and the sick members of the family. Traditionally female role is wife, mother, daughter, sister have family members thus nursing could be said to have its roots in the home. Nursing role has always entailed humanistic caring, comforting and supporting, nourishing, cleaning aspect to the patient. Knowledge of these simple skills was passed down from generation to generation, tenderness, concerns, love and hope practices in nursing evolved.
19
BEGINNING OF CIVILIZATION 5000 BC TO 1 AD: Definition: Civilization is the product of our higher qualities as exercised first by original and superior individual and then accepted or followed by a sufficient numbers of human beings to make it a social fact. Prof. Lyna Theorndike. Medicine and nursing in early civilization: The new Stone Age period: Egypt: The oldest medical records have come from Egypt date back to 1600 BC – 3000 BC Writing was introduced first. 4000 BC – Produced a calendar of 12 months with 30 day. - 5 days to celebrate the birth of God. 5000 BC – man improved to built the houses, pyramids Invented axe and grow own crops. The priest physician was the greatest of all priests. He is called as ―IMHOTEP‖ means the cometh in peace. Temples were used as halls of healing health. At the time ―animism‖ replaced by ―mythology‖ they believe life after death. They worshiped Isis, Mother earth who helped the sick most frequently through the dreams. Temples become centers of community and national life. Persons who were ill were bought to the temple, left there over night to seek the priestly intercession of the gods. The priests were helped by one group of temple women who were of high social positions and held the rank of priestess. They are believed to perform some nursing duties. ―Eber Papyrus‖ is known as the oldest complete medical book in the world. Contains a classification and description of disease and surgery. Berlin Papyrus – focused on the treatment of disease of the anus. Hygienic principle followed by the Egyptian especially cleanliness of body and dress. They practiced circumcision. They recognized the importance of an adequate system of drainage, good water supply and also the inspection of slaughter house. Nurses role: Women in Egypt had no career but had some freedom the mother had a position of authority. Mother and daughter probably nursed the sick in their homes. Journal reference: Nursing times. January 21 volume 94 page no 34 to 36 Kante (Balck Smith) Soknolonba they come from the caste that makes knives, tools and weapons. Female circumcision is family tradition. Here removal of labia and vaginal orifice is reduced. She can excise 40 girls per day with out any problem. Excised from babies to 20 yrs olds using alcohol as antibiotic and paste of leaves and takes about a month to heal. They do it because they consider it is a form of purification and rite of passage to women hood. Ancient Egypt people were organizing probably some people believe that women who have not been excised will eventually not be able to have intercourse or become pregnant. Because the clitoris will grow until it obstruct the orifice.
20
Babylonian (Iraq): Began as early as 4000 to 3000 BC the first Babylonian empire was founded by king ―Hamurabi‖. He developed a code of laws for the whole empire. Enclosed the treatment of the diseased people from poor and defenseless class. Punishment for doctors was severe, if patient died. E.g., Doctors hands were cut off, Nurse were treated as slaves Health beliefs and treatment: They believed that illness was due to 1. Sin and displeasure of the God 2. Punishment from sinning Principle mehtod of treatment: 1. Ridding the human body of the demons of disease by incantations. 2. Application of herbs. The nurse carried out the care and treatment as directed by the physician. Palestine (israles): The practice of hygienic and health rules were given by Moses. The hospitably and visiting the sick was considers as their duty. Some of the health rules were‖ Inspection and selection of food what to eat and what not to eat. Disposal of excreta by burial with enough sand. Disinfecting and purification. Hygiene of women after child birth. Reporting and isolating communicable disease. Quarantine. Circumcision as a religious practice and as a sanitary measure. Hebrew nurses had a high position and participated care full in planned programmed of visiting the sick at their homes. Persia (iran): Both Persians and Hebrews had religious law and practices regarding physical health, ―Zend-Avesta was written by ―Zoroaster‖ who lived about 600 B.C. Fire, earth, and water were considered as sacred elements and among those fire purest. Health beliefs and treatment: Illness is due to evil spirit and they had three types of practitioners they were, 1. Those who treat with knife and heal. Called as Surgeons. 2. Those who treat with herbs and heal. 3. Those who treat with prayer and holy words and heal. Hebrews: Many rules and regulations in regard to social and religious custom and health sanitary practices are compiled into what is called the mosai code. This code presents a systematic organized method of prevention of disease it includes principle of personal hygiene relating to rest, sleep, and cleanliness. Hours of work and special rules for women, midwifery principles of public hygiene and signification regarding food, disposal of excreta, garbage, and isolation quarantine disinfecting and reporting of communicable diseases. The high priest was priest physician and health inspector. They practice excellent hospital, visiting and caring for the sick were a religious duty. 21
NURSING: Ancient Hebrew nurses had a high position and participated careful in planned programmed of visiting the sick at their homes and caring for them. The Hebrew nurses were active in promoting and maintaining physical, mental and community health and they continued their services in health maintenance and health education. Ancient Americans: In the North and South America the culture was highly developed before Columbus found the new continent there were several group of people as the Mayas, Incas, and Aztecs. Mayas – Practiced human sacrifices to care illness. Ideas and Aztecs were skilled engineers and built roads and suspension bridges. They believed that disease is caused and by the displeasure of the Gods. Disease were prevalent and treated with bloodletting, cupping or sucking, massaging, sweating, splinting, setting of bones, tooth extraction, amputation, suturing and bandages. Greece: They believed medicine was of divine origin and was represented by many God. They worshipped ―Apollo‖ as god of the sun. He was regarded as the God of Healing. The unclean such as the dying and obstetrical patients were not allowed to come in or to remain in the temple. It was not until after 170 A.D. To the Greeks, hospitality was a virtue and a religious duty. So they met this by providing organized charity and cared for the poor and sick. They considered death and birth as sources of pollution. Greeks built great sanctuaries for healing the sick and for incubation. This period ―Attendants‖ served the sick. Along with the priest and physician. The era of scientific medicine and perhaps nursing begins with ―Hypocrites‖. He was born in ―Cosine‖ in 460 BC. He was the son of a priest physician At this time ―Hippocrates‖ laid the foundation for the science of biology as well as the study of comparative anatomy. He believed that disease was due to man‘s disobedience to the laws of nature and not due to evil sprit. Since he led the scientific way of practice, he is known as the ―Father of Scientific Medicine‖ His method of treatment was based on four principles. Observe all symptoms. Study the patient. Evaluate honestly and. Assist nature. Hippocratic medical achievement can be grouped in the four major areas: Rejection of all beliefs in the super natural origin of disease. Development of through patient assessment and recording. Establishment of the highest ethical standards in medicine. Author of medical books. The symbol of caduceus: 2 wings resembles speed of work Serpents – the emblem of wisdom and rejuvenated and immortality.
22
INDIAN: The earliest literature of India consists of the Sanskrit Vedas believed to have existed in 1600 BC Rig Veda – Disease was regarded as the result of divine wrath. Atharvana Veda – It deals innumerable incantations and charms for the practice of magic, disease, injuries, health and fertility. Ayur Veda – It deals with medicine, surgery and children disease. The samhitas (Books) gives the details of hospitals and attendants. The Shushrutha, Samhita states that the physician, the patient, the medicine and attendant are the four essential facts in the care of disease. It describes the nurse as one who is cool headed and pleasant in her behavior. Nurses are very attentive to the requirements of the sick and strictly follow the instructions of the physician. During 500 BC to 300 AD Buddhism raised the practice of medicine rose to new lights but surgery declined. Pharmaceutical gardens were maintained to supply herbs and drugs. Large numbers of hospital were established and monastic universities were founded. Famous among them were Dhakshasela and Nalanda. Status of women in india: The main activities were management of the home and care of the family numbers during illness. CHINA: Sen. – long was known as the father of medicine they practiced vaccination physiotherapy as early as 1000 B.C. They recognized disease like syphilis, Gonorrhea, they could treat anemia with the liver in their diet and thyroid with iodine, leprosy with chaulmoogra oil. Journal reference: Nursing Times January 21 Volume 94 Page No.28-29 Sexually transmitted infections have a long pedigree they mentioned in Bible, ancient Chinese and Greek medicine texts. Until the 15th century the most common sexually transmit infection to be gonorrhea, which on treated can lead to infertility and various chronic conditions. In the 15th century a new deadly sexually transmitted pestilence took Europe by storm. Syphilis is called as ―great Pox‖ syphilis emerge result of transoceanic exchange. This concept developed by the historian William H. Mc Neill, states that when societies came into contact for the first time they lack natural resistance to each other‘s infection. Common people believed that disease was due to evil spirit and who ever touches the person the evil spirit gets into other body. ROME: They copied much from Greece they were idol worshippers and in later period they worshipped there emperors also. They had good system of sanitation, paved roads and bridges. Drainage system and sewers were made; drinking water was brought out by aqueducts. They had public baths for men and women and had public dispensary. Women of Rome had certain amount of freedom, old women and men of good character did nursing. 23
CEYLON: Ceylon adopted India‘s methods. There were hospitals and well prepared physicians and nurses to attend to the sick. NURSING IN EARLY CHRISTIAN ERA: Christian Motive in Nursing:Christianity taught that one could give kind service to humanity without expectation of any reward. Some of the teachings of the Christ influenced the nursing. The story of god Samaritan in the bible insisted particular attention towards the sick and poor. This idea motivated nursing, medicine and charity. While the other religions believed that illness is due to fate, Christians did not accept illness as something necessary or deserved. From the Christian teachings, the concept of altruism evolved the care of sick or disabled as a corporeal act of mercy. To feed the hungry. To give water to thirsty. To cloth the naked. To visit the imprisoned. To shelter the homeless. To care for the sick. To bury the dead. Early Christian Ordersapostolic Orders: there were three groups of Christian women k known as apostolic orders. They were either unmarried or widows Deacons visit the homes of the poor and sick and provided food and money for the needy and prayed with them. They gave medicines and their services according to their ability and knowledge. PHOEBE: Phoebe was a Greek lady she helped to nurse the sick in their homes. So she had been awarded the dual honor of being the world‘s first visiting nurse. And she was known as for runner of the modern public health nurse Fabiola: She was a very beautiful young lady who made a public confession about her sins and turned her home to a free Christian hospital. She gathered sick from the streets and nursed them. Paula: Paula was the friend of fabiola. She was wealthy and very intelligent.When her husband died she joined Christianity. She and her daughter, Estonia, went to Palestine and settled in the Bethlehem. Here she built hospices (place of shelter for travelers) and hospitals for the sick. She and her staff did the nursing. She established a monastery in Bethlehem and gathered a group of devoted women. After her death, in 404 AD her work was carried on by her daughter. Beginning of the first century‘s church and teachings of Jesus Christ expressed concern for orphans, the poor, and travelers and above all, the sick, religious influence raised the social position of nursing. Men and women committed to church spread the philosophy of Christianity while providing nursing care to the sick. The deaconesses of the early church, widowed and unmarried lay women appointed by the bishops visited the sick 24
much like modern visiting nurses. The Romans visiting nurses soon become ‗first visiting nurse‘ Phoebe (55 A.D) is the most noted deaconesses in nursing history. Fabiola established first general hospital in Rome in 330A.D. Although nursing became increasingly humanistic, there were no efforts to start a formal education or training for nurses. Early middle age: Early middle age is the Dark Age in the history of nursing. This era began with the fall of the mighty Roman Empire. A cording to the self needs of the time three protective units was developed. The monasticism The feudalism The guilds. The Monasteries became the chief place for education, medicine, and nursing. They gave medical and nursing care to travelers, poor and needy. In feudalism the king owned all the land. He gave portions of land to his favorite subjects who were knights. The training of knight, which become known as ―chivalry‖ stressed service to others, protection and defense of the weak. Guildes: This was the first organization of workman. In guilds learning skill was stressed, higher standards of work encouraged and unethical practices were checked this has been fallowed in nursing. In early middle ages nursing had developed roots, purpose and leadership. This period is considered as dark ages in the history. The monastic orders also developed during this time. One of the earliest organizations for men in nursing the parabola, brotherhood was established during this period. Responding to the needs created by the black plague this group organized a hospital and traveled throughout Rome caring for sick. The order of Benedictine which still exists was founded during this time increased the number of men entering nursing. Such famous monastic nurses‘ St. Brigid, St. Scholastic and St. Hilda were founding schools, tending to the sick and giving to the poor. These monasteries were offering care to the sick and education to the uneducated. Augustine sisters found giving care for mentally retarded and mentally ill in the Greece was known to be oldest order of nursing sisters. In some of medieval a hospital nursing was done by dedicated women and nursing brothers. One nurse being allotted to 15 patients by day, but each night nurse was responsible for 100 patients during this stage. Late middle ages (1000 a.d-1500 a.d): This late middle age is ‗crusades‘ (means religious war between the Muslims and Christians) for 200 years (between 1096-1291) During this, there was great need for hospitals and care givers, in 1050 some wealthy merchants of Amalfi founded two hostels in Jerusalem, and these took upon themselves a combination of warfare charitable relief and hospital nursing. Military nursing orders were formed for the first time, soldiers were used to give care for the needy whenever they were free, and serving brothers carried on regular ward duties at all times. They gave food to pilgrims, alms to poor, and the care for the sick.
25
Mendicants were traveling monks their activities was giving nursing care to the sick. They formed several nursing and religious and non religious (secular orders) for providing nursing care. Indivisual nurse of the time: St. Hildegard: she wrote books on medicine in which she described about jaundice, lung disease, and dysentery. St. Elizabeth of Hungary (1207- 1231) Visited the sick in the hospitals. St. Catherine of Siena (1347- 1380) When plague came to her town she spent day and night in giving care to patients. Queen Elizabeth of Portugal She founded a hospital for the poor and nursed the sick. Queen Osabel: introduced ten types of hospitals and ambulances for injured on battle. Queen Naslilida; founded hospitals and personally gave care. Organization of the hospitals Crowded living conditions and increase in the spread OF DISEASES caused the demand for more hospitals. The first hospital in England (1036 AD) was built at York fallowed by St.Barthalomeus hospital (1123), St. Thomas hospital (1213)in London which was used many years later by Nightingale for clinical experience of nursing students. Bethlehem hospital later became first mental hospital. Response of nursing to the needs of the society (1500 – 1850): Dark ages of nursing: The beginning of the 16th century was marked with religious, political and industrial revolutions. As ‗Protestantism‘ sweep across the Europe, monastery hospitals were closed along with the early nursing orders affiliated to them. There was shortage of nurses to care for the sick poverty, epidemics like leprosy; typhoid and plague were critical health problems at this time. To meet this crisis, women who committed crime were recruited to serve as nurses in lieu of surviving jail sentences. Thus society viewed nurses as disreputable and the feeling of disrespect towards nurses. The working conditions of the nurses deteriorated, the pay was poor and nurses were considered as menial servants. Attempts to improve nursing and images of nurses were abandoned. Industrial revolutions resulted in physical and mental stress and unsanitary conditions. It is commonly agreed that ‗darkest period‘ in the history of nursing that is from 17th to 19th century.During this period nurses were poorly fed, over worked and badly treated only those who could find nothing else to do did nursing. Nurses were lacking in skills and morals. The beds were large and many patients were put together there was no segregation or isolation. In those days doctor did most of the work like doing dressing and giving medicines. Nursing included mostly cleaning, laundry, and scrubbing. The lack of hygienic and sanitation and increasing poverty in urban resulted in serious health problems in 15th to 17th century. Sisters cared for people in hospitals asylums and poor houses. They did home visiting also to care of the needy. Mrs. Fliedner in 19th century wrote notes on nurses training. The first ever written by a woman and taught practical nursing. She also taught religion and ethics. The method employed for training nurses during this period become a model for modern secular 26
nursing and attracted many visitors including Florence nightingale and Mrs. Elizabeth fry. Modern nursing: Florence Nightingale era:Florence Nightingale was borne on 12th may 1820 in Florence, Italy to an English wealthy family. She was interested in charitable work and became familiar with catholic sisters and American missionaries. In her quest to become a nurse she visited Kaisers worth hospital and was impressed by its systematic nursing programmed. She enrolled herself to the nursing training programmed in 1847. In 1853 she had an opportunity to study under ‗Sisters of charity‘ in London. During this period she brought about major reforms in hygiene, sanitation and nursing practice and reduced the mortality rate of the Barracks hospital in Scutari, Turkey from 42.7% to 2.2% in 6 months Nightingale was the superintendent of nurses at king‘s college hospital until she left to take care the wounded soldiers during the Crimean war in 1854. Secretary of the war sir Sydney her best requested Florence nightingales help and she was accompanied by 38 nurses reached sciatic on 4th Nov. 1854 to Barnacle hospital. She demonstrated her skills as an administrator. She spent her own money to improve the conditions of diet kitchen and saw that diets are given according to the needs of the patients. She improved the conditions and sanitation facilities. In 1960 she wrote nursing philosophy which reflected the changing needs of the society. She saw the role of nursing as having changing of somebody‘s health based on the knowledge of how to put the body in such a state to be free from the disease or to recover from disease. Florence nightingale developed the first organized nursing school in 1860 at St. Thomas hospital London. She was honored as a national heroine by the queen. It was opened with 15 students. Duration of the programmed was one year. The courses study included class room and bed side classes by the sister. Theoretical classes and examination by the doctors and each nurses was to keep note book on which she kept a record of her daily observations, treatment and care given to her patients. In 1865 Nightingale drew some detail suggestions or system of nursing in hospitals in India. This was the beginning of modern nursing in India. Nurses were recruited in India for first time in 1914. As a result of her work the attitude towards nursing was changed. Between 1860 – 1893 the nightingale system of training spread all over the world by graduates from the school. Growth of contemporary nursing (19th century): Shortly before world war 2nd, curriculum in school of nursing was revised with more emphasis on social sciences. Preventive and social aspects were integrated. During post world war 2nd development of nursing was on to the specialty areas like psychiatry, neurology. Major factors influenced health care development through nursing. In 1869, American medical association developed committee on the training of nurses. As a result hospital based school of nursing of nursing under medical supervision emerged. 1n 1847, Linda Richards, Americas first trained nurse, graduated from women hospital, Boston. Lillian Wald and Mary Brewster established the first public health nursing service towards the end of 19th century. During World War 1 and 2nd the nurses had to 27
take much independent judgment because physicians were serving the armed forces overseas. Then it was realized and accepted that nurses were also able to take decisions safely and were able to provide effective care to the injured. The civil war (1861- 1865) stimulated the growth of nursing in the United States. After the civil war, nursing schools in the United States and Canada began to follow the nightingale plan. Nursing in hospitals expanded in the late nineteenth century, but nursing in the community did not increase significantly until 1893, when Lillian Wald and Mary Brewster opened the Henry street settlement. It was one of the first community health services to focus on the health needs of poor people living in the New York City tenements. Nurses working in this settlement had greater responsibility for their clients than nurses working in hospitals because they frequently encountered situations that required action independent of physician‘s orders. In the eighteenth century, the growth of cities brought an increase in the number of hospitals and a greater role for nurses. Smallpox epidemics in the French colonies increased the need for nursing services. Growth of nursing in 20th century: Nursing education from 1900 to 1935 was predominantly based in hospital diploma programs. Of the more than 1800 diploma programs in existence in the mid 1930s less than 100 baccalaureate nursing programs were available for general nursing education. In 1923 the Rockefeller foundation funded a survey of nursing education, the Gold mark report. The report concluded that nursing education needed increased financial support and suggested that the money be given to university schools of nursing. As a result nursing programs such as those at Yale University and Vanderbilt University received funds for expansion. As the nursing education developed, nursing practice also expanded. In 1901 the army nurse corps was established, followed in 1908 by the navy nurse corps. Nursing specialization was also developing. In the 1920s graduate nurse midwifery programs began, and beginning in the 1950s specialty organizations such as the association of operating room nurses (1949) were formed. The classic Brown report of 1948 written by Dr. Esther Lucille Brown, a social scientist, significantly changed the course of nursing education. She examined nursing service and education from a societal perspective. Her report, funded by the Carnegie Foundation suggested all nursing education programs affiliate with universities and has their own budgets. By 1952 Dr. Mildred Montage expanded current nursing education systems. These systems created the associate degree nursing program, offering a third educational track for the basic nursing student. By 1988 only 9% of graduating nurses had a diploma education, 33% had a baccalaureate degree, and the remaining 58% had associate degrees (NLN, 1990). At 1953 work of the national league for nursing (NLN) with universities began to develop graduate nursing programs nationwide. Nursing at the doctoral level was initiated by New York University as early as 1934. As of 1988 there were 46 doctoral nursing programs (NLN, 1990). The 30 years of educational and practice changes from the 1950s to the 1980s expanded specialization for nurses. Margareta Styles and Inez Hinsvark edited the American 28
nurse‘s association study on credentialing. It examined these new roles and the credentialing process in the growth of the nursing profession. DEVELOPMENT OF NURSING IN INDIA: During 1688, a hospital built for civilians in Madras, but same staff of the military hospital took care of both hospitals. In 1797, another hospital built for the poor people of Madras named as ‗lying in hospital‘ in this hospital, the Govt. first started a training program for midwives in1854. The Govt. hospital for women and children Egmore is one of the chief midwifery training schools in Madras. At Bombay JJ hospital and Sir Cowasji Jehangir ophthalmic hospital was started. Nurses from England came to work in both the hospitals. Later several hospitals came up with advanced study in nursing. At Delhi, Lady Hardinge medical college hospital was established in1911. In 1915 the training program for nurses started. Development of nursing in mission hospitals in india: India‘s religions, Hinduism and Islamism hampered the progress of nursing in India for a long time. Further, the low status of women, the racial prejudices, general illiteracy and poverty played a part in hindering attempts to develop good health care system. When East India Company came to India, establishing hospitals to provide medical relief. During the later part of 19th century, missionary nurses who came to India from England, Australia France and United States. Worked hard to establish missionary centre which in many cases served as health clinics for treating and teaching the public. In India, mission hospitals were first to begin the training of nurses. There are lots of prejudices about sending decent educated girls for nursing. Hinduism and Muslim religions prevented girls joining nursing hence, Christian girls alone could be trained at first. At first the training began with 1 Yr. course but by 1905, it had been extended to 3 Yrs course. Nursing education advanced gradually in India in spite of the difficulties of religious, racial and political conditions. The present diploma nursing program includes midwifery, Christian medical college and hospitals started in vellor by 1900 AD started first nursing college in India by 1946. Nursing development later periods: 1943 – Marked an awakening that had great influence on the practice of nursing in India with world war 11 The realization came for preparation of Indian nurses for administration and teaching posts. Military and civil nursing services instituted a course for nurses who were interested in teaching. In 1946 Bhore committee report described nursing conditions as disposable and stressed the importance of having educated Indian women to join the profession to raise the standard. Nursing education in india: Nursing education began with a short period of training of midwives for 6 months. With close supervision of their practical experience. And a certificate was given to them after training. In 1871, this system of training was changed and included into general nursing for a period of three years. And midwifery for period of 9 months. The present nursing program includes midwifery, community health nursing, & general nursing. to prepare nurses for purpose of administration, supervision and teaching post certificate courses 29
started in RAK college of nursing, Delhi & CMC Vellore , PC B.Sc. nursing first started in Trivandrum , Basic B.Sc. nursing in RAK college of nursing & CMC Vellore. M.Sc. nursing in RAK College of nursing, in 1960.people came to know the value of higher education in nursing so the standard of nursing increased gradually. In the 19th century lady duffer in fund started to educate women physicians, nurses and midwives. This fund is mainly used to improve the medical facilities for women. Evolution Of Nursing Education In India: We can summarize the history of nursing education in India as follows:1871 – School of nursing started in general hospital Madras. 1886 – School of nursing in a full-fledged form was started in J.J. hospital, Bombay. 1892 – Many hospitals in Bombay started nursing associations which were intended to provide additional facilities for the training of local nurses. 1908 – TNAI established. 1909 – Bombay presidency nursing association was formed. 1910 – United board of examination for nurses was organized. 1913 – South India Board was organized. 1926 – First nurse‘s registration act passed in Madras. 1935 – Madras and Bombay nursing councils were established. 1942 – ANM programmed started. 1943 – School of Nursing at RAK College, New Delhi. 1943 – Diploma programmed in nursing administration started in New Delhi. 1946 – Four year B.Sc. nursing programmed started in RAK College and CMC, Vellore. 1947 – INC act was passed. 1949 – INC was established. 1959 – M.Sc. Nursing started in RAK College. 1963 – Post basic B.Sc. programmed started in various institutions 1968 – M.Sc. nursing at CMC, Vellore 1972 – Basic degree programmed started in Kerala 1985 – M.Sc. nursing stated in CMC Ludhiana. 1985 – IGNOU established. 1986 – Curriculum change for GNM programmed from three and a half years to three years. 1986 – M. Phil programmed started in RAK, Delhi. 1987 – M.Sc. Nursing started in Kerala 1987 – Separate directorate of nursing was created in Karnataka State. 1988 – M.Sc. Nursing at NIMHANS 1992 – Ph. D in RAK College, New Delhi 1992 – Post basic programmed started under IGNOU 1994 – M.Sc. nursing at MAHE, Maniple 1994 – Basic B.Sc. programmed under school of Medical education in Mahatma Gandhi University, Kottayam. 1996 – M.Phil and Ph.D at MAHE, Maniple. 2001 – PhD at NIMHANS.
30
Examinations and certificates: There was no uniformity of courses or educational institutional requirements. Till1907 there was no uniformity of courses or educational institution requirements. Later they organized and setup rules for administration and standard of training and conducting examination certificates were given for the successful candidates. In 1926 certificates are registered by ‗madras nurses and midwives council‘ later state registration council set up. International and national organization: On the international sense, the birth of WHO in 1948 gave an impetus to the strengthening of medical services all over the world. Than there were number of national and international organizations were formed to solve the problems existing in the world International council of nurses: The international council of nurses (ICN) was founded in 1899 by Mrs. Bedford Fenwick. It is an international association of professional women. Membership is open to all self governing national nurses associations. The Indian council was affiliated to ICN in1912. The head quarters of ICN are located in Geneva, Switzerland. Nurses of national association are automatically members of ICN. The ICN publishers a quarterly journal, the international nursing review. It provides opportunity for nurses to attend international conferences visit other countries for study, employment. Indian nursing council: The Indian nursing council was established under the act of parliament, known as the Indian nursing council act, 1947. The council meets once a year and the functions of the council arePrescribing minimum syllabus for the training of nurses Inspection of nursing institutions the recognisision of examined bodies The maintenance of register of Indian nurses It is an autonomous body. State nursing councils: The state nursing council is responsible for registration of nurses. It has the responsibility to exert general supervision over the performance of the nurses with in the jurisdiction. It includes substandard nursing services, negligence of duty and unethical behavior of registered nurses. Trained nurses association of India: It is a professional organization whose membership is open for all registered nurses. It was formed in 1908. The aims of TNAI are To uphold in every way the dignity and honor of the nursing profession To promote a sense of ‗spirit de corps‘ among all nurses To elevate nursing education and to raise the standard of training To strive to bring about a more uniform system of education, examination, certification and registration. Professional development in 20th century: In the early 20th century professional organization such as the American nurses association, the Canadian nurses association, the international council for nurses, the national league for nursing and the American association of colleges of nursing were established. The American journal of nursing first published in 1900 and was the first 31
journal to be owned, operated and published by nurses. Researches were conducted into the field of nursing practice and higher education in nursing. Changing pattern of nursing: Opportunities, avenues available for nurses in the field of nursing service, nursing education, community nursing. There are greater Varity of nursing services and many different ways in which nurse can practice. Vocational opportunities are more now. The functions of professional nurse in hospital nurse after her qualification can assume positions in nursing service as:1. Staff nurse. 2. Ward sister. 3. Departmental nurse. 4. Nursing superintendent grade II. 5. Nursing superintendent grade I. 6. In-service education director. 7. Clinical nurse specialist. 8. Nurse anesthetist. 9. Nurse researcher. CHANGES IN THE FIELD OF NURSING HAVE EXPANDED THE ROLE OF NURSES: 1. Care giver: Care giving role is the primary role of nurses. The care should meet the physical, emotional, socio-cultural, intellectual and spiritual needs of the client. Nurse‘s addresses holistic health care needs of the client. Quality care provides d with minimum cost of time and energy. Care should be provided to promote wellness, prevent illness, restore health, and facilitate coping with disability or death. 2. Communicator: Without clear communication effective nursing care is impossible. The use of effective interpersonal and therapeutic communication to establish and maintain helping relationship with clients. 3. Teacher: As a teacher nurse explains the concepts and facts about health, demonstrates the procedures such as self care activities, reinforces client‘s behavior, and evaluates progress in learning, teaching may be unplanned and informal or planned and mere formal 4. Counselor: The use of therapeutic interpersonal communication skills to provide information, make appropriate referrals, and facilitate the client‘s problem solving and decision making skills. 5. Decision maker: To provide effective care nurse uses decision making skills, throughout the nursing process. The nurse plans the action by deciding the best approach for each client, by using decision making skills.
32
6. Leader/ manager: Nurses manage the time and resources of the practice setting when providing care. As manager/ leader, nurses coordinate and delegate care responsibilities and supervise other health care workers. 7. Comforter: Nurses should care for the whole person rather than simply the body comfort and emotional support often help give the client strength to recover, while carrying out nursing activities. Provide comfort by demonstrating care of the client as an individual with unique feelings and needs. 8. Rehabilitator: Rehabilitation program will help the client to adapt as fully as possible, by using her or his own knowledge and skill. 9. Protector and asdvocator: As a protector the nurse helps to maintain the safe environment to the client and take steps to prevent injury and protect the client from possible adverse effects. As an advocate, the nurse protects client‘s human and legal rights and provides assistance in asserting those rights. CAREER ROLES: 1. Clinical nurse specialist: The nurse with advanced degree, education, experience who is considered to be an expert in a specialized area of nursing, carries a direct client care, consultation, teaching clients, families and staff and conduct research. 2. Nurse practitioner: Nurse with advanced degree, work in a variety of health cares settings or in independent practice to make health assessment and deliver primary care. 3. Nurse midwife: Nurse who completes a performance in midwifery provides prenatal, intra- natal and post natal care. 4. Nurse anethetist: A nurse, who completes a course of studying anestheology, carries out pre operative visits and assessments administer and monitor anesthesia during surgery, and evaluate post operative status of the clients. 5. Nurse administrator: A nurse who functions at various levels of management in health care setting is responsible for management and administration of resources and personnel involved in giving client care. 6. Nurse educator: Nurse with advanced degree teaches in educational or clinical setting, teaches theoretical knowledge and clinical skills and conducts research. 7. Nurse researcher: Nurse conducts research for improvement of nursing practice, education, administration.
33
8. Nurse entrepreneur: Nurse with advanced degree who may manage a clinic or health related business, conduct research, provide education or serve as an adviser, consultant to institution or political agencies. Nursing of the future: History of nursing revealed us how some learned people have worked hard to bring and develop nursing as it is today. Every age we need nurses who are able to share the work for the progress. They have to:1. Participate in professional organizations. 2. Giving expert nursing care where it is necessary. 3. Working for welfare of the nation. 4. Having selfless devotion to the service of mankind with sympathy and empathy. 5. Being loyal to chosen profession. 6. Showing courage to face any situation. 7. Being aware of present trend. 8. Having dedication to service. 9. Acquiring inspiration to attain the goal. 10. Nursing in 1960, was patient centered. Quality care became the concern after 1970. CONCLUSION: The practice of nursing has changed greatly over time. Development of nursing gives information of qualitative improvement in the field of nursing. Now nursing is collaborative care of individuals, families and communities. It also includes promotion of health, prevention of illness, care of ill, disabled, and dying people, advocacy, promotion of safe environment, research, participation in shaping health policy and inpatient and Heath system management and education. Development of nursing enables the nurses to overcome their difficulties and it provide opportunity for them to acquire knowledge about the pros and cons of practices. For effective patient care one must know how the forerunners have dedicated their life to the profession. Thereby the modern nurses can provide quality and efficient care to the client.
34
BIBLIOGRAPHY: Potter and Perry; fundamentals of nursing; 4th edition; Moby company; philadelpha Kozier Barbara; fundamentals of nursing 5th edition; Addison wasley California(1995) Rosdahl, Bunlar Caroline; text book of basic nursing; 7th edition; Lippincot; Philadelphia (1999). Bolander Rao Verolyn; Sorensen and Luckmann‘s Basic nursing; A psychological approach; 3rd edition; W.B.Sounder‘s company; Philadelphia. Taylor carol; Liller‘s carol; Fundamentals of nursing; 4th edition; Lippincott Company; Philadelphia. Jeanette Lancaster; Concepts of Advanced nursing; Mosby company, London(1982) B.T. Basavanthappa; fundamentals of nursing, 1st edition (2002); Jaypee brothers; New Delhi Milk walsh ―Watson‘s clinical nursing and related sciences‖ , Bailliere tindall publications 2001, chapter 1 page no. 4-10 Ann .B. Hamric, Judith .A. spross, Charlene .M. Hanson, Advanced Nursing Practice 1996 , Saunders company publishers Janice, Rider Ellis, Celia, Hartley, ―Nursing in today‘s world‖, 8th edition, Lippincott publishers, chapter 4, Pp 106-20. T. K. Indrani, ―History of nursing‖ Jaypee publications 2004, chapter 1 Pp3-45. Grace Paul N Rao, ―History of Nursing‖ N. R Brother publishers 1993, Chapter 1, and Pp 1-106. JOURNAL REFERENCE: The Nursing Journal of India, Health for ally by 2000 AD, Vol (xxxviii) 1977, January. The Nursing Journal of India, Gems of thought from Florence Nightingale , may 1997 Nursing Times January 21, vol.94. Www. Google .com The Omaha system; bridging nursing education – Velfrinn @ fiten.ev.net. 29.7.06. Carrier partner, history of nursing, volume1, April 2008, page 10-11
35
CODE OF ETHICS (INC)
Introduction: Ethics includes personal behaviors and issues of character e.g. kindness, tolerance and generosity. Ethic is derived from the word ETHOS – ethos as defined by Bernard Harding compromises distinction attitudes, which characterize the cultural outlook of professional group. Ethics are the distinction between right and wrong based on a body of knowledge, not just based on opinions. Ethics in nursing is set of moral codes of professional behaviors towards holistic care. The ethical code is a set of guidelines formulated by the members of profession with the help of specialists in the field of nursing leaders, advocate\lawyers at times members from the society. Purposes of code of ethics in nursing: Standards for the behaviors of nurse and provide general guidelines for nursing action in ethical dilemmas. The code helps to distinguish between right and wrong at a given time especially when alternatives appear just as satisfactory. The code enables a correct decision and a uniform decision within the groups. Helps to protect rights of individuals, families and community and also the right of the nurse. Uses of code of ethics: Acknowledge the rightful place of individual in health care delivery system. Constitutes towards empowerment of individual to become responsible for their health and wellbeing. Contributes to quality care. Identifies obligations in practice, research and relationships. Inform the individual, families, community and other professionals about expectation of nurse. Ethical principles: 1. Ethical principles of respect and autonomy : Respect for a person involves: - level of understand of another person or empathy and reducing exploitation. Autonomy: - person‘s independence, self determining action allow the patient to make decision. 2. Principle of beneficence:Activity seeking benefits, promotion of good. The duty to do balance between benefits and harms, Paternalism is an undesirable outcome of beneficence, in which the health care provider decides what is best for the client and attempt to encourage the clients to act against his or her own choices. 3. Principle of justice and families:Basic principle is that each person has equal right to the liberty available to everyone. 4. Principle of veracity: - The obligation to tell the truth. 5. Principle of fidelity: - The duty to do what one has promised.
36
Ethical dilemma: An ethical dilemma occurs when there is conflict between two or more ethical principles. No correct decision exists. The nurse must make a choice between two alternatives that are equally unsatisfactory. Such dilemmas may occur a result of differences in cultural or religious beliefs. Ethical reasoning is the process of thinking through what one ought to do in an orderly and systematic manner to provide justification for actions based on principles. CODE OF ETHICS FOR NURSES IN INDIA: 1. The nurse respects the uniqueness of individual in provision of care. Nurse: Provides care for individual without consideration of caste, creed, religion, culture, ethnicity, gender, socio-economic and political status, personal attributes, or any other grounds. Individualize the care considering the beliefs, values and cultural sensitivity. Appreciates the place of individualize in the family and community and facilities participation of significant others in the care. Develop and promotes trustful relationship with individuals. Recognizes uniqueness to response of individuals to interventions and adapts accordingly. 2. The nurse respects the rights of individuals as partners in care and help in making informed choices. Nurse: Appreciates individuals‘ right to make decisions about their care and therefore gives adequate and accurate information for enabling them to make informed choices. Respects the decisions made by individuals regarding their care. Protects the public from misinformation and misinterpretations. Advocates special provisions to protect vulnerable individuals/groups. 3. The nurse respects individual’s right to privacy maintains confidentiality and shares information judiciously. Nurse: Respects the individuals‘ right to privacy of their personal information. Maintains confidentiality of privileged information except in life threatening situations an uses discretions in sharing information. Takes informed consent and maintains anonymity when information is required for quality assurance/academic/legal reasons. Limits the access computerized to authorize persons only. 4. Nursing maintains competence in order to render quality nursing care: Nursing care must be provided only by registered nurse. Nurse strives to maintain quality nursing care and upholds the standard of care. Nurse values containing education initiates and utilize all opportunities for self development. Nurse values research adhering to ethical principles.
37
5. The nurse is obliged to practice within framework of ethical professional legal boundaries: Nurse: Adheres to code of ethics a code of professional conduct for nurses in India developed by Indian nursing council. Familiarizes with relevant laws and practices in accordance with the law of the state. 6. Nurse obliged to work harmoniously with members of the health team: Appreciates the team efforts in rendering care. Cooperates, coordinates and collaborates with members of the health team to meet the needs of people. 7. Nurse combines to reciprocate the trust invested in nursing profession by society: Nurse: Demonstrate personal etiquettes in all dealings. Demonstrate professional attributed in all dealings.
CODES OF PROFESSIONAL CONDUCT FOR NURSES 1. Professional responsibility and accountability: Nurse: Appreciates sense of self worth and nurtures it. Maintains standards of personal conduct reflecting credit upon the profession. Carries out responsibilities within the framework of the professional boundaries. Is accountable for maintaining practice standards set by Indian Nursing Council. Is accountable for own decisions and actions. Is compassionate Is responsible for continuous improvement of current practices. Provides adequate information to individuals that allow then informed choices. Practices healthful behaviors. 2. Nursing practice: Nurse: Provides care in accordance with set standards of practice. Respect individuals and families in the context of traditional and cultural practices promoting healthy practices and discouraging harmful practices. Treat all individuals and families with human dignity in providing physical, psychological, emotional, social and spiritual aspects of care. Promotes participation of individuals and significant others in the care Ensures safe practice Consult, coordinates, collaborates and follows up appropriately when individuals care needs exceed the nurse‘s competence. 3. Communication and interpersonal relationship: Nurse: Establish and maintains effective interpersonal relationships with individuals, families and communities. Upholds the dignity of team members and maintains effective interpersonal relationship with them. Appreciates and nurtures professional role of team members. 38
Cooperates with other health professionals to meet the needs of the individuals, families and communities. 4. Valuing human being: Nurse: Takes appropriate action to protect individuals‘ from harmful unethical practice. Consider relevant facts while taking conscience decisions in the best interest of individuals Encourages and supports individuals in their right to speak for themselves on issues affecting their health and welfare. Respects and supports choices made by individuals. 5. Management: Nurse: Ensures appropriate allocation and utilization of available resources. Participates in supervision and education of students and other formal care providers Uses judgment in relation to individual competence while accepting and delegating responsibility. Facilitates conductive work culture in order to achieve institutional objective. Communicates effectively following appropriate channels of communication. Participates in evaluation of nursing services. Participates in policy decisions, following the principle of equity and accessibility of services. Participates in performance appraisal. Works with individuals to identify their needs and sensitizes policy makes and funding agencies for resources allocation. 6. Professional advancement: Nurse: Ensures the protection of the human rights while pursuing the advancement of knowledge. Contributes to the development of nursing practice. Participates in determining for upholding own knowledge an competencies. Contributes to care professional knowledge by conducting and participating in research. AUTONOMY AND ACCOUNTABILITY AUTONOMY: Introduction: Autonomy means that individuals are able to act for themselves to the level of their capacity. It is the right of individuals, governing their actions according to their own purpose and reason. Professional nurse autonomy is defined as belief in the centrality of the client when making responsible discretionary decisions, both independently and interdependently, that reflect advocacy for the client. Critical attributes include caring, afflictive relationships with clients, responsible discretionary decision making, collegial interdependence, and proactive advocacy for clients. Antecedents include educational and personal qualities that promote professional nurse autonomy. Accountability is the primary consequence of professional nurse autonomy. Associated feelings of 39
empowerment link work autonomy and professional autonomy and lead to job satisfaction, commitment to the profession, and the professionalization of nursing. A student-centered, process-orientated curricular design provides an environment for learning professional nurse autonomy. To support the development of professional nurse autonomy, the curriculum must emphasize knowledge development, understanding, and clinical decision making. Respect for autonomy requires that a person honors another‘s right to govern him or herself. The legal doctrine of informed consent for treatment and for participation in research. The following are required for a patient to give informed consent: Disclosure adequate presentation of relevant information about the proposed treatment or study. Understanding adequate comprehension of the disclosed information. Voluntary agreement free assent, uninfluenced by external controlling factors. Competence adequate decision-making capacity. The principle of autonomy may be difficult to apply in patient care when there is strong conviction on the part of the nurse or other members of health care team that respecting self-determined choice is not really in the best interest of the patient. In this type of situation, the nurse may need to consider limits of individual patient autonomy and the criteria for justified paternalism on the part of the nurse. Paternalism is defined as the overriding of patient choices or intentional actions in order to benefits to the patient. Although paternalism is seldom justified in the care of patients, there is reason to believe that some situations warrant overriding patient autonomy. When the benefits to be realized are great and the harms that will be avoided are significant (Childress, 1982). ACCOUNTABILITY: Introduction: Accountability is the process that mandates that individuals are answerable for their actions and have an obligation to act. Accountability involves assuming only the responsibility that are within one‘s scope of practice and not assuming responsibility for activities in which competences has not been achieved. Accountability involves admitting mistakes rather than blaming others and evaluating the outcomes of one‘s own actions. Accountability includes a responsibility to the client to be competent to render nursing services in accordance with standards of nursing practice and to adhere to the professional ethics code. The concepts of Accountability have two major attributes: - answerability and responsibility. Accountability can be defined in terms of either of these attributes but answerability for how one has promoted, protected and met the health needs of the client. It means to justify or to give an account according to accepted moral standards or norms for choices and actions that the nurse has made and carried out. It involves a relationship between the nurse and other parties and it‘s contractual. The terms of legal accountability are contained in licensing procedures and state nurses‘ practice acts. The terms moral accountability are contained in the ANA code for 40
nurse and other standards of nursing practice in the form of norms set by members of the profession. It is noted that accountability means ―providing an explanation or rationale for what has been done in nursing role.‖ Accountability of nursing personnel: Nursing personnel are accountable for: 1. Providing safe and therapeutic environment for the patients. 2. Delivering component and personalized care. 3. Maintaining adequate supplies of material and equipment for smooth functioning of the ward/unit. 4. Maintaining accurate and up to date records and reports. 5. Maintaining good interpersonal relationships. 6. Protecting client‘s legal rights and privacy. 7. Working within ethical and legal boundaries. 8. Keeping pace with changing health needs and developing technology. 9. Delivering care as per standards lay down by profession, statutory body and institution. 10. Delegating responsibility appropriately. 11. Contributing to development of the profession. ASSERTIVENESS Introduction: Assertiveness is a tool for expressing ourselves confidently and a way of saying yes and no in an appropriate way. It is considered as health behavior for all people against personal powerlessness and results in personal empowerment. Nursing has determined that assertive behavior among its practioners is an invaluable component for successful professional practice. Assertiveness is a style of behavior to interact with people while standing up for your rights. Assertive manner certainly means that we‘ll feel more empowered and more in control of circumstances. However, it is definitely not a strategy to get our own way more frequently. Assertiveness offers many benefits: We create health, meaningful relationship. There is less friction and conflicts. There is increased self respect as well as respect from others. Our self esteem is enhanced and we always feel in control. Our productivity at work and the home increases. There‘s less stress at work and overall sense of well being. In expressing ourselves appropriately, we needn‘t hold grudges, or store pent – up emotions. Our emotional and physical health improves. As nurse work in different situations they have to be assertive in order to meet the challenges and to win the cooperation from others.
41
LEGAL CONSIDERATIONS (LEGAL ASPECTS IN NURSING) Introduction: Knowledge of legal aspects in nursing is absolutely essential for each nurse to safeguard self and clients from legal complications. Consumers are each becoming increasingly aware of their legal rights in the health care. It is essential; therefore, a nurse should know her legal rights and professional boundaries, and their consequences of nonconformity. Members of public may become victim of violence unintentionally even by the gentle hands of nurse or by the tender touch of a surgeon or a physician. As a nurse it has become an important necessity to be aware of the legal aspects associated with caring and helping people in the health industry today. Nursing legislation: The first nursing law created was that of nursing registration in 1903 and they have only evolved and expanded over the years to create a thick book which must be studied today by aspiring nurses. Laws and regulations as they affect nurse in India are controlled by state legislation, as state registration acts and a central act, the Indian nursing council act, which was enacted in 1947; and amended in 1957 The legal aspects of nursing are taught and expected to be kept up on throughout every nurse's career. Employment as a nurse does not only require a nursing degree but knowledge of the medical laws that will apply to you should there is a misunderstanding or challenge by a patient or their family. A nursing job is something many young people aspire to but without the legal knowledge behind them, many hospitals will not hire them now that legal issues are becoming more and more problematic. Legal implications are as follows: 1. Torts. 2. Assault. 3. Battery. 4. Negligence. 5. Malpractice 6. Fraud 7. False imprisonment 8. Invasion of privacy 9. Legal documents 10. Informed consent Torts: torts are when others interfere in individuals‘ privacy, mobility, property or personal interests. Assault: Assault occurs when a person puts another person in fear of a harmful or offensive contact. The victim fears and believes that harm will result as a result of the threat. Battery: it is an intentional touching of another‘s body without the other‘s consent. Negligence: it is conduct that falls below the standard of care that a reasonable person ordinarily would use in a similar circumstances or it is described as lack of proper care and attention carelessness. 42
Malpractice: failure to meet the standards of acceptable care which results in harm to another person, Fraud: it results from a deliberate deception intended to produce unlawful gains. False imprisonment: it occurs when a client is not allowed to leave a health care facility when there is no legal justification to detain the client or when restraining devices are used without an appropriate clinical need. Invasion of privacy: it includes violating confidentiality intruding on private client or family matters, and sharing client information with unauthorized persons. Legal documents: it comprised: a) Advance directive: written document recognized by law that provides directions concerning the provision of care when a person is unable to make his or her own treatment choices. b) Do not resuscitate orders: written order by a physician when a client has indicated a desire to be allowed to die if the client stops breathing or the client‘s heart stops beating. Informed consent: it is clients‘ approval [or that of the clients‘ legal representative] to have his or her body touched by a specific individual. NURSING LIABILITIES AND PREVENT MEASURES: In order to protect you from malpractice suits, nurses must take as many precautions as they can during their daily shifts. Recording, documenting and reporting your daily routines and decisions is one of the most common ways to make sure you are on track with your patience and in the right. ► All nursing observations should be noted carefully, describing accurately not only any typical or erratic changes in the patient‘s conditions, but also any lack of cooperation, or any other behavioral problems. ► Patients complains should be recorded as accurately and specifically as time and space on the chart would permit some complaints often provide a clue to the cause of an accident that might otherwise would have been difficult to explain. ► Nurse must report through proper channels, any activity or lack of it, by any subordinates which indicates that they are not properly trained to carry out the assigned functions and duties, ► Authorities must be informed regarding any kind of equipment, materials or supplies, which for any reasons less than safe for use in the patient‘s care. An alert nurse will always be aware of the fact that accidents can and will inevitably occur. ► Insurance protection: there is a moral and practical necessity for a nurse to purchase good liability coverage. LEGAL RESPONSIBILITY: Legal responsibility in nursing means to practice nursing within the guidelines laid down by the law of centre/state, statutory bodies and institutional polices. The main responsibility of nurses is to provide care based on nursing diagnosis, prioritizing the needs; planning, implementation and evaluating the nursing care. Nurse provides care to the patient based on needs, respect, dignity, and right without considering race, nationality, caste, creed, color or socio economic status. There are certain determinants of legal framework for nursing practice in India: -
43
INDIAN NURSING COUNCIL ACT Norms Code of ethics and professional conduct STATE NURSING COUNCIL ACT
Central/state government acts Norms
Legal framework for nursing practice
Standing orders
Precedents
44
Institutional policies, rules, regulations, standing orders
1. Registration: Licensing is a mandatory procedure for practice of nursing. Registration aims at protecting patients by providing qualified nurses. The nurse is responsible to obtain registration in the respective State Nursing Registration Council. Employers should recruit only as per the State Nursing Home Act. 2. Legal Liability/Act Of Negligence: License of a nurse can be suspended or cancelled for any act of negligence or mal practice, following a specified procedure.
Legal liability/ act of negligence
Criminal (IPC)
Civil
Under section 304 of Indian penal code (IPC)
Tort in civil court (Negligence e.g. not giving railing bed to conscious patient causing fall of patient)
E.g. wrong medication leading to death of patient 3. Medico – Legal case (M.L.C.):
A medical legal case is a patient who is admitted to the hospital with some unnatural pathology and has to be taken care of in concurrence with the police and/or court. Types of clients which are categorized as MLC in a hospital are: Road traffic accidents. Injuries inflicted during brawls/fights, shooting, bomb blasts etc. Suicide. Burns. Poisoning. Rape victim. Assault.
45
Nurses role in a medico-legal case: 1. obtain complete history from patient or significant other(s) 2. Inform the police officer/constable on duty in the hospital and the CMO. 3. When it is made a MLC. Then record it on the patient‘s case sheet with red ink at right hand top corner. 4. Do not give any statement about patient‘s condition to police, magistrate or media. Only a doctor has to give information. 5. When a patient has to be discharged, inform the CMO. After clearance from them, then only he/she can be discharged. 6. If a MLC patient absconds inform the CMO immediately and the treating doctor. 7. No patient can leave against medical advice. 8. Documentation the care given to patients timely, accurately and duly sign the nurses notes. 9. Records and all the documents pertaining to patient should be handled with care, during the stay in the hospital. They must be kept safely and should be handed over to the authorized person as designated by the hospital authority. 10. Incase death of a MLC; the body is not to be handed over to the relatives. It needs to be accurately labeled and sent to the mortuary CMO and/ or police officer should be informed simultaneously. 11. Appropriately authority must be informed. 4. Correct identity: A nurse/midwife is responsible to make sure that all babies born in hospital are correctly labeled at birth and handed over to right parent. Unknown/unconscious patients must be labeled as soon as their identity is known. Patients who have to undergo surgery should be appropriately identified and labeled Site of operation to be correctly marked particularly where symmetrical sides or organs there. Operation theatre (O.T.): scrub nurse has to see all the instruments/ swabs are returned. She has to say ‗OKAY‘ before closure by the surgeon. 5. Left Against Medical Advice (L.A.M.A.): Inform medical officer in charge. Signatures of both patients and witness to be taken as per institutional policy. 6. Patient’s Property: Inform patient on admission that hospital does not take responsibility of his belonging. If patient is unconscious/ or otherwise required then a list of items must be made, counter checked by two staff nurses and kept under safe custody. 7. Dying Declaration: Doctor or nurse should not involve themselves in dying declaration, in case where police records the dying declaration. Dying declaration is to be recorded by the magistrate. But if condition of patient becomes serious then medical officer can record it along with two nurses as witness. Dying Declaration can be recorded by the nursing staff with two nurses as witness when medical officer is not present. Then the declaration to be sent immediately under sealed cover to the magistrate.
46
8. Wills: For this doctor has to be present for he can recode if requested. 9. Examination of rape case: Female attendant/female nurse must be present during the examination. 10. Artificial human insemination: Written consent should be obtained from both donor and recipient. Donor and recipient must have the same blood group. Donor‘s and recipient‘s identity should be kept confidential. All related documents should be kept confidential and safe. 11. Poison case: Do not give either verbal or written opinion. Do not allow to take photos unless special permission is granted by appropriate authority. Do not give any information to public or press. Preserve all evidence of poisoning. Collect and preserve all excreta, vomits and aspirates, seal them immediately and send to forensic laboratory at the earliest. 12. Consumer Protection Act(1986): Consumer protection act was passed by parliament in 1986 to provide for better protection of the interest of consumers and focuses on consumer justice through the establishment of consumers councils and authorities for the settlement of consumers disputes and matters connected therewith. The scope of the Act is wide enough to include a vast variety of services. Rights of a consumer/ patient are: Right to safety. Right be informed. Right to choose. Right to be heard. Right to seek redresses. Right of consumer education. Nurses role to prevent complications: 1. Review nursing practice periodically. Update knowledge and improve skill by attending short term courses, in-service education and continuing education programmes. 2. Should have complete knowledge of all rules and regulations of hospital and know their descriptions (duties and responsibilities). 3. Follow nursing practice standards/protocols. 4. Be a keen observer. 5. Written instructions must have rules and code of practice laid down to ensure the safety and well being of patients and nurses. 6. All hospitals must have rules a code of practice laid down ensure the safety and well being of patients and nurses. 47
7. Maintain records and reports of the unit properly. 8. Follow 6 R‘s – right patient, right drug, right time and right route with right technique. 9. Check the treatment order and use professional judgment before implementing. 10. Do not exceed the limits of nursing procedure laid down by statutory bodies. CONCLUSION: Every nurse should act as per the legal guidelines for nursing practice while caring for patients since negligence may cause a great distress to nurse, the patient and others, as well as to reputation of the institution. ―Every individual is ordinarily liable for their own negligence.‖ Therefore nurse have a responsibility of seeing that no harm comes to their patients and also to themselves.
48
BIBLIOGRAPHY: 1.BT Basvanthapa. Nursing administration. Ed.3rd. Jaypee Publishers; New Delhi. 2000; 474-510. 2.Chitty Kay Kittrell. Professional Nursing Concepts and challenges. Ed 4th. Elsevier Saunders. 2005; 521-72. 3.Indian nursing council. Teaching material for quality assurance model: nursing; Ed.1st. Indian nursing council. New Delhi. 2006; 44-50, 62. 4.Joan L. & Parker. Conceptual Foundations of Professional Nursing Practice. Mosbys. 1991; 149-160. 5.Marry Lucita. Nursing Administration. Elsevier. 2005; 251-57. 6.Nursing Times Nightingale. June 2007(3); 49-51. 7.Potter & Perry. Fundamentals of nursing. Ed. 5th. Mosbys. 2001(1);401-23
49
ROLE OF I.N.C. AND K.N.C. History: • The discipline of Nursing was at a fairly mature level before the passage of the Act in 1947. • Original training in Nursing was however, started with the initiative taken at Madras in 1370`s with the beginning of the 20th century. There was established training centers in the Presidencies of Bombay, Madras & Bengal. • Many training centers were established in different parts of the country. There was no uniformity in the patterns of training. There were many reasons for this: • The shortage of educated women. • The setting up of separate hospitals for the women and children as per needs of the society. • Cultural factors coming in the way of large scale. • Bombay presidency nursing association was formed in 1909. • Bombay Nursing Council was established in 1935. Members of INC: The council is composed of representation of • State registration council. • Central of state health department • Military Nursing Services • Indian Red Cross Society • Colleges of schools of Nursing. • Health SCHOOLS & PC schools • Trained Nurses association of India (INAI) • Medical Council of India • Indian medical association • Members of Parliament. Organizational Structure:
50
Office bearers of the council for the year under report: • Mr. T. Dileep Kumar – President • Ms. K.D. Varyani – Vice President Composition of the Council consisting: 1.One nurse enrolled in a state register elected by each State Council; 2.Two members elected from among themselves by the heads of institutions recognized by the Council for the purpose of this clause in which training is given a. For obtaining a University degree in Nursing; Or b. In respect of a post – certificate course in teaching of nursing and in nursing administration; 3.One member elected from among themselves by the heads of institutions in which health visitors are trained; 4.One member elected by the Medical Council of India. 5.One member elected by the Central Council of the Indian Medical Association. 6.One member elected by the Council of the Trained Nurses Association of India. 7.One midwife or auxiliary nurse – midwife enrolled in a State Register, elected by each of the State Councils in the four groups of States of State mentioned below, each group of States being taken in rotation in the following order namely :1.Kerala, Madhya Pradesh, Uttar Pradesh and Haryana. 2.Andhra Pradesh, Bihar, Maharashtra and Rajasthan. 3.Karnataka, Punjab and West Bengal. 4.Assam, Gujarat, Tamil Nadu and Orissa ; 8. The Director General of Health Service, ex-officio ; 9.The Chief Principal Matron, Medical Directorate, Army Headquarters, ex-officio ; 10. The Director of Maternity and Child Welfare, Indian Red Cross Society, ex-officio; 11. The Chief Administrative Medical Officer (by whatever name called) of each State other than a Union Territory, ex-officio ; 12. The Superintendent of Nursing Services (by whatever name called) ex-officio from each of the States in the two groups mentioned below, each group of States being taken in rotation in the following order, namely ; 13. a) Andhra Pradesh, Assam, Maharashtra, Madhya Pradesh, Tamil Nadu, Uttar Pradesh West Bengal and Haryana ; 14. b) Bihar, Gujarat, Kerala, Karnataka, Orissa, Punjab & Rajasthan; 15. Four members nominated by the Central Government, of whom at least two shall be nurses, midwives or health visitors enrolled in a State register and one shall be an experienced educationalist ; 16. Three members elected by Parliament, two by the House of the People from among its members and the other by the Council of States from among its members. COMMITTEES OF INC: 1. Executive Committee of the Council to deliberate on the issues related to maintenance of standards of nursing programs. 2. The Nursing Education Committee, The committee is constituted to deliberate on the issues concerned mainly with nursing education and policy matters concerning the nursing education. 51
3. Equivalence Committee – to deliberate on the issues of recognition of foreign qualifications which is essential for the purpose of registration under section 11(2) (a) 0 (b) of the Indian Nursing Council Act, 1947, as amended? 4. Finance Committee – This is another important Sub-Committee of the Council which decides upon the matters pertaining to finance of the Council in terms of budget, expenditure, implementation of Central Govt. orders with respect to service conditions etc. The Main Functions of INC: 1.To establish and monitor a uniform standard of nursing education for nurses midwife, Auxiliary Nurse-Midwives and health visitors by doing inspection of the institutions. 2.To recognize the qualification under section 10(2) (4) of the Indian Nursing Council Act, 1947 for the purpose of registration and employment in India and abroad. 3.To give approval for registration of Indian and Foreign Nurses Possessing foreign qualification under 11(2) (a) of the Indian Nursing Council Act, 1947. 4.To prescribe the syllabus & regulations for nursing programs. 5.Power to withdraw the recognition of qualification under section 14 of the Act in case the Institution fails to maintain its standards under section 14 (1)(b) that an institution recognized by a State Council for the training of nurses, midwives, auxiliary nurse midwives or health visitors does not satisfy the requirements of the Council. 6.To advise the State Nursing Councils, Examining Boards, State Governments and Central Government in various important items regarding Nursing Education in the Country. Function #1 To establish and monitor a uniform standard of nursing education for nurses midwife, Auxiliary Nurse-Midwives and health visitors by doing inspection of the institutions. Guidelines for Establishment of New Nursing Schools / Colleges in India Approved By Indian Nursing Council. Guidelines for Establishment: 1.Any organization under the Central Government, State Government, Local body or a Private or Public Trust, Mission, Voluntary registered under Society Registration Act or a Company registered under company`s act wishes to open a school of Nursing, should obtain the No Objection / Essentiality certificate from the State Government. 2.The Indian Nursing council on receipt of the proposal from the Institution to start nursing programmed, will undertake the first inspection to assess suitability with regard to physical infrastructure, clinical facility and teaching faculty in order to give permission to start the programmed. 3. After the receipt of the permission to start the nursing programmed from Indian Nursing Council, the institution shall obtain the approval from the Start Nursing Council and Examination Board. 4.Institution will admit the students only after taking approval of State Nursing Council and Examination Board.
52
Inspection: 1) Inspection for Enhancement of Seats: Indian Nursing Council conducts inspection of the instruction once the institution is found suitable by Indian Nursing Council and on receipt of the fees and the proposal for Enhancement of seats. 2) Periodic Inspections: Indian Nursing Council conducts periodical (after 3 years) inspection of the institution once the institution is found suitable by Indian Nursing Council to monitor the standard of nursing education and the adherence of the norms prescribed by INC. Institution are required to pay annual affiliation fees every year. However, if the institution does not comply to the norms prescribed by Indian Nursing Council for teaching, clinical & physical facilities, the institution will be declared unsuitable. 3) Re-Inspections: Re-inspections are conducted for those institutions, which are found unsuitable by Indian Nursing Council. The institutions and the government are informed about the deficiencies and advised to improve upon them. Once the Instruction takes necessary steps to rectify the deficiencies, Institution should submit the compliance report with documentary proof of the deficiencies pointed out and re-inspection fees. On receipt of the Compliance report & fees from the institution it will be considered for re-inspection. 4) First Inspection: First inspection is conducted on receipt of the proposal received from the institute to start any nursing program prescribed by Indian Nursing Council. The proposal should have some requisite documents: Function # 2To recognize the qualification under section 10(2)(4) of the Indian Nursing Council Act, 1947 for the purpose of registration and employment in India and abroad. Recognition of qualifications. Effect of qualification: • Those people who were already nurses will continue to be a nurse. • Any person holding a recognized higher qualification shall be entitled to have the qualification entered as a supplementary qualification in any State register in which he or she is enrolled, and after the said date no person shall be entitled to have entered as a supplementary qualification in any State register any qualification which is not a recognized higher qualification. • A citizen of India holding a qualification which entitles him or her to be registered with any Council of Nursing or Midwifery (by whatever name called) in any foreign country, may, with the approval of the Council, be enrolled in any State register • A person not being a citizen of India who is employed as a nurse, midwife, auxiliary nurse-midwife, teacher or administrator in any hospital or institution situated in any State for purposes of teaching, research or charitable work may, with the approval of the President of the Council, be enrolled temporarily in the State register for such period as may be specified in this behalf in the order issued by the said President: Provided that practice by such person shall be limited to the hospital or institution to which he or she is attached. 53
Function # 4 To prescribe the syllabus & regulations for Nursing programs: Achievement so far: Revised GNM syllabus: Implemented in all States from 2005-2006 academic year. – General Nursing and Midwifery course is the basic curse in nursing in all kinds of health care settings. The revised syllabus incorporated following components. – 6 months Internship – New subjects introduced – Increased duration to 3 and ½ years Revised Basic B.Sc. (Nursing) syllabus: Implemented from 2005-2006 in all Universities. • The revised syllabus incorporated following components • Internship added • New subjects included • New format of syllabus evolved in order to facilitate teachers and to have uniform standard of education. Revised Post Basic B.Sc. syllabus implemented from 2005-2006 in all Universities: • Undergraduate nursing program at post basic level is a broad based education with the academic framework, which builds upon the skills and competencies acquired at the diploma level. It is specifically directed to the upgrading of critical thinking skills, competencies and standards of in-service nurses for practice of professional nursing and midwifery. This revision of syllabus is in tune with National health policy 2002 for training of graduated nurses Vis a Vis diploma nurses. Prepared Post basic diploma in Cardio-Thoracic Nursing: • Post basic diploma in Cardiac Nursing is designed to prepare specially trained Cardio – Thoracic Nurses. The outcome programmed will be to have more nurses prepared as cardio – thoracic nurses for providing nursing care in various health care settings. Prepared Post basic diploma in Operation Room (OR) Nursing: • Nurses play a key role in the effective functioning in Operation Room Nursing is designed to prepare specially trained Operation Room. • The outcome of the programmed is to have more nurses prepared as operation room nurse effectively as a member of the operation room surgical team. Prepared Post basic diploma in Orthopedic and Rehabilitation Nursing: • Post basis in Orthopedic & Rehabilitation Nursing is designed to prepare specially trained or Rehabilitation Nurses. The outcome of the programmed will be to have more nurses orthopedic & rehabilitation nurses providing competent care at the institutional. Revised ANM syllabus: Implementation from 2006 – 2007 academic years: • components and SBA module of MOHFW including use of selected life saving drugs and intake obstetric emergencies approved by the MOHFW • IMNCI module for basic health workers safety guidelines for infection control practices • Biomedical waste management policies. CODE OF ETHICS & PROFESSIONAL CONDUCT FOR NURSING PRACTICE DEVELOPED. • The code of ethics and professional conduct helps to protect the rights of individuals, families and community and also the rights of nurses. 54
Prepared Practical Record Book for School and college of nursing to have nursing education in India: • This booklet is very document for students and is a written for teachers Prepared case study outline: • The case study format will help student for critical thinking and application through the analysis of cases encompassing several nursing specialties in a variety of hospital, clinical and community settings. Prepared Laboratory Equipments and Articles: • INC has prepared the minimum list of Laboratory equipments and articles including A.V aids required for different laboratories which are essential for school / college at nursing to enhance teaching learning activities. Prepared Post Basic Diploma in Oncology Nursing: • It is significant to train nurses an oncology nursing, Nurses need to be trained in the area of impact of Cancer genetics, risk analysis and prevention, palliative care, long term survival, Cancer in aged, special counseling, Paediatric Oncology, Chemotherapy and Care patients receiving radiation treatment etc. • In this direction Indian Nursing Council has prepared one year Post Basic Diploma in Oncology Nursing to provide specialized nursing care to the patients in the hospitals and in community. Prepared Post Basic Diploma in Critical Care Nursing: • INC has prepared one-year post basic diploma course in critical care nursing to prepare nurse specialists to work in critical care setting. The course focuses on roles and responsibilities of nurse in critical care setting, principles, techniques of supervision and Nursing management of patients. Prepared Post Basic Diploma in Emergency and Disaster Nursing: • The emerging trauma scenario and disaster events of mass nature and adding significant strain on the individual‘s life as well as the family and the social system. Illness requiring emergency care is also on the rise. The course is prepared for the trained nurses who can be a specialized nurse in emergency and disaster settings. The duration of this course is one year. Prepared Post Basic Diploma in Neonatal Nursing: • In the view of increase in the awareness of neonatal and maternal health, INC one year post-basic diploma in Neonatal Nursing to provide specialized neonatal Nursing Care. Curriculum for Ph. D in Nursing developed: • The purpose of preparing the syllabus doctoral education to prepare nurse scholars who will contribute both to the development application of knowledge in nursing for enhancing quality of nursing education, research, dissemination of nursing knowledge. Orientation workshop for Ad-hoc Inspectors: • Inspectors were oriented for filling up the revised inspection perform. Three workshops were conducted i.e., in Mumbai, Chennai and Jaipur. Curriculum for independent Nurse Midwife practitioner developed: • The Nation policy 2000 includes reduction of maternal and infant mortality as one of the socio-demographic to be achieved by 2010. The single most important way to reduce maternal death in India would be to ensure that a skilled health professional is present at every birth. 55
• Skilled care during childbirth is important because millions of women and newborns develop serious and hard to predict complications during or immediately after delivery. • Skilled health professions such as doctors or nurses who have midwifery skills can recognize these complications and either treat them or refer women to health centers or hospitals immediately if more skilled care is needed. function # 5 Power to withdraw the recognition of qualification under section 14 of the Act in case the Institution fails to maintain its standards under section 14 (1)(b) that an institution recognized by a State Council for the training of nurses, midwives, auxiliary nurse midwives or health visitors does not satisfy the requirements of the Council. Removal of recognition: • If it appears to the council that the courses of study and training and the examinations to be gone through in order to obtain a recognized qualification from any authority in any State or the conditions for admission to such courses or the standards of proficiency required from the candidates at such examinations are not in conformity with the regulations made under this Act or fall short of the standards required • If it appears to the council that an institution recognized by a State Council for the training of nurses, midwives, 1[auxiliary nurse-midwives] or health visitors does not satisfy the requirements of the Council, the Council may send to the Government of the State in which the authority or institution, as the case may be, is situated a statement to such effect, and the State Government shall forward it, along with such remarks as it may think fit to the authority or institution concerned and, in a case referred to in clause (b) to the State Council also, with an intimation of the period within which the authority or institution may submit its explanation to the State Government. • On the receipt of the explanation or, where no explanation is submitted within the period fixed, then on the expiry of the period, the State Government shall make its recommendations to the Council. • The Council, after such further inquiry, if any, as it may think fit to make, and in a case referred to in clause (b) of sub-section (1), after considering any remarks which the State Council may have addressed to it, may declare,(a) In a case referred to in clause (a) of that sub- section, that the qualifications granted by the authority concerned shall be recognized qualifications only when granted before a specified date, Or (b) in a case referred to in the said clause (b), that with effect from a date specified in the declaration any person holding a recognized qualification whose period of training and study preparatory to the grant to him of the qualification was passed at the institution concerned shall be entitled to be registered only in the State in which the institution is situated. • The Council may declare that any recognized qualification granted outside the States shall be a recognized qualification only if granted before a specified date.
56
Function # 6 To advise the State Nursing Councils, Examining Boards, State Governments and Central Government in various important items regarding Nursing Education in the Country.
Equivalency: The university/board from where the student has acquired the qualification shall duly fill up the transcript Performa. The duly filled transcript Performa will be placed before the equivalency committee meeting; the recommendation with regard to equivalency status thereafter will be informed to the concerned candidates. KARNATAKA STATE NURSING COUNCIL: Members of KSNC (Karnataka State Nursing Council 2007 -2012): • President – KSNC & Director, Medical education--Dr. Ramanand Shetty. • Vice President – KSNC--Dr. G. Kasthuri • Registrar, Karnataka State Nrg. Council-- Sri H.L. Ramamurthy. • Nurse Registrar, KSNC—Sri B.N.Maninarayanappa • President, Karnataka medical council—Dr. Chikkananjappa. • The President, Indian Medical Association (Karnataka Branch) OTHER MEMBERS OF KSNC: 1) Dr. Mrs. B.S. Shankuntala 2) Dr. Ratna Prakash. 3) Smt. Sumithra C.N 4) Smt. V.Vimalavathi 5) Mr. B. Tulasidas 6) Smt. Meenaxi 7) Smt P. Shashamma. 8) Smt. T haru P.V 9) Sri Y.H. Sali 10) Smt.Shylaja Krupanidhi 11) Sr. Aileen Methiai… 12) Sri Ganapati Bhat 13) Shri Mohammed Ayaz Khan 57
Functions of Karnataka State Nursing Council: • Regulation of training programmed of the diploma, Graduate and Post Graduate Courses. • Supervision of the practice of the profession by its Member. • Granting recognition to the training institutions and periodical Inspection there on, as the Council is governing authority of physical and clinical facilities in almost all the nursing courses conducted in the institution. • Proscribing syllabus and curriculum for various nursing courses and conducting qualifying examination there for. • Registration and granting certificate to qualified persons to practice their profession and to watch and take action against practice of profession by quacks and check mal – practice as well and to take action. • The Council is as per the Act headed by Director, Health & Family Welfare Services as its President, and has in its Membership in the Council. • The Superintendent of Nursing Services / Assistant Director, Nursing are the Vice – President of the Council and both are duly elected by the members of the council under section 5 of the Act. Duties of Registrars: Registrar Administration & Finance: 1) All matters of administration and finance of the nursing council. 2) Convening Nursing Council meeting 3) Registration, renewal 4) Recognition of Nursing Schools, Licensing of Nursing Establishment. 5) Legal matters. 6) Conducting Elections. Nurse Registrar: 1) All matters connected with the Examinations of General Nursing Midwife, ANM, and Health Visitors etc. 2) Convening Examination Board Meeting & declaration of results. 3) Setting up of syllabus, conducting workshop & seminars and implementation of new syllabus. 4) Preparation of guides, curriculum and other rules of all nursing education, INC, prepared syllabus approval etc. 5) Issuing of examination certificates. 6) All other technical matters connected with nursing services and education in the state. 7) Defining the job responsibilities of each and every category of Nursing. 8) Admission Approval. Discussion: Limitations and constraints of the INC
58
LEGAL ISSUES INTRODUCTION: Safe nursing practice includes an understanding of the legal boundaries within which nurses must function. As with all aspects of nursing today an understanding of the implications of the law supports critical thinking on the nurse` s part. Nurses must understand the law to protect them from liability and to protect their clients` rights. Nurses need not fear the law be rather should view the information that follows as the foundation for understanding what is expected by our society from professional nursing care providers. The laws in our society are fluid and constantly changing to meet the needs of the person‘s the laws are intended to protect. As heath care evolves in our society, so, too, the legal implications for health care evolve. Frequently, nurses function under several sources and jurisdictions of health law simultaneously. Nurses` familiarity with the laws enhances their ability to be client advocates. Legal Limits of Nursing: Professional nurses must understand the legal limits influencing their daily practice. This coupled with good judgment and sound decision making ensures safe and appropriate nursing care. Standards of Care: One of the functions of law, as applied to nursing practice, is to define the standards of care the nurse must provide. All U.S. state legislatures and Canadian provincial parliaments have passed nursing practice acts that define the scope of nursing practice. These acts define nursing practice and expanded nursing roles, set educational requirements for nurses, and distinguish between nursing practice and medical practice. Each act also defines ―registered nursing‖ or ―professional nursing‖ and ―practical or vocational nursing‖. All nurses are responsible for knowing the provisions of the act for the state or province in which they work. Professional organizations are another source for defining the standards of care. The American Nurses Association (ANA) and Canadian Nurses Association (CNA) have developed standards for nursing practice, policy statements, and similar resolutions. The written policies and procedures of the employing institution detail ways in which the nurse is to perform duties. Such policies are usually quite specific and are set forth in procedure manuals found in most nursing units. For example, a procedure and policy outlining the steps that should be taken when changing a dressing or administering medication gives specific information for nurses to perform these tasks. These policies provide another definition of standards of care. Policies and procedures of institutions may be more restrictive than nurse practice acts, but they can never request a nurse to act beyond the standards of practice allowed by law. Licensure: All registered nurses and licensed practical nurses are licensed by the board of nursing of the state or province in which they practice. The requirements for licensure vary, but requirements for education are in most licensing acts, and the nurse must pass an examination. Licensure permits persons to offer special skills and knowledge to the public, but it also provides legal guidelines for protection of the public. 59
All states use the National Council Licensure Examinations (NCLEX) for registered and licensed practical nurse examinations. A nurse`s license can be suspended or revoked by the board of nursing if conduct violates provisions of the licensing statue. For example, nurses who perform illegal acts such as selling or taking controlled substances jeopardize their license status. Before licenses are revoked, nurses must be notified of the charges and permitted to attend a hearing to present evidence on their own behalf. These hearings are not court proceedings but are usually conducted by the state or provincial board of nursing. Some states are provinces provide for judicial review of such cases if the nurse has exhausted all other forms of appeal. Student Nurses: If clients suffer harm as a direct result of nursing students` actions, the liability for the incorrect action is generally shared by the student, instructor, and hospital or health care facility. Student nurses should never be assigned to tasks for which they are unprepared and should be carefully supervised by instructors as they learn new procedures. Although student nurses are not considered employees of the hospital, the institution has a responsibility to monitor the acts of nursing students. Sometimes, student nurses are employed as nursing assistants or nurse` s aides when they are not attending classes. If student nurses are so employed, they should not perform tasks that do not appear in a job description for a nurse` s aide or assistant. For example, even if a student has learned to administer intramuscular medications in class, this task may not be performed by a nurse ` aside. Legal Liability in Nursing: Two basic sources exist for contemporary law. Statutory law is created by elected legislative bodies such as state or provincial legislatures, the U.S. Congress, administrative bodies such as state boards of nursing, or the Canadian Parliament. Common Law is created by judicial decisions made in courts when cases are decided. Criminal Law is concerned with relationships between individuals and governments and with acts that threaten society and its order. Misuse of controlled substances is an example of criminal conduct for nurses. A crime is an offense against society that violates a law. Criminal acts are prosecutes in the criminal justice system .A felony is a crime of a serious nature that usually carries a penalty of imprisonment or death .A misdemeanor is a crime of a less serious nature than a felony, and the penalty is usually a fine or imprisonment for less than a year .In nursing, there are few crimes a nurse would commit if practicing within accepted standards of care. Civil Law: is concerned with the relationships among people and the protection of a person` s rights. Although violations of civil law might cause harm to an individual or property, society as a whole is usually not affected. For example, defamatory statements made about an individual might lead to interpersonal problems, but they do not threaten society as a whole. A Tort is a civil wrong committed against a person or property. Torts may be subtle and difficult to define; they may be classified as intentional or unintentional. Unintentional torts include negligence. Malpractice is one example of an unintentional tort, or 60
negligence. Intentional torts are willful acts that violate another`s rights. Examples are assault, battery, defamation, invasion of privacy. Negligence: is conduct that falls below the standard of care. It is established by law for the protection of others against unreasonable risk of harm, and it is characterized chiefly by inadvertence, thoughtlessness, or inattention. If nurses give care that does not meet appropriate standards, they may be held liable for negligence. Negligence may involve carelessness, such as failing to check a client` s arm band and then administering the wrong drug. Another example of negligence may be administering a medication even when it has been documented that the client has an allergy to that medication. However, carelessness is not always the cause. If nurses attempt a procedure for which they have not been trained and do it carefully but still harm the client, a claim of negligence could be made. Nurses have been involved in several common negligent acts including the following. 1. Intravenous therapy errors resulting in infiltrations or phlebitis. 2. Burns to clients 3. Falls resulting in injury to clients. 4. Failure to use aseptic technique where required. 5. Errors in sponge, instrument, or needle counts in surgical cases. 6. Failure to give a report, or to give an incomplete report, to an oncoming shift. Nurses are responsible for performing all procedures correctly and for exercising professional judgment as they carry out the orders of physicians and duties not ordered but for which they have authority: And nurse who does not meet accepted standards of care while discharging duties or who performs duties carelessly runs a risk of being found negligent. Malpractice: is one type of negligence. It is defined as professional misconduct, unreasonable lack of skill or fidelity in professional duties, evil practice, or illegal or immoral conduct. In a malpractice lawsuit against a nurse, the following criteria must be established. 1. The nurse (defendant) owned a duty to the client (plaintiff). 2. The nurse did not carry out that duty. 3. The client was injured 4. The client` s injury was a result of the nurse` s failure to carry out his or her duty. The best way for nurses to avoid being named in law suits is to follow standards of care, give competent health care, document assessments, interventions and evaluations fully, and develop empathetic rapport with the client. Poor client relations are leading causes of lawsuits. A client who believes that the nurse performed duties correctly and was concerned with his or her welfare is unlikely to initiate a lawsuit. In addition, careful, complete, and objective documentation are keys to avoiding malpractice. Assault: is any willful attempt or threat to harm another, coupled with the ability to actually harm the other person. The victim believes harm will come as a result of the threat. Assault may be subtle; for example, a nurse might attempt to coerce a client into taking a drug he or she does not wish to take. A more blatant example might involve a nurse handing an uncooperative client in the emergency room. Battery: is any intentional touching of another` s body or anything the person is touching or holding without consent. Injury is not a requirement (Black 1979). There have been 61
instances of battery of confined clients by personnel in mental institutions. In a less drastic case, if a nurse attaches fetal electrodes during labor without the consent of the mother, a claim of battery could be made. Invasion of Privacy: Clients have claims for invasion of privacy when their private affairs, with which the public has no concern, have been publiciz. A client is entitled to confidential health care. All aspects of care should be free from unwanted publicity or exposure to public scrutiny. Another form of invasion of privacy is the release of information to an unauthorized person such as a member of the press or the client` s employer. Gossiping about a client` s activities is another form of invasion of privacy and could lead to a charge of slander against the nurse. Another example is a nurse ` s unwanted intrusion in private family matters. A nurse has no right to intrude in matters not directly related to the client` s well-being. For example, a nurse should respect a wish not to inform the client` s family of a terminal illness. Defamation of character: is the holding up of a person to ridicule, scorn, or contempt within the community. There are two types of defamation: slander and libel. For example, if a nurse tells a client that his physician is incompetent; the nurse could be held liable for slander. If the nurse writes such a comment, the charge would be libel. The important issues in a claim of defamation of character are whether the information was shared with third persons and if harm has been done to the reputation of the plaintiff. Informed consent: is a person` s agreement to allow something to happen based on a full disclosure of facts needed to make an intelligent decision. The law has long recognized that individuals have the right to be free from bodily intrusion. In Schloendorff. V. Society of New York Hospital, decided in 1914, the court observed that ―every human being of adult years and sound mind has a right to determine what shall be done with his body‖. The doctrine of informed consent not only requires that a person be given all relevant information required to reach a decision regarding treatment, but also that the person be capable of understanding the relevant information and does, in fact, give consent. One who performs a procedure on a client without informed consent may be found civilly liable for committing battery. A client signs general consent forms when admitted to the hospital or other health care facility. Separate special consent forms must be signed by the client or a representative before specialized procedures are performed. The following factors must be verified for consent to be valid: 1. The person giving consent must be mentally and physically competent and be legally an adult. 2. The consent must be given voluntarily. No forceful measures may be used to obtain it. 3. The person giving consent must thoroughly understand the procedure, its risks and benefits, as well as alternative procedures. 4. The person giving consent has a right to have all questions answered satisfactorily. If a client is deaf, illiterate, or has some other impediment of communication (such as speaking a foreign language), an interpreter should be available to explain the terms of consent. In addition, the hospital admission form states the terms and conditions of 62
admission, including necessary medical treatment, release of information, treatment of personal valuables, and payment for hospital care. Legal Concepts And Nursing Practice: In addition to encountering legal problems in the care of clients, nurses may share liability for errors made by physicians and other health care personnel or for inadequate care provided by their employing institutions. Physician Orders: The physician is responsible for directing the medical treatment of a client. The nurse is obligated to follow the physician` s order unless he or she believes the order is in error or would be detrimental to clients. Therefore all orders must be assessed, and if one is determined to be erroneous or harmful, further clarification from the physician is necessary .If the physician confirms the order, but the nurse still believes it is inappropriate, the supervising nurse is informed. A written memorandum to the supervisor detailing the events in chronological order and the reasons for refusing to carry out the order should protect the nurse from disciplinary action. The supervising nurse should help resolve the questionable order. A nurse who carries out an inaccurate order may be legally responsible for harm suffered by the client. The physician should write all orders, and the nurse should be sure they are transcribed correctly. Verbal orders are not recommended because they leave possibilities for error. If a verbal order is necessary as in an emergency, it should be written and signed by the physician as soon as possible, usually within 24 hours. A difficult area regarding physician orders involves an order of ―no code‖ or ―do not resuscitate‖ for a terminally ill client. In the past many physicians were reluctant to write such an order because they feared legal repercussions for ―abandoning‖ a client. If a physician has documented in his progress notes that the client` s condition is deteriorating and that the decision not to administer cardiopulmonary resuscitation has been made, the physician us perfectly justified in writing a no code order. Unless the physician decides that such a discussion would be detrimental to the client` s condition, the order should be discussed with the client. In such cases, the physician should also discuss the order with the family. A no code order should be written, not given verbally. Physicians should regularly review DNR orders in case the client` s condition warrants a change. The nurse should be familiar with the institution` s policies and procedures concerning DNR orders. Physicians can list all specifics of DNR orders. Short Staffing: During nursing shortages, the issue of inadequate staffing may arise. The JCAHO has established guidelines for institutions to determine the level of staff needed. These are referred to as staffing rations. Legal problems may arise if there are not enough nurses to provide competent care. If assigned to care of more clients than is reasonable, nurses should attempt to reject assignments by informing the nursing supervisor that they are inappropriate. If nurses are required to accept the assignments, they should make written protests to nursing administrators. Although these protests would not relieve nurses of responsibility if clients suffered because of inattention, it would show that the nurse was attempting to act in good faith. Nurses should not walk out when staffing is inadequate because a charge of abandonment could be made. 63
Incident report: An incident report is filed when something arises that could or did cause injury and that was not consistent with good care. For example, if a nurse administers an incorrect dose of medication, a client falls out of bed, or an intravenous solution infiltrates the skin causing sloughing and scar formation, the nurse should complete an incident report .Most institutions provide specific forms for this purpose. The nurse objectively records the details of the incident, and the physician examines the client and reports any untoward effects caused by the error .Subjective assumptions should not be included on the incident report nor should statements assigning blame be included. Reporting Obligations: Nurses are required to make a report in such situations as child abuse, rape, gunshot wounds, attempted suicide, or certain communicable diseases to the appropriate authorities. The nurse may also be required to report unsafe or impaired professionals. Because information that must be reported varies among states and provinces, the nurse should become familiar with the appropriate statutes. Good Samaritan Laws: Good Samaritan Laws have been enacted in almost every state and province to encourage health care professionals to assist in emergency situations. These laws limit liability and offer legal immunity for people who help in an emergency, providing they give the best possible care under the conditions. If a nurse stops at the scene of an automobile accident and gives appropriate emergency care such as using caution when moving the injured person in case of a spinal injury or applying pressure to stop hemorrhage, the nurse is acting within accepted standards, even though proper equipment was not available. Contracts: A contract is a written or oral agreement between two people in which goods or services are exchanged. An oral contract is as legally binding as a written one, but it may be more difficult to prove. A breach of contract occurs if either party fails to carry out agreed obligations. By accepting a job, a nurse enters into an agreement with an employer. The nurse will perform professional duties competently, adhering to the policies and procedures of the institution. In return the employer not only pays for services but also furnishes the facilities and equipment in proper working order to enable the nurse to provide efficient and competent care. Nurses also enter into contractual agreements with clients. Nurses agree to give competent care, and clients agree to pay for the services. When clients sign admission forms upon entering the hospital or agree to nursing care in any health care agency; they initiated the contract. Private duty nurses have specific written contracts with their clients. It is from such contracts that the duty to perform competently arises and the failure to follow through leads to the concept of negligence. Controlled Substances: Another legal issue that might arise for nurses involves the use of controlled substances. It controls substances such as narcotics, depressants, stimulants, and hallucinogens. Nurses may administer controlled substances only under the direction of a licensed physician. Controlled substances should be kept securely locked, and only authorized personnel should have access to them. Criminal penalties for misuse of controlled 64
substances exist. There have been cases in which physicians have illegally prescribed and dispensed controlled substances, and if nurses employed by such physicians fail to report these activities, they may be legally accountable for aiding and abetting the physicians. ETHICAL ISSUES IN NURSING: Definition: Ethics: The term ethics refers to the study of philosophical ideals of right and wrong behavior. In professional practices such as nursing a code of ethics provides guidelines for safe and compassionate care. Nurses` commitment to a code of ethics guarantees the public that nurses adhere to professional practice standards. Ethics is the study of good conduct, character, and motives. It is concerned with determining what is good or valuable for all people. Autonomy: Autonomy refers to a person` s independence. As a standard in ethics, autonomy represents an agreement to respect another` s right to determine a course of action. Respect for another` s autonomy is fundamental to the practice of health care. The agreement to respect autonomy involves the recognition that clients are ―In charge of their own destiny in matters of health and illness‖ For example, the purpose of the preoperative consent that clients must read and sign before surgery is the assurance in writing that the health care team respects the client` s independence by obtaining permission to proceed. The consent process implies that a client may refuse treatment, and in most cases the health care team must agree to follow the client` s wishes. Health care professionals agree to abide by a standard of respect for the client` s autonomy. Beneficence: Beneficence refers to taking positive actions to help others. The practice of beneficence encourages the urge to do good for others. Commitment to beneficence helps to guide difficult decision wherein the benefits of a treatment may be challenged by risks to the client` s well-being or dignity. A child` s immunization may cause discomfort during administration, but the benefits of protection from disease, both for the individual and for society, outweigh the temporary discomforts. Justice: Justice refers to fairness. Health care provides agree to strive for justice in health care. The term often is used during discussions about resources. What constitutes a fair distribution of resources may not always be clear. In these cases national discussion about just distribution of resources often helps to clarify methods for achieving fairness. Fidelity: Fidelity refers to the agreement to keep promises. A commitment to fidelity explains the reluctant to abandon clients, even when disagreement arises about decisions that a client may make. The standard of fidelity also includes an obligation to follow through with care offered to clients. For example, if a nurse assesses a client for pain and then offers a plan to manage the pain, the standard of fidelity encourages the nurse to monitor the client` s response to the plan. Professional behavior by the nurse includes revision of the plan as necessary to try to keep the promise to reduce pain. 65
PROFESSIONAL NURSING: Code of Ethics: A code of ethics is a set of ethical principles that are accepted by all members of a profession. A profession` s ethical code is a collective statement about the group` s expectations and standards of behavior. Codes serve as guidelines to assist nurses and other professional groups when questions arise about correct practice or behavior. The nursing code of ethics, as in other professions, sets forth ideals of conduct. The American Nurses Association (ANA) and the International Council of Nurses have established widely accepted codes that professional nurses attempt to follow. These codes differ somewhat in specific emphasis, but they reflect the same basic principles, including responsibility, accountability, advocacy, confidentiality, and veracity. Nurses agree to responsibility for specific actions and accountability for the consequences. To practice responsibly, professional nurses also agree to maintain competence in their practice and to use competence in the application of judgment. Accountability: Accountability refers to the ability to answer for one` s own actions. The nurse balances accountability to the client, the profession, the employer, and society. For example, a nurse may know that a client who will be discharges soon remains confused about how to administer insulin. The action that a nurse takes in response to this situation will be guided by the sense of accountability. The goal is the prevention of injury to the client. Responsibility: The term responsibility refers to the characteristics of reliability and dependability. The term implies an ability to distinguish between right and wrong. In professional nursing, responsibility includes a duty to perform actions well and thoughtfully. When administering a medication, for example, a nurse is responsible for assessing the client` s need for the drug, for giving it safely and correctly, and for evaluating the response to it. By agreeing to act responsibly, the nurse gains trust from clients, colleagues, and society. Confidentiality: The concept of confidentiality in health care enjoys widespread acceptance in the United States. Federal legislation known as HIPAA (Health Insurance Portability and Accountability Act of 1996) requires it. The legislation defines the rights and privileges of clients for protection of privacy without diminishing access to quality care. In addition to a requirement for education of all employees in health care about the HIPPA protections, the legislation establishes fines for infractions .Medical records may not be copied or forwarded without a client` s consent. Health care information, including laboratory results, diagnosis, and prognosis, is not shared with others without specific client consent. This practice even includes preventing other family members or friends of the client from acquiring health care information. The commitment to confidentiality is particularly challenged as medical records become computerized. Preservation of confidentiality is often in competition with the need to facilitate access to information. In the case of computer access, health care institutions work to protect confidentiality by using special access codes that limit what certain employees can find on a computer system. Veracity: A part of the ANA code of conduct addresses the issue of veracity, another aspect of reliability. Veracity in general means accuracy or conformity to truth. As a part of the 66
nursing code of ethics, veracity guides nurses to practice truthfulness. Although in most circumstances veracity is an obvious asset, the practice of truthfulness may be challenged during the delivery of health care. A nurse may have to balance competing interests in certain cases. In some instances it may be tempting to tell a child that a medicine tastes good when it does not or that a procedure will not hurt when it probably will, to achieve a level of compliance. Professional codes of ethics guide the nurse to tell the truth, however, and it is a rare circumstance where other principles would support another behavior. International Council of Nurses Code of Ethics for Nurses Nurses have four fundamental responsibilities: to promote health, to prevent illness, to restore health, and to alleviate suffering. The need for nursing is universal. Inherent in nursing is respect for human rights, including the right to life, to dignity and to be treated with respect. Nursing care is unrestricted by considerations of age, colour, creed, culture, disability or illness, gender, nationality, politics or social status. Nurses render health services to the individual, the family and the community and coordinate their services with those of related groups. Nurses and People: The nurse` s primary responsibility is to those people requiring nursing care. In providing care, the nurse promotes an environment in which the human rights, values, customs, and spiritual beliefs of the individual, family and community are respected. The nurse ensures that the individual received sufficient information on which to base consent for care and related information. The nurse holds in confidence personal information and uses judgment in sharing this information. The nurse shares with society the responsibility for initiating and supporting action to meet the health and social needs of the public, in particular those of vulnerable populations. The nurse also shares responsibility to sustain and protect the natural environment from depletion, pollution, degradation and destruction. Nurses and Practice: The nurse carries personal responsibility and accountability for nursing practice and for maintaining competence by continual learning. The nurse maintains a standard of personal health such that the ability to provide care is not compromised. The nurse uses judgment regarding individual competence when accepting and delegating responsibility. The nurse at all times maintains standards of personal conduct which reflect well on the profession and enhance public confidence. Nurses and the Profession: The nurse assumes the major role in determining and implementing acceptable standards of critical nursing practice, management, research, and education. The nurse is active in developing a core of research based professional 67
knowledge. The nurse, acting through the professional organization, participates in creating and maintaining equitable social and economic working conditions in nursing. Nurses and Co-workers: The nurses sustain a cooperative relationship with co-workers in nursing and other fields. The nurse takes appropriate action to safeguard individuals when their care is endangered by a co-worker or any other person. AMERCIAN NURSES ASSOCIATION CODE OF ETHICS The nurse provides services with respect for human dignity and the uniqueness of the client unrestricted by considerations of social or economic status, personal attributes, or the nature of health problems. The nurse safeguards the client` s right to privacy by judiciously protecting information of a confidential nature. The nurse acts to safeguard the client and the public when health care and safety are affected by the incompetent, unethical, or illegal practice of any person. The nurse assumes responsibility and accountability for individual nursing judgments and actions. The nurse maintains competence in nursing. The nurse exercises informed judgment and uses individual competence and qualifications as criteria in seeking consultation, accepting responsibilities, and delegating nursing activities to others. The nurse participates in activities that contribute to the ongoing development of the profession` s body of knowledge. The nurse participates in the profession` s efforts to implement and improve standards of nursing. The nurse participates in the profession` s efforts to establish and maintain conditions of employment conducive to high quality nursing care. The nurse participates in the profession` s effort to protect the public from misinformation and misrepresentation and to maintain the integrity of nursing. The nurse collaborates with members of the health professions and other citizens in promoting community and national efforts to meet the health needs of the public.
68
CANADIAN NURSES ASSOCIATION CODE OF ETHICS The body of the code is divided into the following sources of nursing obligations: CLIENTS: A nurse is obliged to treat clients with respect for their individual needs and values. Based on respect for clients and regard for their rights to control their own care, nursing care should reflect respect for client` s right of choice. The nurse is obliges to hold confidential all information about a client learned in the health care setting. The nurse has an obligation to be guided by consideration for the dignity of clients. The nurse is obligated to provide competent care to clients. The nurse is obliged to represent the ethics of nursing before colleagues and others. The nurse is obliged to advocate clients` interests. In all professional settings, including education, research and administration, the nurse retains a commitment to the welfare of clients. The nurse has an obligation to act in a fashion that will maintain trust in nurses and nursing. HEALTH TEAM: Client care should represent a cooperative effort, drawing on the expertise of nursing and other health professions. By acknowledging personal or professional, limitations, the nurse recognizes the perspective and expertise of colleagues from other disciplines. The nurse, as a member of the health care team, is obliged to take steps to ensure that the client receives competent and ethical care. SOCIAL CONTEXT OF NUSING: Conditions of employment should contribute to client care and to the professional satisfaction of nurses. Nurses are obliged to work toward securing and maintaining conditions of employment that satisfy these goals. RESPONSIBILITIES OF THE PROFESSION: Professional nurses` organizations recognize a responsibility to clarify, secure, and sustain ethical nursing conduct. The fulfillment of these tasks requires professional organizations to remain responsive to the rights, needs, and interests of clients and nurses. ETHICAL ISSUES IN NURSING: Do-Not-Resuscitate or No-Code orders: A do-not-resuscitate order means that: no attempts are made to resuscitate a patient who stops breathing or whose heart stops beating. Physician will write DNR on the chart of the patient if the patient surrogates as expressed a wish that there be no attempts to resuscitate. However, many physicians are reluctant to write these orders especially when this issue is a source of conflict between the families or between individual family members. In some cases the physician who believes the patient will not benefit from resuscitative measures may indicate verbally to the nurse only the slow code (or show code) should be called; ie, in the case of cardio pulmonary or respiratory arrest, calling a code or Resuscitating the patient is to be delayed until these measures will be ineffectual. Slow codes are never hood practice and health care institutions now have policies forbidding their use. 69
ABORTION: All human life is of equal value. The life of the child in the womb is neither more nor less important than that of the mother. There is therefore no moral objection to measures aimed solely at curing a life-threatening condition in an expectant mother, even if this leads to the child's death. In such circumstances (for example, ectopic pregnancy in the fallopian tube), treatment that is ethical does not involve deliberately killing the baby. Abortion is contrary to the medical ethics in the Hippocratic Oath, both in its original version (derived from ancient Greece) and modern reformulations such as the World Medical Association's 1948 Declaration of Geneva. The declaration states: "I will maintain the utmost respect for human life, from the time of conception." While infanticide is legally and socially treated as murder and few in our culture would approve of it, the killing of unborn infants (often called fetuses in order to still the conscience and minimize the social stigma) has become both legally and socially acceptable. For some women, unmarried and married, abortion is just another form of birth control. The truth is that the scripturally unlawful taking of human life is always murder, whether it is that of the unborn embryo, fetus, or infant, or that of the supposedly useless members of society such as the handicapped and aged. Abortion is murder This being true, the use of any means of birth control that would prevent the embryo's developing in the uterus, such as the I.U.D. and certain drugs, would be morally wrong as this would be abortion in the earliest possible stage even though the woman may not know that abortion is occurring at that time. Also morally wrong would be the taking of the life of the unborn even when continuing the pregnancy to term would either really or supposedly endanger the life of the mother. That would be abortion nonetheless, and abortion is murder. Forced abortion in China: Chinese government economic policy has had disastrous effects on the country's agricultural system, particularly the major famines of the late 1950s. Population growth was falsely blamed for these disasters and a notorious population control programmed was introduced. From the late 1970s, parents were forbidden to have more than one child. Chinese law refers to abortion "as required by the family planning programmed." There is abundant evidence of forced abortion and sterilization, yet the Chinese government's population control programmed has been supported by assistance from the United Nations Population Fund and the International Planned Parenthood Federation since 1979. Britain and other western countries make substantial grants of taxpayers' money to both of these organizations. The programmed has led to a resurgence of female infanticide which has caused an imbalance in the ratio between males and females, which has, in turn, seriously affected fertility rates. Female and disabled infants are left to die of neglect in some estate-run orphanages. Euthanasia Our society is becoming more and more morally perverse in regard to the sanctity of life. With the legalizing of abortion, the ensuing low view of life is reaching into still other The "living will" may prove useful. We live in an age of specialization, when more and more patients are being treated by physicians whom they do not know very well. The "living will" is a written document 70
which speaks for the patient if he becomes incompetent and helps protect the physician from legal liability. Many states now have laws requiring compliance with "living will" documents executed in advance by competent adults. Efforts are being made to effect uniform "living will" laws for the nation. These laws are binding upon the physician so that if he does not wish to observe the "will" he must cooperate in transferring the patient to another physician. Areas of man's existence. "The right to die," "dying with dignity," and other such concepts dealing with quality and value of life are pervading the thinking of our society. One such concept is called euthanasia, or "mercy killing." Euthanasia is the practice of deliberately easing into death an individual who is suffering from a painful or incurable disease or handicap. The request for such a death may be a voluntary one by the suffering individual, or from one who is legally responsible for such an individual. Either is morally unacceptable, being in the first case tantamount to suicide, and in the second, murder. A related facet is passive euthanasia, or the withholding of life-giving sustenance, as in the starving of a newborn having a congenital defect or the withholding of reasonable life support from a terminally ill patient. From acceptance of euthanasia in these medically related areas, it is but a small step to the justification for putting away socially or financially burdensome individuals to alleviate responsibility for their care. Such death by design is nothing short of murder and should be an unthinkable option for any morally guided individual or society. While a patient is capable of giving valid consent, a doctor has no authority to treat the patient unless that consent is given. However, the patient cannot ethically refuse treatment with the intention to bring about his own death. The ethical objection to suicide is reflected in law. In Britain, for compassionate reasons, there are no legal penalties for a person who attempts suicide, but assisting a suicide remains an offence. Parliament recognized that people who have tried to kill themselves need help rather than punishment. There is therefore no legal right to suicide, and certainly no right to involve others in killing oneself. This is because the right to life is an inalienable right. No one may dispose of an innocent person's life, and In addition to the moral implications of euthanasia there are also social implications to consider, such as the lessening of respect for the sick, the elderly, the handicapped, as well as for life itself. There would also, undoubtedly, be deterioration in the provision of health care for such individuals. Society would degenerate to a survival of the strongest, the most capable, and the most useful. Living Wills Or Advanced Directives: The problem of having the "right to die" is an ethical issue resulting from modern medical technology. Today biological life can be maintained for months and years after the brain has ceased to function. The question is, do we keep the physical body going even after the person we once knew is no longer "there"? Answers to this or similar questions are not easy. We have no historical or Biblical precedent on such issues. The "right to die" is a different issue than euthanasia. It is not the "right" to an easy, painfree death. Neither is it the "right" to will one's own suicide. Basically it is the right to die a natural death in the event a person is afflicted with a terminal illness and the attending physician has determined that there can be no recovery and that death is imminent. 71
Consequently he does not want to be placed on a support system which affects an unnatural existence and merely prolongs death. For such a person Donation of Organs and the Body: With the advent of organ transplants, the need for many body organs has grown greatly. Most such organs must be taken from people who have recently died, usually within thirty minutes or so of death. The state has made easy provisions for people to donate any organs they wish or to donate the whole body for research. One simply fills out a donor card in the presence of witnesses. Most states make such provisions on drivers' licenses. The donation of organs or the body for such purposes is certainly in harmony with Scriptural teaching on loving and helping our neighbor. Donations for transplants should not be looked upon, however, as some way to achieve immortality but as a gesture of life to someone in need. We know of nothing in God's Word which would prevent us from donating our dead bodies to medical science. If the whole body is donated, the state normally cremates the body after it has served its purposes. The state then holds a funeral service (in addition to any memorial service the family may have had). In most cases it is possible for the family to request the body to be returned for their own family funeral. We encourage believers who wish to donate organs or their bodies to counsel with their ministry and also to consider the wishes of their families. An appropriate Christian funeral or memorial service should be planned for the edification of the family and the brotherhood. BLOOD TRANSFUSION: The practice of transfusion medicine involves a number of ethical issues because blood comes from human beings and is a precious resource with a limited shelf life. In 1980 the International Society of Blood Transfusion endorsed its first formal code of ethics, which was adopted by the World Health Organization and the League of Red Crescent Societies. A revised code of ethics for donation and transfusion was endorsed in 2000. Blood donation as a gift, donor confidentiality, donor notification and donor consent, consent for transfusion, the right to refuse blood transfusion, the right to be informed if harmed, and ethical principles for establishments, are discussed in the international and Indian contexts. The practice of transfusion medicine involves a number of ethical issues because blood comes from human beings and is a precious resource with a limited shelf life. It involves a moral responsibility towards both donors and patients. Decisions must be based on four principles: respect for individuals and their worth, protection of individuals' rights and well being, avoidance of exploitation, and the Hippocratic principle of premium non noncore or "first do no harm". History of transfusion ethics: Ethics is a dynamic process in relation to the state of scientific knowledge; public awareness and the local laws, at any given time and place. This is clear when we review the history of transfusion ethics (1) The earliest mention of human transfusion, in 1492, describes efforts to save the life of Pope Innocent VIII. Blood was extracted from three 10-year-old boys and transfused to the Pope. All three boys and the Pope died. Some two centuries later transfusion was attempted again. In 1667, Dr Richard Lower transfused sheep's blood to a mentally-ill man to cure him. The patient was given 20 shillings to undergo this experiment. 72
The same year a 34-year-old man underwent repeat transfusions of calf's blood. This resulted in a classical hemolytic transfusion reaction and the court banned future transfusions. Human-to-human transfusion was resurrected by James Blundell, a London obstetrician, to save the lives of women with obstetric hemorrhage. By the early twentieth century, a number of advances had been made in transfusion medicine, in the form of the discovery of blood groups and preservation, making transfusion safer ISBT code of ethics: In 1980 the International Society of Blood Transfusion (ISBT) endorsed its first formal code of ethics. A revised code of ethics for blood donation and transfusion was endorsed in 2000, with inputs from various concerned organizations. It gave recommendations regarding the ethical responsibilities of the donor, the collection agency and the prescribing authority. This code is reproduced below: A code of ethics for blood donation and transfusion: The objective of this code is to define the ethical principles and rules to be observed in the field of transfusion medicine. 1. Blood donation, including hematopoietic tissues for transplantation shall, in all circumstances, be voluntary and non-remunerated; no coercion should be brought to bear upon the donor. The donor should provide informed consent to the donation of blood or blood components and to the subsequent (legitimate) use of the bloo.d by the transfusion service. 2. Patients should be informed of the known risks and benefits of blood transfusion and/or alternative therapies and have the right to accept or refuse the procedure. Any valid advance directive should be respected. 3. In the event that the patient is unable to give prior informed consent, the basis for treatment by transfusion must be in the best interests of the patient. 4. A profit motive should not be the basis for the establishment and running of a blood service. 5. The donor should be advised of the risks connected with the procedure; the donor's health and safety must be protected. Any procedures relating to the administration to a donor of any substance for increasing the concentration of specific blood components should be in compliance with internationally accepted standards. 6. Anonymity between donor and recipient must be ensured except in special situations and the confidentiality of donor information assured. 7. The donor should understand the risks to others of donating infected blood and his or her ethical responsibility to the recipient. 8. Blood donation must be based on regularly reviewed medical selection criteria and not entail discrimination of any kind, including gender, race, nationality or religion. Neither donor nor potential recipient has the right to require that any such discrimination be practiced. 9. Blood must be collected under the overall responsibility of a suitably qualified, registered medical practitioner. 10. All matters related to whole blood donation and haemapheresis should be in compliance with appropriately defined and internationally accepted standards. 11. Donors and recipients should be informed if they have been harmed. 73
12. Transfusion therapy must be given under the overall responsibility of a registered medical practitioner. 13. Genuine clinical need should be the only basis for transfusion therapy. 14. There should be no financial incentive to prescribe a blood transfusion. 15. Blood is a public resource and access should not be restricted. 16. as far as possible the patient should receive only those particular components (cells, plasma, or plasma derivatives) that are clinically appropriate and afford optimal safety. 17. Wastage should be avoided in order to safeguard the interests of all potential recipients and the donor. 18. Blood transfusion practices established by national or international health bodies and other agencies competent and authorized to do so should be in compliance with this code of ethics. SOME IMPORTANT ISSUES ARE BEING HIGHLIGHTED: Ethical issues related to donors: Blood donation as a gift: The WHO recommends that national blood services should be based on voluntary, non-remunerated blood donation. No one should be forced to donate, for family or economic or any other reason. The trade of human blood and body parts is unethical. "The dignity and worth of the human being should be respected." Non-remunerated blood donation is considered a gift and the blood centre has a right to accept or defer it if unacceptable. Donor deferral might appear as discrimination and a violation of a human right, but the patient's right to safer blood is more important than the donor's right to not to discriminated against, as blood centers are made to help patients and not donors. Donor confidentiality, donor notification and donor consent: Donor confidentiality is an important issue. Personal information disclosed by the blood donor during the course of a pre-donation interview and information obtained from the various tests performed on the donated component, are expected to be held in confidence by the donor centre. Donor screening and testing used to be simple. Today's donors are asked intimate questions about their lifestyles and put through a battery of laboratory tests. This has had significant repercussions for the relationships between blood centers, blood donors, physicians and patients. The blood donor, an ostensibly healthy individual until notified of an abnormal result by the blood centre, may seek a physician's advice and doubt the creditability of the testing procedure and deferral policies. A more specific test might turn out to be negative and the donor may be labeled as healthy. This donor might return to the blood centre asking for compensation for the unnecessary mental anguish and the expenses incurred and might never donate again. The donor room personnel and the donor may have misunderstandings about confidentiality. There is often a tension in donor centers between the need to keep the donor information confidential and the need to disclose relevant information to third parties such as family members, employers, public health authorities and police officers. Blood safety depends partly on the information provided by the donor and it is also the donor's ethical duty to provide truthful information. It is unethical to willfully conceal information about high-risk behavior or medical history. 74
Ethical issues related to patients: Ethical issues related to patients include access to risk-free safe blood free of charge or need of replacement, informed consent for transfusion, the right to refuse the transfusion, and the right to be informed if harmed. Consent for transfusion: Consent for transfusion has to be informed consent (5). The patient should be informed of the known risks and benefits of transfusion, and alternative therapies such as autonomous transfusion or erythropoietin. Only then should the consent be documented. If the patient is unable to give prior informed consent, the basis of treatment by transfusion should be in the best interests of the patient. Right to refusal: The patient's right to refuse blood transfusion should be respected. Some religious sects such as Jehovah's Witnesses do not accept blood transfusions. Followers of this belief live in India as well and there have been instances of blood refusal here. Right to be informed if harmed: If the patient has been transfused blood and components that were not intended for him/her, whether harmed or not, he/she has the right to be informed (6, 8). Similarly a patient who has inadvertently received blood positive for a transfusion transmissible marker has a right to be informed and given due compensation. Ethical principles for blood establishments: A profit motive should not be the basis of establishing and running blood transfusion services. Wastage should be avoided to safeguard the interests of all potential donors and recipients (3). The situation in India: With the rising awareness of ethical issues in every field of medical care and research in India, awareness is growing in the field of transfusion medicine as well. But we are nowhere near the international code of ethics. In the 1990s, in response to public interest litigation a Supreme Court order banned professional blood sellers and directed the government to formulate a national blood policy. The National Blood Transfusion Council, with the National Blood Policy as a tool, and the Drugs Controller, with the help of the Drugs and Cosmetics Act, now aim to ensure blood safety and ethical transfusion practices in India. ETHICAL DILEMMA: Ethical problems can cause d9istress and perplexity for both clients and care givers. Controversy is the very nature of ethical deliberations, and few people like conflict. Ethical decisions are usually very important and are made under stressful circumstances. Ethical issues should be processed carefully so that decisions are not made solely on an emotional level. As discussed previously, an ethical outcome is not obtained by considering only what people want and feel. Therefore having a pattern or a guide for thinking through ethical conflicts or dilemmas is very helpful. Several such guides are in the nursing literature. Although each patterns or decision making matrix looks a bit different, they all advocate a similar approach and include the same relevant points. Moral reasoning is the thinking that happens after a person recognizes he or she is in an ethical conflict and before he or she takes action on it. It is a form of analysis that encourages thorough consideration of an ethical conflict in light of agreed upon moral norms. It should also be remembered that moral reasoning is not a process that moves in a straight line, even though it is pictured that way. Instead, the steps in the process may be considered simultaneously or in a different order, depending on the situation. Decision making based on ethical reasoning is similar to the nursing process because it requires 75
deliberate systematic thinking. The nurse first determines that an ethical problem exists, in a sense making a diagnosis. There is a data gathering stage, usually followed by a consideration of options based on ethical rationale and principles. After alternatives are considered, persons in an ethical conflict come to a point of action that can be evaluated in an ongoing manner. PROCESS FOR RESOLUTION OF ETHICAL DILEMMA Recognition of the ethical dilemma
Gather relevant factual information
Clarify the personal context Of the ethical dilemma
Identify and clarify The ethical concepts
Construct and evaluate Alternative courses of action
Take Action 3. International Society of Blood Transfusion [homepage on the Internet]. A code of ethics for blood donation and blood transfusion. [Cited 2006 June 15]. Available from: http://www.isbt-web.org/files/documentation/code_of_ethics.pdf
76
ROLE OF REGULATORY BODIES AND PROFESSIONAL ORGANISATION
ORGANIZATION: According to L. White, "Organization is the arrangement of per sonnel for facilitating the accomplishment of some agreed purpose though allocation of functions and responsibilities." PROFESSIONAL ORGANISATION : Professional organization provides a mean through which your own professional development can be channeled w ith authorit y because of their representative character. It provides you an opportunit y to express your viewpoints, develop your leadership qualities and abilities and keep you well informed of professional trends and news. All qualified nurses must parti cipate in their professional state and national organizations to keep themselves informed of new developments and for upgrading the profession. Some of the organization discussed below are recognized at national and international level and have a great rol e in uplifting the nursing profession. INDIAN NURSING COUNCIL – INC: The Indian Nursing Council is a statutory body constituted under the Indian Nursing Council Act, 1947. It was established in 1949. The council is responsible for regulation and Maintenanc e of a uniform standard of training for nurses, Midwives, Auxiliary Nurses Midwives and Health visitors. Indian Nursing Council Act, 1947 : Indian Nursing Council Act, 1947, provides for constitution and composition of the Council consisting of the followin g: 1. One nurse enrolled in a state register elected by each State Council; 2. Two members elected from among themselves by the heads of institutions recognized by the Council for the purpose of this clause in which training is given: a. For obtaining a University degree in Nursing; or b. In respect of a post-certificate course in teaching of nursing and in nursing administration; 3. One member elected from among themselves by the heads of institutions in which health visitors are trained; 4. One member elected by the M edical Council of India. 5. One member elected by the Central Council of the Indian Medical Association. 6. One member elected by the Council of the Trained Nurses Association of India. 7. One midwife or auxiliary nurse -midwife enrolled in a State Register, elected by each of the State Councils in the four groups of State mentioned below, each group of States being taken in rotation in the 77
following order namely: a. Kerala, Madhya Pradesh, Uttar Pradesh and Haryana. b. Andhra Pradesh, Bihar, Maharashtra and Rajasthan. c. Karnataka, Punjab and West Bengal. d. Assam, Gujarat, Tamil Nadu and Orissa ; 8. The Director General of Health Services, ex -officio; 9. The Chief Principal Matron, Medical Directorate, Arm y Headquarters. 10.The Chief Nursing Superintendent, Office of the Director Gene ral of Health Services. 11.The Director of Maternit y and Child Welfare, Indian Red Cross Societ y. 12.The Chief Administrative Medical Officer (by whatever name called) of each State other than a Union Territory. 13.Four members nominated by the Central Government, of whom at least two shall be nurses, midwives or health visitors enrolled in a State register and one shall be an experienced educationalist. AMENDMENTS IN I.N.C. ACT 1947 : The Act was amended in November 1957 to provide for the following things: 1. Foreign Qualification : a) A citizen of India holding a qualification which entitles him or her to be registered with any registering body may, by the approval of the council, be enrolled in any state register. b) A person not is citizen of India, who is employed as a Nurse, Midwife, ANM, Teacher or Administrator in any hospital or institution in any state, by the approval of President of Council, is enrolled temporaril y in state register. In such cases foreign qualifications are recognized temporaril y for a period of 5 years. If one continues to practice in India, an extension of recognition should be sort from INC. 2. Indian Nurses Register : a) The council shall cause to be maintained in the prescribed manner a Register of Nurses, midwives, ANM & Health visitors to be kno wn as the Indian Nurses Register, which shall contain the names of all persons who are for the time being enrolled on any state register. b) Such register shall be deemed to be a public document within the meaning of the Indian Evidence Act, 1872. ORGANISATION CHART :
78
Committees: 1. Executive Committee : of the Council to deliberate on the issues related to maintenance of standards of nursing programs 2. The Nursing Education Committee : The committee is constituted to deliberate on the issues concerned main l y with nursing education and policy matters concerning the nursing education. 3. Equivalence Committee: to deliberate on the issues of recognition of foreign qualifications this is essential for the purpose of registration of the Indian Nursing Council Act, 1947, as amended. 4. Finance Committee: This is another important Sub -Committee of the Council which decides upon the matters pertaining to finance of the 5. Council in terms of budget, expenditure, implementation of Central Govt. orders with respect to service conditions etc. Functions: To establish and monitor a uniform standard of nursing education for nurses, midwives, auxiliary nurse Midwives and health visitors by doing inspections of the institutions. To recognize the qualifications for the purpose of re gistration and employment in India and abroad. To give approval for registration of Indian and Foreign nurses possessing foreign qualification. To proscribe the syllabus and regulation for nursing programmed. Power to withdraw the recognition of qualifica tion standards, that an institution recognized by a state council for the training of nurses, midwives, auxiliary nurse midwives or health visitors does not satisfy the requirements of council. To advise the state Nursing Councils, examination board, stat e government and central government in various important items regarding nursing education in country. GUIDELINES FOR ESTABLISHMENT OF NEW NURSING SCHOOL/COLLEGE IN INDIA APPROVED BY INC: 1. Any organization under the central Government, State Government, Local body or a Private or Public Trust, Mission, Voluntarily registered under societ y Registration Act wishes to open a school of nursing should obtain the no objection /Essentiality certificate from the state Government. 2. The Indian Nursing Council on rece ipt of the proposal from the institution to start nursing programmed will undertake the first inspection to assess suitability with regard to Physical Infrastructure, clinical facilit y and teaching facult y in order to give permission to start the programmers. 3. After the receipt of the permission to start the Nursing programmers from INC, the institution shall obtain that approval from the State Nursing Council and examination Board. 79
4. Institution will admit the students onl y after taking approval of state nursing council and examination board. 5. The INC will conduct inspection every year till the first batch completes the programmers. Permission will be given year by year till the first batch completes. TYPE OF INSPECTION : 1. First Inspection: The first ins pection is conducted on receipt of the proposal received from the institute to start any Nursing programmed prescribed by INC. 2. Re-Inspection: Re-inspections are conducted for those institutions, which are found unsuitable by INC. The institution and the government are informed about the deficiencies and advised to improve upon them. Once the institution takes necessary steps to rectify the deficiencies, institution should submit the compliance report with documentary proof of the deficiencies pointed out and re-inspection fees. On receipt of the compliance report and fees from the institution, it will be considered for re -inspection. 3. Periodic Inspection: INC conducts periodical ( aft er 3 years) inspection of the institution once the institution is found suitable by INC to monitor the nursing education standards and adherence of norm prescribed by INC. Institutions are required to pay annual affiliation fee every year. However, if the institution does not compl y to the norms prescribed by INC for te aching, clinical and physical facilit y, the institution will be declared unsuitable. PROGRAMMES UNDER I.N.C : 1. ANM 2. GNM 3. Post Basic B.Sc. Nursing 4. B.Sc. Nursing 5. M.Sc. Nursing 6. M. Phil 7. Doctorate in Nursing RESOLUTIONS : I. Maximum period fo r students to complete revised ANM and GNM course is 3 and 6 years respectivel y. II. INC resolved that maximum age for teaching facult y is 70 years subject to the condition that he/she should be physicall y and mentall y fit. III. Admission to married candidate for the entire nursing programmed allowed subject to the conditions that they should produce medical fitness certificate. IV. Relaxation of norms to establish M .Sc. (N) programmed: As per INC norm, onl y those institutions can start M .Sc. programmed where at least one batch of students has qualified B .Sc. (N) programmed. INC resolved apart from these institutions the super specialt y hospitals can also open 80
the M.Sc. (N) programmed. Even though the institutions are not having B. SC. (N) Programmed . V. Relaxation of stu dent patient ratio for clinical practice: 1:3 student patient ratios instead of 1:5 student patient ratios. VI. Relaxation of teaching facult y qualification to start a B .SC. (N) programmed. At least 2 M .SC. (N) qualified teaching facult y to be available to sta rt BSC (N) programmed for next 4 years in order to combat acute shortage of nursing and teachers till the position of M .SC. (N) qualified teaching facult y improves. VII. To maintain qualit y of post graduate in nursing, INC resolved not to have M.SC. (N) program med through distance education. VIII. Institution should have its own building within 2 years of establishments. IX. Maximum No. of 60 seats can be sanctioned to those institutions which are having less than 500 bedded hospital. And 100 seats can be sanctioned to those having 500 bedded hospitals. REGISTRATION OF ADDITIONAL QUALIFICATION: INITIATIVES BY I.N.C. 1. Teaching material for Quality Assurance Model(QAM) prepared : QAM in nursing is the set of elements that are related to each other and comprise of planni ng for qualit y, development of objectives setting and activel y communicating standards, developing indicators, setting thresholds, collecting data to monitor compliance with set standards for nursing practice and appl ying solutions to improve care INC has developed a Qualit y assurance programmed for nurses in India. The project was implemented in 2 hospitals in New Delhi and PGI, Chandigarh for 3 months duration. The impact of QAM model adopted in Chandigarh can be seen in the paper cutting which was publi shed in Tribune on April 19th, 2004 2. Princes Srinagarindra award : Mrs. Sulochana Krishnan, Ex - Principal of RAK College of nursing was awarded Princes Srinagarindra, Thailand, award which is an international award to individual(s) registered nurse(s) in honor of princess Srinagarindra, her royal highness and in recognition of her exemplary contribution towards progress and advancement in the filed of nursing and social services Mrs. Sulochana Krishnan name was proposed by INC from India. 3. Development of Curriculum for HIV/AIDS and training for nurses : Indian Nursing Council in collaboration with NACO and Clinton foundation is developing a curriculum for training of nurses in HIV/AIDS areas. It will be a 6 day training programmed . The pilot study was conducted in Mumbai and Hyderabad.
81
4. National Consortium for Ph.D. in Nursing constituted 6 study centers recognized under National consortium for Ph. D in nursing : MOU has been signed between INC, WHO and RGUHS National consortium for Ph.D. in Nursing has been constituted by Indian Nursing Council (INC) in collaboration with Rajiv Gandhi University of Health Sciences and W.H.O, under the Facult y of Nursing to promote doctoral education in various fields of Nursing. Applications for enrolment in PhD in nursing were invited from eligible candidates by advertising in the national leading dailies from all over the country by the RGUHS. 125 appeared for the entrance test conducted on 07th January 2007. 5. MOU (Memorandum of Understanding :) signed between INC and Sir Edward Dunlop Hospitals Ltd for advancing standards of nursing education and practices in India to meet challenges currently faced b y Nursing. Memorandum of Understanding (MOU) is entered at New Delhi on 11th April 2006 between Indian Nursing Council and Sir Edward Dunlop Hospitals (I) Ltd. for developing the strategic framework for advance standards and investment plan for advancing standards of nursing education and practices in India with the following objectives. 1. Provide training 2. Graduate, Post -graduate, and Ph. D courses. 3. Organizing Research Activities. 4. To help fill gaps in India and internationall y benchmarked standards of nursing education and practice, including credentialing etc., so that Indian nurses can directl y be accepted to meet inter national standards. 5. Train the facult y so as to provide high qualit y teaching staff to training institutes in the country. 6. Steps taken up to enter into MRA under the Comprehensive Economic Cooper ation Agreement (CECA) between India and Sing apore : This was signed in June 2005 and has come into force fro m 1st August 2005. In that, it has been agreed that India and Singapore would enter into mutual recognition agreements (MRAs) in Medical, dental and nursing services in the healthcare sector
7. All State Registrars were invited to attend the two days meeting : The objective was to ensure the uniformity and to maintain the qualit y of nursing education in the country. It was also aimed to understand the problem/issues of each state nursing council and evolve co nsensus between INC and SNRC. 8. The Indian Nursing Council (INC) : initiated the live register in the state of Tamil Nadu. The primary objective of the project is to conduct nurses census i.e., to collect the data regarding number of working nurses as defined by INC. INC decided to conduct the pilot study in the Sivaganga District of Tamil Nadu. 266 were found trained registered nurses out of 841 nurses.
82
STATE NURSING COUNCILS : Registration in state nursing council is very necessary for every nurse. It is necessary to be registered in order to function officiall y as a professional nurse. Registration councils are functioning in all the states of India and they are affiliated to I.N.C. A register of names of professional nurses is maintained by each state nurses Registration Council. These names are also put into the Indian Nurses Register maintained by the Indian Nursing Council. Nurses, midwives, auxiliary nurse midwives and health visitors are registered. All degree holding nurses also have to get the r egistration in state council. The present functions of the State Nurses Registration Council are: 1. Recognize officiall y and inspect schools of nursing in their states. 2. Conduct examinations. 3. Prescribe rules of conduct, take disciplinary actions, etc. 4. Maintain registers of Graduate nurses, nurses holding degrees in nursing, midwives revised auxiliary nurse midwives or multi -purpose workers and health visitors. The State Nursing Council is an independent body. Though the State Nursing Council functions indep endentl y; it has to obtain approval from state government for all the By-Laws passed by it and decisions taken. The State Nursing Councils are administrativel y headed by the Registrar who usuall y is a nurse. There is deput y registrar who also is a nurse. There is a staff consisting Accountant and other staff as clerks and peons to help him in his day to day work and functions. The President and Vice-President are elected by members from amongst themselves. The elections procedures for all the categories a re laid down by statutory provisions in By-Laws of the Councils. Some of the members on the council are still nominated by the Government whereas majorit y is elected by following the electoral procedures. FUNCTIONS OF THE REGISTRAR OF THE STATE NURSING COUNCIL: 1. To draw a programmed for examinations of various t ypes of educational programmed at all centers at the same time. 2. To prepare a time schedule for written and practical examinations, to prepare Roll number sheets of students and send them to var ious examination centers. 3. After examiners have drawn the question papers, to get them printed under strict confidential atmosphere and keep up the secrecy regarding them. 4. To prepare examination results and communicate the results to concerned instit utions. 5. To prepare the diploma certificates and registration certificates of nurses who have been qualified for both.
83
6. To arrange for inspections to ascertain that the institutions are carrying out the educational programmed as per syllabus, condi tions and rules and regulations laid down by State Council. TRAINED NURSES ASSOCATION OF INDIA (TNAI) : The T.N.A.I. is the national professional association of nurses. The association had its beginning in the association of nursing superintendents which was founded in 1905 at Lucknow. The organization composed of 9 European Nurses holding administrative post in hospital. They saw the need to develop nursing as a profession and also do provide a forum where professional nurses meet and plan to achieve these ends. The first president was Miss Allen Martian. First Secretary: Miss Burn. Objectives: a. Uphold the dignit y and honor of nursing profession. b. Promote a sense of spirit de-corps among all the nurses. c. Enabling member to take counsel together on matters rel ating to their profession. The association of nursing superintendents therefore sought the help and co –operation of nurses throughout the country. A decision was made in 1908 to establish a trained nurses association at the annual conference at Bombay and accordingl y association was inaugurated in 1909. These two organizations operated under the same leadership until 1910, when TNA elected its own officers. In 1922, the two organizations were brought together as the ―Trained Nurses Association of India. The aims of TNAI are similar to those of original organization. These aims centre on the needs of the individual and the problems of the nursing profession as a whole. These aims include the following: 1. To standardize, upgrade, develop nursing education and to elevate nursing education. Development of various colleges of nursing in the different states of India is a result of this function of the national organization of nursing that is, the TNAI. Thus the TNAI has contributed greatl y to meet this aim. 2. To improve the living and working conditions of the nurses and also develop the educational conditions available for nursing. To improve the economic standards of the nurses in India. The state government in every state has been directed by TNAI to appoint a nurse as the nursing director. 3. To provide registration for qualified nurses and to provide reciprocit y of registration within different state in the country and within different countries. The TNAI has established the following organization .
84
The association has established the following organizations: a. Health visitor league (1922) b. Midwives and auxiliary nurses: Midwives Association (1925) c. Student Nurses Association (1929 -30) Membership: The membership consists of: Full Members: Fully qualified Registered Nur ses Associate Members: Health visitors, midwives and A.N.Ms. Affiliate Members: Student nurses and members of the affiliated organizations e.g. Christian nurses‘ league. Membership of TNAI is obtained by application and submission of copy of one‘s state re gistration certificate. One can appl y for a life membership. BENEFIT FROM T.N.A.I. MEMBERSHIP : 1. Various professional issues like representation to central pa y commission. 2. Holding National level conferences, scientific and business sessions. 3. Low cost publications for members and students. 4. Continuing education programmed for updating knowledge on various topics at regular interval. 5. Socio-economic welfare programmed for destitute members. 6. Research studies conducted regularl y for the benefit of the members. 7. At home with patron of TNAI member at Rashstarlpati Bhawan every year on nurses day celebrations. 8. Scholarship for TNAI member and students nurses. 9. Annual grant to state branches to hold activities. 10.One fourth railway concession for TNAI members. 11.The guest room facilities at the headquarters and also in some states. PUBLICATION: o Hand Book of T.N.A.I. , published in1913 o Nursing Journal of India published monthl y. WHO Day, International Nursing Day and International Women‘s Day and other related activities are ce lebrated with the initiative of T.N.A.I. in all states of country. STUDENTS NURSES ASSOCIATIONS (S.N.A.): The student nurses associations were established in 1929 which is a nationwide organization. In 1954, SNA celebrated the silver jubilee and number of unit was 117. Now SNA have more than 506 units. S .N.A. having separate biennial conference. There is a full time secretary for SNA at national level. OBJECTIVES OF S.N.A: 1. To help student to uphold the dignit y and ideals of the profession for which they are qualifying. 2. To promote a corporate spirit among student for the common good. 85
3. To furnish nurses in training with advice in their case of study leading to professional qualification. 4. To encourage leadership abilit y and help students to gain a wide knowledge of the nursing profession in all its different branches and aspects. 5. To help the student to increase their social contacts and general knowledge in order to assists them to take their place in the world when they have furnished their training. 6. To increase professional, social and recreational developments and arranging meetings, games and sports. 7. To provide a special section in the “Nursing Journal of India ” for the benefit of students. 8. To encourage student to compete for prizes in the student nursing exhibition and to attend national and regional conferences. The whole organization of SNA is similar to that of TNAI. Local units are established in the institution. The Diary of various events is kept b y SNA Secretary. The diary for all the students are presented at the time of national conferences, the diaries from all the units are presented. Later on, the SNA unit moves to the national level as the TNAI. MANAGEMENT OF S.N.A : The governing body of the association shall be the council of TNAI which will receive the recommendations of the General Committee of the SNA for consideration. The General Committee of SNA shall consist of: 1. President of TNAI or one of the Vice -President if President wishes to delegate this responsibilit y. 2. Vice Presidents of SNA State Branches, Honey. Treasurer of TNAI, National SNA Advisor who must be a full member of TNAI, State 3. Branch SNA Advisors, Secretaries of SNA State Branches , Secretary General of TNAI. The General Committee shall meet once in a year a time of TNAI council meeting. SNA General Body : At National Level Comprises i) Members of SNA General Committee ii) 3 representative from each unit i.e. SNA Vice President, SNA Secretary and SNA Advisor iii) All SNA delegates attending the conference SNA General Body at State Lev el: It consists of i) State SNA Executive Committee Members (State Branch President, Vice President, Advisor, Secretary, Treasurer and Programme Chairperson). ii) SNA Unit representative (Vice President, Secretary, SNA Advisor) 86
SNA Units Each SNA Unit should e lect its own members of Executive Committee in its GBM (General Body Meeting) and these members are SNA Unit Advisor, Vice President, Secretary, and Programmed Chairperson. The SNA General Body Meetings should be held at regular intervals the agenda for th ese meetings will be according to the needs of unit members and objectives of SNA. SNA unit advisor is responsible to see that as soon as a nurse has graduated, she is given an SNA to TNAI form for membership in TNAI. This form must be signed by the Nursin g Head of the Institution and sent to Secretary General of TNAI. Membership: The student nurse can obtain membership of student nurses Association during their training period and SNA membership can be transferred to TNAI membership. The membership fee in SNA is quite less, which is easil y met by the nursing student. They can take membership in TNAI after completion of basic education by obtaining a certificate from the institution in which they have studied within 6 month after completion of studies. ACTIVITIES OF S.N.A: A wide variet y of activities are encouraged for S.N.A. Keeping in view the objectives of association and to strengthen curricular and co curricular components as follows. A. Organisation of meetings & conferenes: At the TNAI conference two representatives of SNA from each state are invited as observer and these students representative are vice -president and secretary of the state branches. They are invited to attend business meetings as observer. Three to four days conference is held for SNA members bienniall y. Member discuss and find solution for various problem faced by the students. These conferences are held bienniall y at state level. At the units usuall y the meeting is held monthl y or bi - monthl y. B. Maintenance of diary: This is a bienn ial record book drawn up for the use of unit secretaries. The diaries are assessed annuall y by the state, SNA advisers and two best diaries are sent by state to the national SNA advisor for biennial evaluation and awards. These diaries are assessed for pro fessional, educational, extra - curricular, social, cultural and recreational aspects. C. Exhibition: Exhibition is very useful and very popular activit y of the association. All categories of students are eligible to participate either individuall y or in groups. They can prepare models, charts & posters on the subjects taught in their course of studies. Now, their activit y is competed at the state 87
level and one best entry under each category and section is entertained at national level. D. Public speaking and writing: Public Speaking and writing are encouraged to increase self confidence and help them gain skill in communication through debates, panel discussions, seminar on the theme of conference. Students are also encouraged to write for nursing general of India on professional topic. E. Project undertaking: At the time of celebration of international nurses day students are given project work on health related topics. Regular project work is also given by institution to students. F. Propagation of nurs ing profession: Other professional and general public should be invited to celebration of professional and non professional activities such as nurse‘s week, WHO day. The other activities such as variet y entertainment programme, game, sports etc. are organi zed by nurses to acquaint general public with nursing profession. G. Fund raising: To meet the expenses at head quarter and SNA state level unit, it is necessary to raise the fund through voluntary donations. H. Socio cultural and recreation activities: To channelize your student energy, fine arts activities such as drama, dance, music and painting are arranged and competitions are also held at state and national level. Sports and games competitions are also held. Other activities: These can be in the fo rm of quiz on general knowledge and professional topics, article writing, poetry writing, smile competitions etc. Hobbies such as sewing, stitching, knitting etc. should also be arranged. INTERNATIONAL PROFESSIONAL ORGANISATIONS : INTERNATIONAL COUNCIL OF N URSES (ICN): MISSION: To represent nursing worldwide, advancing the profession and influencing Health policy. Introduction: The ICN is federation of national nurses association (NNAs), representing nurses in more than 128 countries. Founded in 1899, ICN is the world‘s first and widest reach international organization for health professionals. Operated by nurse for nurses, ICN works to ensure qualit y nursing care for all, sound health policies globall y, the advancement of nursing knowledge and the presence w orld wide of a respected nursing profession and a competent and satisfied nursing workforce. I.c.n. Goals: 1. To influence nursing, health and social policies, professional and socio economics standards worldwide. 88
2. To assist national nurses associations (NNA s) to improve the standard of nursing and the competence of nurses. 3. To promote the development of strong national nurses associations. 4. To represent nurses and nursing internationall y. 5. To establish, receive and manage funds and trust which contribute to the advancement of nursing and of ICN. In shorts 3 main goals: - To bring nursing together worldwide. - To advance nurses and nursing worldwide. - To influence health policy. Core values: 1. Visionary leadership . 2. Inclusiveness. 3. Flexibilit y. 4. Partnership. 5. Achievement. The ICN code for nurses is the foundation for ethical nursing practices throughout the world. ICN standard, guidelines and policies for nursing practices, education, management, are globall y accepted as per basis of nurse‘s policy. ICN advances nursing, nurses and health through its policies, partnership, advocacy and leadership development, ICN is particularl y active in: Professional nursing practice: - Advanced nursing practice . - HIV/AIDS, TB and malaria . - Women‘s health. - Primary health care . - Famil y health. - Safe Water. Nursing regulations: - Code of ethics, standards and competencies. - Continuing Education . Socio economic welfare for nurses: - Occupational health and safet y. - Human resources planning and policies . - Carrier development . - International trade in professional services . Governance of icn: Meetings: ICN meets every 4 years. The quadrennial meetings are called as "Congresses" and when they are in session, the organization is called as the International Congress of Nurses.
89
The ICN board o f directors numbers15 and is comprised of the president, three vice president and 11 members elected on the basis of ICN voting area.
Function: 1. To provide policy directions to fulfill the objectives of ICN 2. To establish categories of members hip and determine their rights and obligations. 3. To act upon recommendations of the board of directors relating to admission and readmission of member associations into ICN. 4. To receive and consider information from the board regarding ICN activities. 5. To receive nominees for the board and to elect the board. 6. To act upon proposed amendments to ICN constitution. 7. To act upon recommendation of the board of directors for the amount of NNA‘s dues. 8. To act through mail or any written communication on ICN business th at requires immediate attention. Publication: International Nursing Review American Nurses Association (A.N.A.) Establish: 1911 Purpose: To improve qualit y of nursing care Activities: - Establish standards for nursing care - Develop educational standard - Promote nursing research - Establish a professional code of ethics. - Oversee a credentialing system. - Influence Registration affecting health care. - Protect the economic and general welfare of registered nurses. - Assist with professional development of nurses by pro viding continuing education programmed. 90
Membership: Federation of state nurses association - Individual registered nurses can participate in ANA by joining their respective state nurses association. Publication: American general of nursing . American Nurses. Concusion : It is to conclude that the knowledge of all above discussed organization is must for every nursing personnel. So that by utilizing this knowledge we can update our knowledge and can advance the nursing practices, taking this profession to the h igher standards.
91
BIBLIOGRAPHY ( REFERANCES ): Mrs. Swinder Kaur‘s, "Professional adjustment, ward management and trends in nursing". Edition 1 s t , published by lotus publications. Pp. 37 -52. Ann. J. Zwemer‘s, "Professional Adjustment and ethics for nurses i n India," Edition 6 t h , published by B.I Publications.Pp 232 -249. Mr. Kamal S. Joglekar‘s, "Hospital ward management, professional adjustments and trends in nursing", Edition 12 T H , Published by vora medical publications, Pp 132 -153. Sue C. Delaune and Patri cia K. Ladner‘s, "Fundamentals of nursing standards and practice", Edition 7 t h , published by Delmar publishers, Pp 216-217. www.google.com.
92
EDUCATIONAL PREPARATION FOR NURSES Meaning:Educational preparation for nurses means preparing the nurses at university level and school of nursing, at hospital level and at community level. Why educational preparation is necessary for nurses: Nursing is interpreted in different ways by different people. It is still thought by many people that nursing is only taking care of sick person. It is only helping the doctor in treatment of the patients. No medical service is complete without nursing or without trained nurses: Nursing comprises of several responsibilities like dealing with patients of medical illness, clients having surgeries, psychiatric or pediatric patients. Nursing also involves other duties like maintaining patients, dispensing medication, setting up the equipments of an operation theatre and many other routine jobs. Growth of health industry: The demands for nurses are also increasing making a “career in nursing”. Schools, colleges, hospitals, community health centers need trained and qualified nurses. Statistics of nurses (Source Indian Nursing Council 1986): Last 40 years have produced 4271 B.Sc. nursing and M.Sc. nursing degree nurses. Around 200,000 General Nurses are produced. For large infrastructure of health centers, for 600 million population of rural India around 100,000 of ANM/FHW are produced till date. Studies reveal nurses dissatisfaction with staffing because they are overloaded with work. This is because of the lack of nursing personnel so; there is need for educational preparation of nurses. Total nursing manpower required for urban and rural nursing services given by high power committee up to 2006 was – Nurse midwives : 743114, Public health nurses : 34875 Health supervisor : 107960 ANM / Health worker: 323882 Criteria for selection in nursing: Candidates, who wish to apply for nursing courses, should pass physics and chemistry and biology as main subjects. Major Courses in nursing: The major courses their duration and their eligibility requirements are: Name of Course Duration Eligibility ANM/Health Worker 18 Months 10th Standard G.N.M. 3 ½ Years 10+2 with Biology, Physics and Chemistry B.Sc. Nursing 4 ½ Years 10+2 with Biology, Physics and Chemistry Auxiliary Nurse Midwifery Program: It is a nursing programmed with the duration of 18 months. It was first started at S. Mary‘s Hospital Taren in Punjab in 1951. Initially, very few training centers undertook to give this course, but the financial aid given by the Govt. of India under the scheme for 93
preparing personnel for Primary Health Centers gave a great impetus to the training programmed. General Nursing Midwifery Programmed: The Indian nursing council at its meeting in 1950 came out with some important decisions relation to the future pattern of Nursing Training in India. One the important decisions was that there should be only two standards of training of nursing and midwifery. So, the General Nursing and Midwifery course was started. Basic B.Sc. Nursing: It is the nursing programmed at university level. It was first started in 1948 in Rajkumari Amrit Kaur College of Nursing, New Delhi. Similar Course in B.Sc. Nursing was started by other universities also. After the completion of these major courses, there are other certificate courses and master degrees in Nursing and doctorate in Nursing. Name of Course Duration Eligibility Post basic B.Sc. Nursing 2 years 1 yrs experience with diploma in nursing M.Sc. Nursing 2 Years B.Sc. Nursing with 1 Year experience M. Phil. in Nursing 2 Years part time M.Sc. Nursing , 1 ½ year Regular Ph. D in Nursing 3 years After M.Sc. Nursing 2 years After M. Phil Nursing 1. Post Basic Post Certificate B.Sc. Nursing:-. The need for higher training for certificate nurses was stressed by Mudaliar Committee, and the two years‘ Post Basic certificate B.Sc. Degree programmed after G.N.M. was started in 1962. 2. Post Graduation Education: Two years formal course in Master of Nursing programmed was started in 1959 in Raj Kumar Amrit Kaur College of Nursing and one can choose specialty according to his/her choice. 3. M. Phil Nursing Programmed: M. Phil nursing programmed is first started in Raj Kumari Amrit Kaur, College of Nursing on Oct. 15, 1986. This is the programmed for one and half year for regular candidates and two years for part time candidates. 4. Ph.D. Programmed:Ph. D programmed was started in few colleges like College of Nursing P.G.I., College of Nursing CMC Vellore, R.A.K. College of Nursing, Delhi. It is a 3 years programmed after M.Sc. Nursing and 2 years programmed after M. Phil in Nursing.
94
CONTINUING EDUCATION
Meaning: ► It is ―any extension of opportunities for reading, study and training to any person and adult following their completion of or withdrawal from full time school/or college programmed. ► Continuing education is an ―educational activity‖ primarily designed to keep the registered nurses abreast of their particular field of interest and do not lead to any formal advanced standing in the profession (Nursing Thesaurus of the International Nursing Index.) ► Continuing education in nursing consists of planned learning experience beyond a basic nursing educational programmed. These experiences are designed to promote the development of knowledge, skills and attitudes for the enhancement of nursing practice, thus improving health care to the public (ANA). Need for continuing education in nursing: 1. Phenomena of Change: Basically the need for continuing education emerges from phenomena of change, Change in what is known about man and how he functions in health and illness, changes in the ways in which people meet the challenge to survive in a dynamic age, and change in the objectives. Organization and financing of health services. 2. Altered professional roles: As the society changes and as new technologies and knowledge is emerges, the professional roles and altered. The individual who avoid chance of acquiring new knowledge, he meet the challenge of change, he cannot adopt himself according to the changing demands. 3. Effective and wise leadership and competent practitioners: For the development of good leaders, continuing education must be there in nursing educational according to the demands of society she has to become competent practitioner. 4. To fulfill needs of nurse practitioner: The nursing profession itself and larger society highlight the need for planned programmed of continuing education. These include charging functions of the nurse, an increasing trend toward specialization. THE NURSE AND RESPONSIBILITY OF CONTINUING EDUCATION: With the scientific advancement, technologic innovations, social changes and with the emergence of new patterns of health care, traditional roles of nurses are under close scrutiny and some must inevitably give way to new roles. If goal of providing the best possible health care for all people is to be achieved, nurses must become involved in creating new solutions for problems both old and new. They must justify and initiate charges needed for the improvement of nursing case. This must become the responsibility of every nurse. Philosophy of Continuing Education: It has been believed that the system of higher education which provides the basic preparation for the members of a profession must also provide opportunities for practitioners to keep abreast of advances in their field. 95
Philosophy of Continuing Education in Nursing: It encompasses various aspects of life and is not limited the professional education. Continue education is concerned with development of the nurse as a person, a practitioner and a citizen. These are closely interrelated but each must be considered in identifying Philosophy of Education. Nurse‘s philosophy of life, nursing and education, belief etc. will influence the philosophy of continuing nursing education. It focuses on the individual learner. Philosophy in thought of relating to basic belief. Actions are guided by one‘s belief, how one teaches relates to his belief about learning and education. Philosophy is based on value; social change the thoughtful teacher recognizes that one‘s philosophy of education is always an emerging one rather than a static one. Learning must be a continuous process throughout the lifespan, not limited to formal courses of study. Planning for continuing Education: ► A successful continuing education programmed is a result of careful and detailed planning. . ► Planning is essential if learning needs of nurses are to be met and if available resources are to be met and if available. ► Planning is required at all levels, local, state, regional and national and eventually international to avoid duplication of efforts. ► Planning help to keep a minimum gap in meeting the continuing education needs of nurses. ► Planning must be on going or continuous because rapid technologic advances and proliferation of knowledge demands continuous planning to meet ever changing learning needs. Planning Process:Nurses identify most closely with planning for client care, but the principles of planning apply to a wide variety of situations various approaches may be used in planning for continuing education. The Planning Formula 1. What is to be done? Get a clear understanding of what your unit is expected to do in relation to the work assigned to it. Break the unit‘s work into separate jobs in terms of the economical use of men, equipment, space, materials and money you have at your disposal. 2. Why is it necessary? When breaking the units into separate jobs, think of the objectives of each job. This may suggest alternate methods or the possibility of eliminating parts of jobs or whole jobs. 3. How is it to be done? In relation to each job, look for better ways of doing it in terms of the utilization of men, materials, equipment and money. 4. Where is to be done? Study the flow of work and the availability of the materials and equipments best suited men for doing the job. 5. When is it to be done? Fit the job into a time schedule that will permit the maximum utilization of men, materials, equipment and money, and the completion of the job at the wanted time. 96
6. Who should do the job? Determine what skills are needed to do job. Successfully, select a train the man best fitted for the job.
CAREER OPPORTUNITIES For the nurse means opportunities for a nurse to develop her own career in nursing. There was a time when professional nurses had very little choice of service because nursing was mostly centered in the hospital and bedside nursing. Many nurses served as staff nurses only with practically no chance of change or promotion. The Opportunities for a nurse can be set as: 1. Hospital Nursing Services 2. in School of Nursing 3. in college of Nursing 4. in Community Health Nursing 5. Nursing service in Industry. 6. Nursing service as private duty nurse. 7. Nursing service in the Red Cross society. 8. Nursing service for military personnel. 9. Nursing service abroad. 10. Opportunities for male nurses. 1. Hospital Nursing Services: a) Staff Nurse (3 yrs G.N.M. / Psychiatric Nursing Diploma/Certificate, recognized by INC. b) Senior Staff Nurse: - (G.N.M. or B.Sc. Nursing and have experience as staff Nurse of not less than 5 years. c) Nursing Superintendent Grade II (Experience as a senior staff Nurse). d) Nursing Superintendent Grade-I (should have experience as Nursing Superintendent Grade-II) 2. Nursing Services in the School of Nursing: a) Nursing Tutor (B.Sc. Nursing or M.Sc. Nursing) or a diploma in Nursing education and administration. b) Clinical Instructor (B.Sc. Nursing or M.Sc. Nursing with or without experience). c) Principal, School of Nursing (M.Sc. Nursing or B.Sc. Nursing and should have teaching experience in school of nursing not less than 5 years.) d) Public Health Nurse or Community Health Nurse (Diploma in Public Health Administration) 3. Nursing Services in the College of Nursing: ► Principal, College of Nursing (M.Sc. nursing or equivalent degree or Ph. D in Nursing or other doctorate degree and teaching experience in college not less than 5 years) ► Lecturer (M.Sc. Nursing) ► Senior Lecturer: - Experience as Junior Lecturer. ► Assistant Professor: - (M.Sc. Nursing or Ph. D in Nursing with any specialty) and have teaching experience in the college of Nursing not less than 5 years). ► Clinical Instructor (B.Sc. Nursing or M.Sc. Nursing with or without experience) ► Professor (M.Sc. Nursing or Ph. D in Nursing with any specialty and should have teaching experience in the college of nursing not less than 5 years.) 97
4. in Community Health Nursing: ► Community Health Nurse/ Community Nursing Officer (B.Sc. Nursing or G.N.M). ► Health Supervisor ► Nurse Midwife (G.N.M or B.Sc. Nursing). 5. Nursing service in Industry ► Industrial Nurse (G.N.M & B.Sc. Nursing Experienced). 6. Nursing Service as a Private Duty Nurse ► (B.Sc. Nursing /Post Basic B. Sc Nursing). 7. Nursing Service in the Red Cross Society 8. Military Nursing Services (G.N.M/ B.Sc. Nursing or M.Sc. Nursing) and were given the rank from Lieutenant to Brigadier. 9. Nursing Service in abroad:- (G.N.M./B.Sc. Nursing/ M.Sc. Nursing with or without experience) 10. Nursing Services in other areas:- Like research and writing and editing books, full time secretaries on the state level with the TNAI (Rich experience in the profession) 11. Opportunity for Male Nurses:- They are valuable in activities of professional organizations where travel is often necessary. NURSING EDUCATION Nursing education is the professional education for the preparation of nurses to enable them to render professional nursing care to people of all ages, in all phases of health and illness. Aims of Nursing Education: To provide the professional nursing care to people of all ages, in all phases of health and illness in a variety of setting. To prepare the nurses for providing care at institutional level. To prepare the nurses for rendering community services through primary health centre. To prepare integration of health and social aspect, theory and practice in generalized public health nursing. To provide an adequate, sound scientific foundation, intelligent nurses to understand the functioning of body and mind in health and disease. To prepare nurses who will be able to work cooperatively with team members who are engaged in health and welfare work To insure opportunities for initiative and resourcefulness, sense of responsibility for oneself and others and broad professional and cultural interest. Role of Nursing Education ► Nursing education is the professional education for the preparation of nurses to enable them to render professional nursing care to people of all ages, in all phases of health and illness, in a variety of settings. ► Nursing education impart scientific and up to date knowledge in the area of medical, social, behavioral and biological sciences. ► Nursing education helps the nurses to inculcate the appropriate nursing skills and the right attitude to the students. Theoretical and practical knowledge is essential for rendering intelligent and efficient nursing care. ► Nursing education prepare nurses as a good leaders to provide qualitative care. 98
► Nursing education helps to implement health care programmed and health care services in community. ► Nursing education helps to improve the professional development of each nurse and their profession. ► Nursing education helps the nurse to develop as a person of self-awareness, self direction, and self motivation through curricular and extra-curricular activities. ► Nursing education prepares nurses in participating scientific nursing research investigations, its results will be added up to the body of nursing knowledge. ► Nursing education inculcates democratic values, e.g. Respect to individuality, equality, toleration, co-operative living, faith in change. ► Nursing education enable the nurses to co-operate with team members who re engaged in health and welfare work. ► Nursing education enable the nurse to understand the functioning of body and mind in health and disease. ► Nursing education prepare the individual to earn his/her livelihood and make himself/herself self-sufficient and efficient economically and socially.
Scope of Nursing Education ► Increase in health consciousness in India, the quality of health services has also improved. So, skilled and specialized nurses can get excellent employment opportunities in government or private hospitals Nurses can also get employment in clinics, nursing homes, orphanages, old age homes, industries, military services, schools and other places. ► Nurses can get specialized duties like taking care of patients in pediatric, orthopedics, psychiatry, obstetric and other sections. ► Nursing education provides the scope in teaching, supervising and higher level of administration. ► Nursing education has great scope for male nurses. They are valuable in activities of professional organizations where travel is necessary. ► Nursing has great scope in abroad. They can find jobs in specialized field like surgical, medical, ICU, CCU and Emergency Room (ER) ► Nurses get high pay packet in abroad. ► Nurses get many opportunities for studying and settling there in abroad. Conclusion: It is concluded that every individual who want to be a nurse must have some special education and nurses can have variety of career opportunities and have wide scope in nursing.
99
Bibliography:1. Basavanthappa BT, Nursing Administration, 1st edition, published by Jaypee Brothers. PP-516-517, 521-522,543-56. 2. Neerja K.P., Text book of Nursing education, 1st edition, published by Jaypee Brothers.PP-9-12, 159,388. 3. Kamal S Joglekar, Hospital ward management, professional adjustment and trends in nursing, edition 1997 published by VORA Publication PP 107-109. 4. Trained nurses association of India, Nursing in India, published by Aravali Printers and publisher pvt. Ltd. New Delhi, PP 145. 5. Zwemer. J.Ann, Professional adjustment and Ethics for nurses in India 6th edition 1995 published by B.I. Publication PP-175. 6. www.google.com
100
ROLE OF RESEARCH, LEADERSHIP AND MAGEMENT Introduction: Nurse means to foster or cherish; to treat or handle with care; to bring up; to train; to preserve. So the term ―nurse‖ suggests attendance and service. In 1966, Virginia Henderson gave her concept of the unique function of the nurse as follows: ―The unique function of the nurse is to assist the individual, sick or well, in the performance of those activities contributing to health or its recovery (or to peaceful death) that he would perform unaided if he had the necessary strength, will or knowledge, and to do this, in such a way as to help him gain independence as quickly as possible‖. Role of research in nursing: The root meaning of the word research is to search again or to examine carefully. Research is diligent, systematic inquiry or study to validate and refine existing knowledge and develop new knowledge. Acc to Gowin and Millman (1969): “Research is an abstraction and selection from an infinite variety of possible things that one might study.‖ According to Arnold Lancaster: ―Research may be defined as planned, systematic search for information for the purpose of increasing the total body of man‘s knowledge. It involves looking for information which at the time is not available or for which that has no generally accepted evidence.‖ According to Notter: ―Research is a process systematically searches for new facts and relationships.‖ MEANING OF NURSING RESEARCH: Nursing research is one area of research which includes the breadth and depth of the disciplines of nursing, the rehabilitative, therapeutic and preventive aspects of nursing as well as the preparation of practioners and personnel involved in the total nursing spheres. Nursing research is directed toward helping well people to improve their status and stay healthy, as well as assisting clients who are sick or disabled by an illness to maintain or improve their health. According to Vreeland: “Nursing research is concerned with systematic study and assessment of nursing problems or phenomena, finding ways to improve nursing practice and patient care through creative studies, initiating and evaluating change and taking actions to make new knowledge useful in nursing.‖ According to Polit and Hungler: “Nursing research is a process in which the researcher scientifically collects data to be used in the clinical, administrative or instructional area in order to find solutions to nursing problems, evaluate nursing practices, procedures, policies or curriculum, assess the needs of the patients, staff or students, and make decisions to change or continuous various nursing process which in turn advances the scientific knowledge in nursing field‖.
101
Nursing research is defined as a scientific process that validates and refines existing knowledge and generates new knowledge that directly and indirectly influences nursing practice. Development of nursing research from Nightingale to the present: Nurse‘s participation in research has changed drastically over the last 150 years. Initially, nursing research evolved slowly from the investigations of Nightingale in 19th century to the studies of nursing education in 1930‘s and 1940‘s and the reaesh of nurses and nursing roles in 1950‘s and 1960‘s.in 1970‘s and 1980‘s an increasing number of nsg studies focused on clinical problems were conducted. Clinical research continues to b a major focus for 1990‘s. FLORENCE NIGHTINGALE: Nightingale‘s (1859) initial research focused on the importance of a healthy environment in promoting the patient‘s physical and mental wellbeing. She studied aspects of environment such as ventilation, cleanliness, purity of water and diet to determine the influence on patient‘s health. Nightingale also collected and analyzed morbidity and mortality data of soldiers of Crimean war. The research of Nightingale enabled her to change the attitudes of military and society toward the care of sick. She made a major impact on patient‘s health. She used the research knowledge to make significant changes in society such as testing public water, improving sanitation, preventing starvation and decreasing morbidly and mortality. Nursing research from 1900 to the 1960s: The American Journal of nursing was first published in 1900, and in 1920s and 1930s case studies began appearing in this journal. in 1950,ANA‘s study on nursing functions and activities findings were reported in Twenty Thousand Nurses Tell Their Story and based on which ANA developed statement on functions, standards and qualifications for professional nurses in 1959. During 1950‘s clinical research began expanding in nursing specialty groups as community health, psychiatric mental health, medical-surgical, pediatrics and obstetrics, developed standards of care. The increase in nursing research activity during 1940s prompted the publications of first nursing journal, nursing research in 1952. In 1950s and 1960s, nursing schools began introducing research and steps of research process at the baccalaureate level. The number of nurses with Master‘s degree with research background also increased during this period. In 1953 the Institute for research and Service in Nursing Education was established at Teacher’s College, Columbia University, New York that provided learning experiences in research for doctoral students. In 1960s a number of clinical studies focuses on quality care and development of measurement criteria of patient outcomes were performed. An additional research journal The International Journal of nursing studies was published in1963.In 1965; the ANA sponsored the first series of nursing research conferences to promote the communication of research findings and use of these findings and use of these findings in practice. Nursing research in the 1970s: In late 1960s and 1970s nurses developed models, conceptual frameworks and theories to guide nursing practice. 102
In 1978 China started publishing the journal Advances In nursing science that included nursing theorists work and related research that provided direction for future nursing research. In 1970 ANA established Commission on Nursing Research .In 1972 this commission established the Council of Nursing Researchers to advance research activities provide an exchange of ideas and recognize excellence in research. It also sponsored research programs nationally and internationally. In 1970s Sigma Theta Tau, the international research honor society for nursing, sponsored national and international research conferences. IMAGE published by Sigma Theta Tau, in 1967 includes research articles and summarizes of research conducted on selected topics .two additional research journals first published in 190s are Research in Nursing and Health in 1978 and Western Journal of Nursing Research in 1979. Nursing research in the 1980s and 1990s: In 1980‘s the focus was on conducting clinical research and clinical journals began publishing more studies. A new research journal published in 1987, Scholarly Inquiry for Nursing Practice and two in 1988, Applied Nursing Research and Nursing Science quarterly. The little of the clinical research knowledge was used in practice in 1980s.During 1982 and 1983 materials from federally funded project, Conduct And Utilization Of Research in Nursing (CURN) were published to facilitate the use of research to improve nursing practice. In 1983 first volume of Annual Review of Nursing Research was published. Another priority in 1980s was to obtain increased funding for nursing research. The ANA created The National Institute for Nursing Research (NINR) in 1985.The purpose of this centre was to conduct, support and dissemination of information regarding basic and clinical nursing research, training and other programs in patient care research the NINR seeks more money for nursing research so that studies in the priority Areas can be funded. In 1990s, numerous high quality studies are being conducted to develop a scientific body of knowledge for nursing. Importance of research in nursing: Nursing is accountable to society for providing high quality care and seeking ways to improve that care. Through nursing research, scientific knowledge can be developed to improve nursing care, patient outcomes, and health care delivery system. Nurses need scientific knowledge to improve their decision making regarding what care to provide patients and how to implement that care. A solid research base is needed to document the effectiveness of selected nursing interventions in treating particular patient problems and promoting positive patient outcomes .Nurses also need research findings to improve the delivery of health care services. Research efforts contribute to professional autonomy for nursing i.e. Freedom to make Discretionary and binding decisions within one‘s scope of practice through selection, generation and testing of a unique body of knowledge which will provide professional autonomy and power. The knowledge generated through research is essential to provide a scientific basis for description, explanation, prediction and control of nursing practice.
103
DESCRIPTION: It involves identifying the nature and attributes the nature and attributes of nursing phenomena and sometimes the relationships among these problems. Through selected research methods, nurses are able to describe what exists in nursing practice, discover new information for use in the discipline. EXPLANATION: In explanation the relationships among variables are clarified reasons for occurrence of certain events are identified. For example: research has indicated that elderly patients are at high risk of developing pressure ulcers related to level of mobility and support services can be used to explain the incidence of pressure ulcers in elderly patients and this knowledge can also be used in selecting nursing interventions to prevent pressure ulcers. PREDICTION: Through prediction the probability of a specific outcome in a given situation can be estimated. However, it does not necessarily enable to modify or control the outcome. CONTROL: Control is to manipulate the situation to produce the desired or predicted outcome. Control can be described as the ability to write the prescription to produce desired results. Nurses could prescribe certain interventions to patients and their families to achieve high quality outcomes. Example: based on research of Meek (1993), nurses could prescribe slowly stoke back massage to promote comfort and relaxation in hospice patients. So, we can say that research enables nurses to promote high quality patient outcomes essential to the development of nursing profession. Research documenting the efficacy and cost effectiveness of nursing interventions is critical for gaining the attention of reimbursement and policy bodies. Nurses can become successful in obtaining health care dollars for their services only if they have a sound practice based on research. ROLE OF RESEARCH IN NURSING: Nursing research is needed to discover, verify, structure and restructure the professional knowledge through systematic inquiry. Research is the only way to: Build a body of nursing knowledge. Validate improvement in nursing. Make health care efficient as well as cost effective. 1. To mould the attitudes and intellectual competence and technical skills: Nursing is service to individual, families, and therefore society. It is based on arts and sciences which mould the attitude, intellectual competencies and technical skills of individual nurse into the desired and to help people, well or sick and cope with their health needs. 2. Filling the gaps in knowledge and practice: Most of the medical and nurses‘ leaders believe that gap is existing between existing knowledge that is affecting nursing and its application. This gap exists in both nursing education and nursing service. To meet the new challenges, investigate unsolved problems and to scrutinize the changes in nursing. The individual nurse must actively seek to understand and apply the basic principles of research.
104
3. Fostering a commitment, accountability to clientele: The ultimate goal o a profession is to improve the practice of its member so that services provided to clientele should have greatest impact. This can be done by continual development of scientific body of knowledge fundamental to its practice that cans b instrumental in fostering commitment and accountability to profession and clientele. 4. Providing basis for professionalism: Nursing has established itself as a profession. The increasing awareness of nurses to include research as an integral part of professional nursing behavior is rapidly increasing. Nurses are extending base of knowledge as a part of professional responsibility and are endorsing scientific investigations to broaden the body of knowledge. Research provides abstract knowledge that is foundation for establishing nursing as a profession. 5. Providing basis for professional accountability: The quality of nursing care can be improved only if scientific accountability becomes part of tradition. Accountability is essential for nurse teacher in dealing with students, for nurse practioner dealing with patients and for nurse administrator dealing with clients or professionals of health care delivery system. It also includes scientific literature for new knowledge so that application of this knowledge becomes part of nursing practice. 6. Identifying the role of nurse in changing society: Nowadays consumers of health care are recognizing health care as a right than privilege due to spiraling costs of health care so there is a need to evaluate the efficacy of presently existing nursing practices in all areas to modify or abandon the practices that have no effect on health status and provide nursing services acc. to needs of clients. 7. Discovering new measures for nursing practice: Practice oriented research is key to discover for improving nursing practice that will improve the quality of nursing care. Scientific studies are needed to understand, explain the functions and forms of nursing care in meeting the needs of society and helping individuals regain or maintain health. 8. Helping to take prompt decisions by the administration to related problems: Nursing administrators are more frequently looking to the findings from research in solving persistent problems in organization, delivery and evaluation of client or patient care. Research in nursing administration can be useful in organizing nursing personnel in most efficacious manner. 9. Helping to improve the standards in nursing education: Nursing educators utilize the findings from research in structuring programs of study, in developing course contents and in designing methods of teachings. 10. Defining the existing theories and discovering new theories: The primary test of nursing research is to develop and refine nursing theories which serve as a guide to nursing practice and which can be organized into a body of scientific nursing knowledge. So, the research nursing helps the nurse practioners, administrators and educators to understand the phenomena with which they deal and to explain, predict and control the occurrences of phenomena. Research aids nurses to be accountable to patients. Scientific inquires provide information that facilitates effective nursing decisions. Nursing research clarifies the forms and functions of profession in meeting the health needs of the society. 105
NURSES RESPONSIBILITY IN RELATION TO RESEARCH: The Code of Ethics for nurses states ―The nurse participates in the advancement of the profession through contribution of practice, education, administration and knowledge development‖. Ideally every nurse should participate in research, but practically all should use research results to improve their practices. All registered nurses should do the following: 1. Read and interpret report of research in their own nursing fields, so that they can keep up-to-date with current knowledge, and where appropriate, base their own policy and practice on their research findings, to do this they must familiar with research concepts and knowledge. 2. Identify areas of nursing where research is needed, nurses should be aware of the boundaries of their knowledge and situations in which lack of information is a serious detriment to effectual decision-making. 3. Collaborate intelligently with researchers (nurses and others) whose work brings them into contact with nursing, assist them as possible, and particularly where patients are involved, be aware of ethical issues which may not always be apparent to research workers themselves. 4. Discuss with patient any research in which they are being asked to participate in the same way as nurses are called upon to discuss with the patients the diagnostic and therapeutic measures prescribed by medical staff. In addition a nurse teacher must:5. Use research findings as a basis for deciding what to teach and incorporate research findings into their teaching. 6. Use research findings as a basis for deciding hoe to teach, make use of psychological theories of learning and techniques of educational assessment. 7. Plan and supervise student‘s project work in a way which will help the students to develop the ways of thinking, questioning, observing, analyzing and testing which are the elements of research. In addition nurse administrators should: 8. Have information about resources (financial, human, mechanical) available for carrying out research and be able to decide nursing research priorities, to make the best possible use of these resources. 9. Initiate and facilitate research in areas where research is needed provide the appropriate ―climate‖, have sufficient understanding of research methods to know what type of research is appropriate to the investigation of particular problems and from where specialist advice may be sought. 10. Monitor the progress of research project to ensure that the work is being carried out is consistent with the agreed objectives. In addition some nurses should:11. Acquire skill in application of research technique, so that they can make use of existing research tools, e.g. patient-opinionate or question are, personality inventors, to carry out similar studies for themselves. 12. Become trained research workers capable of designing tools for nursing research, of leading unit and multidisciplinary research teams and of taking part in planning and 106
formulating research policy for the nursing and midwifery profession in both intra and inter professional capacity. Thus, every nurse regardless of educational preparation can be involved in and benefit from nursing research. LEVELS OF EDUCATIONAL PREPARATION AND LEVELS OF PARTICIPATION IN NURSING RESEARC Level of preparation H: Level of research participation Student nurse. Consumer. BSC nurse. Problem identifier, data collector. MSC nurse. Replicator, concept tester. Doctoral nurse. Theory generator. Postdoctoral nurse. funded program director. ROLE OF LEADERSHIP AND MANAGEMENT IN NURSING: Nursing is a major component of health care delivery system and nursing services are necessary for every client seeking care of any type including health promotion, diagnosis, treatment and rehabilitation. So the nurses must be good leaders and managers to provide quality care to the patients. LEADERSHIP Leadership is the art of getting others wants to do something you are convinced should be done. The origin of the word lead is ―to go‖. The verb to lead can define in several ways to guide, to run in specific direction, to direct, to be first, and to open play. Leadership can be defined as the process of moving or groups in some direction through mostly noncorrosive means. Gardner (1990) says that the leadership as process of persuasion and by which an individual (or leadership team) induces a group to pursue objectives held by the leader or shared by the leader or shared by the leader and his or her followers. Bennis (2001) says that the leader vision so palpable and seductive that others eagerly sign on. Tourengeau (2003) used a broader definition stating that ―leaders are those who challenge the process, inspire a shared vision, enable others to act, model the way and encourage the heart.‖ A leader is a person who influences and guides direction, opinion and course of action. The leaders: Often do not have delegated authority but obtain their power through other means, such as influence. Have a wider role. Are frequently not parts of formal organization? Focus on group‘s process, information gathering, feedback and empowering others. Emphasizing interpersonal relationships. Direct willing followers. Have goals that may or may not reflect those of the organization.
107
NEED OF LEADERSHIP IN NURSING: As the profession makes big strides forward into the new millennium the need for quality nursing leaders at all levels and in all areas and in all areas of profession is rising. Leaders are needed in hospitals, professional organizations, is community and in educational institutions. There is need to develop leadership skills in nursing because: Raise the consciousness of nurses: The nursing leadership is required to raise the consciousness of nurses through an ongoing critique of present system and to offer philosophical and practical rationales for fundamental change based on nursing values. For team building: Leadership techniques are required for team building at the organizational level, ensuring success in all aspects of nursing and maintaining high quality in areas of nursing services, nursing education and nursing administration as a whole. It is needed to align employees in support of goals, for group interaction and blend efforts of diverse specialties. Foundation block for nursing practice: Leadership skills are foundation blocks for nursing professional practice. Nurses can exercise leadership in various ways. It is not limited to formal role. Nurses may be able to lead at bedside, in client teams and management teams. Increase the body of knowledge: It helps the nurses to increase knowledge of business, human resource, organizational behavior and health care system issues in addition to clinical knowledge and skills. She can practice leadership skills if she knows public speaking project planning, management of resources and developing resolutions and position papers. For advocacy in nursing: Leadership is required to convey the standards and ethics of nursing profession and advocate for and contribute to advances in nursing education. To provide direction: Leadership is required for directing for the staff and people towards common goals by use of assignments, orders, policies, procedures, rules, regulations, standards, opinions, suggestions and questions to direct their behavior. Supervision: It helps in providing supervision and contribution towards continuous growth of supervision by inspecting the work of other nurses and evaluating their performance and approving correct performance. Inspiring the staff: Nursing leadership is required to inspire staff and fulfill their personal and institutional goals, create an atmosphere where one would live and work in a dignified manner. Role model: nursing leader is a role model to set an example by own actions and as an advocate for patients and staff. Nursing leadership can be improved in following ways: Fundamental changes are necessary in our attitude towards risk taking, assertiveness and different in opinion. We need to create environment that would least tolerate diversity of the behaviors, personality differences. o Power at high level: increased recognition of role of nursing has usually come through appreciation of their significant contribution to make towards health. o Prepare nurses for collective bargaining: by removing wide variations in many nursing organizations and associations. 108
o Make INC and state nursing council’s strong and autonomous bodies. o A definite number of nurses to be prepared for top management level: courses for head nurses and nursing superintendent. o Leadership without authority does not get recognition: nursing administrators must have authority to reward as well as to initiate punitive measures to subordinates acc. to need. o Nursing should have say in planning of nursing care of patients and insist change in doctor‘s orders and contribute towards effective patient care. o Team spirit must be encouraged between the staff by enforcing and highlighting of handing over and taking over. o Nurse Managers should be provided with adequate resources such as phone, computers in well maintained office, financial and clerical support that are important symbols of position and leadership. o Nursing education should match with nursing service provided in institute\state. o The professional associations must prepare nurses to be well informed in labor relations, collective bargaining, public relations, legal aspects of nursing, ethical issues and nursing standards, media awareness and use, improvement in interactive skills with doctors, patient and administrator. o To have better coordination and obtain better professional output nursing personnel must be under control of nursing administrator and becomes a self governing autonomous body. ROLE OF NURSING LEADERS: The nurse leaders must: o Widen nursing horizons: it is needed to establish lines of communication with other professionals, sectors, and public and policy makers. Interact with like-minded groups and other professional groups, participate and hold more interprofessional meetings and conferences. o To enhance professional knowledge and skill: take clinical specialization from colleges to hospitals and community, engage in clinical and field based research rater than education related topics, write widely on nursing and about nursing , publish more journals ,newsletters and books. o Strive towards professional autonomy: for nurses have to take and accept more responsibility in practice; take up and encourage independent practice; learn and practice accountability and form network of all nursing organizations. o Need to learn new skills: like public speaking and assertiveness; political influencing and advocacy for health; negotiations, economical and financial management; networking and linking; writing and publication.
MANAGEMENT: The word manages comes from the word ―hand‖. Managing means handling things. Acc. to Joseph Massie (1978): Management is defined as the process by which a cooperative group directs action towards common goals. Acc. to George (1988): Management is distinct process consisting of planning, organizing, actuating, activating, and controlling, performed to determine and accomplish the objectives by the use of people and resources. 109
Acc. to O.Tead: “Management is a process and agency which directs and guides the operations of an organization in realizing established aims.‖ Acc. to James Lunde: “Management is principally the task of planning, coordinating, motivating, controlling the efforts of others towards a specific objective.‖ Managers are basically leaders possessing skills. Leadership is one function of management. Management lays more emphasis on control i.e. control of hrs, costs, salaries, overtime, use of sick leave, inventory and supplies. A manager guides, directs, motivates others and a leader empowers others so it can be said that every manager is a leader. Usually the managers: Have an assigned position within the formal organization. Have a legitimate source of power due to delegated authority that accompanies their position. Are expected to carry out specific functions. Emphasize control, decision making, decision analysis and results. Manipulate individuals, the environment money, time and other sources to achive organizational goals. Have a greater formal responsibility and accountability for rationality and control than leaders. Direct willing and unwilling subordinates. Managers are more often associated improving productivity, establishing order and stability and making things run smoothly. Management is process of getting work done through others. The role of managers is to coordinate the efforts of lower level employees i.e. subordinates to advance the goals of organization. Henri Fayol (1925) first identified the management functions of planning, organization, command, coordination and control. Luther Gulick (1937) explained on Fayol‘s management function in his introduction of seven activities of management-planning, organizing, staffing, directing, coordinating, reporting, budgeting, as denoted by mnemonic POSDCORB. In nursing it can be applied as a nurse manager can spend part of day working on budget (planning), met with staff about changing patient management delivery system from primary care to team nursing (organizing), altered the staffing policy to include 12 hr shifts (staffing), held a meeting to resolve a conflict between nurses and physicians (directing), and gave an employee a job performance evaluation (controlling).
110
FUNCTIONS OF MANAGEMENT:
PLANNING
BUDGETING
ORGANISING
MANAGEM ENT
STAFFING
REPORTING
COORDINA-TING
DIRECTING
Planning: it is working out a broad outline, the things that need to be done and the methods of doing them to accomplish the purpose set for the enterprise. Organizing: it is the building up the structure of authority through which the entire work to be done is arranged into well defined subdivisions and coordination. Staffing: it is appointing suitable persons to the various posts under the organization and the whole of personnel management. It is appointing suitable persons to the various posts under the organization and the whole of personnel management. Directing: it is making decisions and issuing orders and instructions embodying them for the guidance of the staff. Coordinating: it is the interrelating the various parts of the work and eliminating of overlapping and conflict. 111
Reporting: it includes keeping oneself and the subordinates informed through records, research and inspection. Budgeting: it helps the nurse supervisor to set the budget for the nursing services. Problem solving: it helps the nurses to solve the conflicts within themselves by providing different measures of decision making. Manage day to day operations: it helps the nursing supervisor to perform the daily activities like nursing rounds, duty roster preparation etc. Empower staff: it is helping others to become all they are capable of being. It is enabling the individuals to do what they do the best. Maintain quality: it is effective in maintaining the quality of nursing services provided to the patients by evaluating, monitoring or regulating the services rendered to the consumers. Controlling: it helps to set the standards, measuring performance against those standards, reporting the results and taking action. Delegating: it is transfer of certain specified functions by the superior to the subordinates authority. It is assigning responsibility and authority to co-worker and ensuring his accountability. Evaluating: the evaluation is the final step of a programme. It helps needs evaluation to do best of his ability. NEED OF MANAGEMENT IN NURSING: Health care is a business and its success depends on nursing participation in changing system for delivering cost effective care and creating strategies to ensure client receive quality care. Nursing has been required to respond to changing technological and social forces e.g. managerial responsibilities evolved in response to an increased emphasis on business of health care. Because of changing trends in health care delivery the nurse manager role is becoming critical to effective, quality patient care and to confront these expanding responsibilities and demands the nurse manager must take new dimensions to facilitate quality outcomes in patient care and meet the institutional goals and objectives. Nurses irrespective of their primary job must assume responsibility functions that are inherent in every nursing job. The nurses in the past used to follow the directions and orders of administrators and physicians but the changing trends in community needs to produce nursing administrators who think independently and can solve problems as well as direct others in goal setting and achievement. The increasing complexity of delivery of patient care requires nurse to be a good manager and needs to be an effective communicator. The managerial activities include delegation, management of people, time and resources for the achievement of organizational goals. Nurse needs to be manager to manage change, resolve conflicts and making organizational goals, focus on care of patient, support of organization, profession and oneself as a professional. Management in nurses makes the nurses able to understand the conditions promoting and innovating the expression of talent among team members. 112
Management helps the nurses to make decisions in organization and encourage nurses to determine ways to make the delivery system to function at its best. Management skills help the nurses to provide visibility for organizational goals, to mediate conflict, serve as coach, and monitor results. It provides opportunity for persons to manage their own work and give clear directions to nursing personnel. The role of management in nursing is to provide opportunities for managers to manage their own work and give clear directions to nursing personnel to assume responsibility in every area of nursing. CONCLUSION: From the above reasons, the nurses must be prepared to look into matters of research, leadership and management. Managerial concepts are needed by nurses at all levels, focus on how to deal with people, how to manage resources and how to manage one‘s job. Research is needed to change the outlook of nursing profession and widen the horizons of nursing profession.
113
BIBLIOGRAPHY: Basavanthapa BT; Nursing Administration (2005), Edition 1st, published by Jaypee brothers, Page no: 1-3,14-17,114-117. Burns Nancy, Groove K Susan; Understanding Nursing Research (1995), Edition 1st,W B Saunders company; Page No:1-9 Basavanthapa BT; Nursing Research (2005), Edition 1st, published by Jaypee brothers, Page no: 1-38. Marquis L Bessie ,Huston J Carol ; Leadership and Management Functions in Nursing ;Edition 5th;Published by Lippincott, Page no:34-35
114
Quality Assurance in Nursing(INC) Introduction: The field of quality assurance is an old as modern nursing. Florence Nightingale introduced the concept of quality in nursing care in 1855 while attending the soldiers in the hospital during the Crimean war. It is a matter of pride for nurses that the nursing profession has attained a distinct position in the search for quality in health care. Quality is rapidly becoming concern to both consumers and the providers of the services. In health care quality is being demanded and expected and providers are judged by the quality of services. And hence there is a need to sensitize and train nursing personnel to provide quality care Concept of quality in health care: Defining quality is difficult. The expense of quality is an interactive process between customer and provider. The customer does not receive anything tangible, mostly only a piece of paper with a promise for a better future e.g.. Doctors write prescriptions. Quality: Quality is defined as the extent of resemblance between the purpose of healthcare and the truly granted care (Donabedian 1986). In an economic dimension quality is the extent of accomplished relief case with a justified use of means and services (Williamson 1999) Government and those who pay of the care will see quality as a weighing out between results and costs to fulfill certain expectations in health care. Concept of quality assurance: Quality assurance is a dynamic process through which nurses assume accountability for quality of care they provide. It is a guarantee to the society that members of profession are regulating services provided by nurses. Quality assurance is a judgment concerning the process of care, based on the extent to which that cares contributes to valued outcomes. (Donabedian 1982 ). Bull 1985 defined quality assurance as the monitoring of the activities of client care to determine the degree of excellence attained to the implementation of the activities. Quality assurance is the defining of nursing practice through well written nursing standards and the use of those standards as a basis for evaluation on improvement of client care (Maker 1998). In health care quality assurance is being demanded and expected and providers are judged by the quality of services and hence there is a need to sensitize and train nursing personnel to provide quality care. . The purpose and objectives and the suggested training program for nursing personnel to enable them to provide quality care is given below. Purposes: To introduce code of ethics and professional conduct for nurses in India to the nursing personnel To prepare nursing personnel for implementation of quality assurance model in nursing Objectives: At the end of the training program the participant will be able to: State the code of ethics and professional conduct for nurses in India. 115
Recognize the significance of following code of ethics and professional conduct in nursing practice. Explain QAM as pre-requisite for quality nursing care Describe practices standard for nurses and their rationale Identify the legal boundaries for nursing practice Prepare nursing care plan following nursing process approach Appreciate the importance of practicing standard safety measures Identify appropriate communication techniques to be used in given interpersonal situation Plan and conduct patient teaching session Identify appropriate management techniques to be used for managing resources in given situation Appreciate the importance of continuing education and research for development of ‗ self ‗, ‗others‘ and of the ‗profession ‗ Describe the institutional disaster preparedness plan and nurses role Approaches for a quality assurance program: Two major categories of approaches exist in quality assurance they are 1. General. 2. Specific. 1) General Approach: It involves large governing of official body‘s evaluation of a persons or agency‘s ability to meet established criteria or standards at a given time. A.) Credentialing: A person generally defines it as the formal recognition of professional or technical competence and attainment of minimum standards by a person or agency According to Hinsvark (1981) credentialing process has four functional components a) To produce a quality product b) To confer a unique identity c) To protect provider and public d) To control the profession. B.) Licensure: Individual licensure is a contract between the profession and the state, in which the profession is granted control over entry into and exists from the profession and over quality of professional practice. The licensing process requires that regulations be written to define the scopes and limits of the professional‘s practice. Law has mandated licensure of nurses since 1903. C.) Accreditation: National league for nursing (NLN) a voluntary organization has established standards for inspecting nursing education‘s programs. In the part the accreditation process primarily evaluated on agency‘s physical structure, organizational structure and personal qualification. In 1990 more emphasis was placed on evaluation of the outcomes of care and on the educational qualifications of the person providing care.
116
D.) Certification: Certification is usually a voluntary process with in the professions. A person‘s educational achievements, experience and performance on examination are used to determine the person‘s qualifications for functioning in an identified specialty area. 2) SPECIFIC APPROACHES: Quality assurances are methods used to evaluate identified instances of provider and client interaction. A) Peer review committee: These are designed to monitor client specific aspects of care appropriate for certain levels of care. The audit has been the major tool used by peer review committee to ascertain quality of care. B) The audit Process : (Stan hope Han Caster 2000) Follow up of problem Topic study selected Recommendations for correcting deficiencies, explicit criteria selected for quality care. Peer review of all cases not meeting criteria. Records reviewed C) Utilization Review (UR): Utilization review activities are directed towards assuring that care is actually needed and that the cost appropriate for the level of care provided. Three type of Utilization Review (UR) is there: a) Prospective: It is am assessment of the necessity of care before giving service. b) Concurrent: a review of the necessity of care while the care is being given. c) Retrospective: is analysis of the necessity of the services received by the client after the care has being given. U.R has been used primarily in hospitals to establish need for client admission and the length of hospital stay. The UR process includes the development of explicit criteria that serves as indicators of the need for services and length of services. Advantages of utilization review: 1. It is designed to assist clients to avoid unnecessary care. 2. It may serve to encourage the consideration of care options by providers, such as home health care rather than hospitalization 3. It can provide guidelines for staff of program development. 4. It provides a measure of agency accountability to the consumer. The major disadvantage to UR is that not all clients are fit for the classic picture presented by the explicit criteria that serves as the basis for approval or denial of care. D) Evaluation Studies: Three major models have been used to evaluate quality they are:1. Donabedian’s structure- process-outcome model 2. The tracer model 3. The sentinel model Donabedian introduced 3 major method of evaluating quality care. a) Structural evaluation: This method evaluates the setting and instruments used to provide care such as facilities, equipments and characteristics of the administrative organization and qualification of the 117
health providers. The data for structural evaluations can be obtained from the existing documents of an agency or from an inspector of a faculty. b) Process evaluation: This method evaluates activities as they relate to standards and expectations of health provider in the management of client care, data for this can be collected through direct observations of provider encounters and review of records, audit, check list approach and the criteria mapping approach are used to establish the client encounter protocol. c) Outcome Evaluation: The net changes that occur as a result of health care or the net results of health care. The data of this method can be collected from vital statistical records such as death certificates or telephone client interviews, mailed questionnaire and client records. The Tracer method: is a measure of both process and outcome of care. To use the tracer method, one must identify a volume of client with a particular characteristic resuming specific health care management. Physicians and nurse practitioners, to identify persons with certain illness such as HTN, ulcers, UTI and to establish criteria for good medical and nursing management of the illnesses have used the tracer method. This method provides nurses with data to show the differences in outcome as a result of nursing care standards. The Sentinel method: It is an outcome measure for examining specific instances of client care the characteristics of this method are, a) Cases of unnecessary disease, disability deaths are counted. b) The circumstances surrounding the unnecessary event or the sentinel is examined in detail. c) In review of morbidity and mortality are used as an index. d) Health status indicator such as changes in social, economic, political and environmental factors are reviewed which may have an effect on health outcomes. Client satisfaction: Client satisfaction can be assessed using person or telephone interviews and mailed questionnaire. Data from client satisfaction surveys are used to measure structure, process and outcome of care givers. Incident review: During a patient‘s hospitalization several incidents may occur which have a bearing on the treatment and patients final recovery. The critical incidents may be:- Delayed attendance by a physician /nurse. - In correct medications. - Lack of cleanliness and asepsis leading to infection. - Carelessness in carrying out nursing procedures e.g. Hot and cold applications. The report should contain the name, age exact time and place, description of how it occurred any precaution taken, conditions of patient before and after the incident etc since these reports are of legal value it should be written carefully given importance to all the details and should be filed safely. Risk management: It can be defined in a program that is developed for propose of eliminating or controlling health care situations that has the potential to inure endangers or create risk to clients. The philosophical intent of such a program would be to do the client no harm that is to 118
administer safe care of whichever clients, groups or populations are being served. Risk management activities are directed towards the identifications, analysis and evaluation of situations to prevent injury and subsequent financial loss. Malpractice litigation: It is a specific approach to be imposed on the health care delivery systems by the legal systems. Malpractice litigation results from client dissatisfaction with the provider and with the content of care received. Quality improvement: Principles and Conditions for total Quality Management Principles: - Continuous quality improvement. - Knowledge of customer expectation needs. - Processes of customer supplier relationship. - Belief in people. - Statistical analysis. - Costs of poor quality. Conditions in the work environment: - Employer involvement. - Improvement. - An environment that supports risk taking. - Team work. - Data collection and analysis skills. - Group interaction skills. - Structure and management to enable improvement. - Tools to facilitate the improvement. Framework for quality: Quality in Nursing Practice: The joint commission on Accreditation of health care organizations (JCAHO) 1997 defines quality improvement (QI) as an approach to the continuous study and improvement of the process of providing health care services to meet the needs of clients and others. Steps in quality improvement: 1) Quality defined: Before the nurse manager and staff can measure trends in nursing practice, they first must know the standards or guidelines that define quality. Professional standards: They are authoritative statements used by the profession in describing the responsibilities for which its practitioners are accountable (Peters 1995) A) Policies: Policies are non-negotiable aspects of practice that allow for no professional judgment or interpretation is their implementation (Peters 1995) E.g. Professional dress policy, informed consent, advanced directives. B) Job descriptions: defined as the qualifications and responsibilities for individuals within a position or job category. E.g. Clinical director, staff nurse etc. 119
C) Outcomes: Outcomes are the conditions to be achieved as a result of care delivery. An outcome tells whether interventions are effective, whether clients progress, how well standards are being met, and whether changes are necessary. a) Professional outcome: a measure of the professional caregiver performance. b) Client outcome: a measure of client status after receiving care. c) Developing quality improvement team: This team composed of staff from all departments within a hospital. Components of Q.I programs: JCAHO’s 10 steps for Q I 1. Establish responsibility and accountability for a Q.I program. 2. Define the scope of service for a clinical area 3. Define the key aspects of service for the clinical area. 4. Develop quality indicators to monitor the outcomes and appropriateness of care delivered. 5. Establish thresholds for evaluation of indicators. 6. Collect and analyze data from monitoring activities. 7. Evaluate results of monitoring activities to determine the need for change in practice. 8. Resolve problems through development of action plans. 9. Reevaluate to determine if the plan was successful 10. Communicate Q.I results to the organization MODELS OF QUALITY ASSURANCE: 1) A System Model for implementation of unit Based Quality assurance: The implementations of the unit based quality assurance program, like that of any other program, and involve making changes in organizational structure and individual roles. One method of facilitating and structuring the change process is the system approach in which the task is broken down into manageable components based on defined objectives. The basic components of the system are 1. Input. 2. Throughput. 3. Output. 4. Feedback. Previous Quality assurance program: Structural change process Unit based quality assurance program System model for unit based quality assurance (from Wayne P.I Quality Assurance Unit based approach 1984). The input can be compared to the present state of systems, the throughput to the developmental process and output to the finished product. The feedback is the essential component of the system because it maintains and nourishes the growth. The boundaries of the system define its integration in the environment is to the other tasks and goals of nursing department, to the process of nursing science in relation to evaluation. Their boundaries should be semi-permeable so that they allow necessary information and energy into and out of the change process.
120
2) American Nurses Association Model: The ANA has developed QA model in 1977 which has wide spread applicability in any healthcare setting and can be used as guide to implement QA program. The first step in developing QA program is continuing education. Many staff nurses and supervisors have not been prepared in the academic setting to develop standards of practice when a quality assurance program is implemented, the continuing education needs of all staff should be ascertained. Quality is not assured if only a small committee evaluates care and understands quality assurance program. 3) ANA Quality Assurance Model: ANA quality Assurance Model (from Susan Clemens, Diana Geeber: Comprehensive, family and community health nursing, 3rd edition Pg. 851). The basic components of the ANA model can be summarized as follows:1) Identify values 2) Identify structure, process and outcome standards and criteria 3) Select measurement 4) Make interpretation 5) Identify course of action 6) Choose action 7) Take action 8) Reevaluate 1) Identify Value: In the ANA value identification looks as such issue as patient/client, philosophy, needs and rights from an economic, social, psychology and spiritual perspective and values philosophy of the health care organization and the providers of nursing services. 2) Identify structure, process and outcome standards and criteria: Identification of standards and criteria for quality assurance begins with writing of philosophy, an objective of organization. The philosophy and objectives of an agency serves to define the structural standards of the agency. Standards of structure are defined by licensing or accrediting agency. Another standard of structure includes the organizational chart, which shows supervisory methods, communication patterns, staff patterns and sometimes staff assignments. A group internal or external to the agency does evaluation of the standards of structure. The evaluation of process standards is a more specific appraisal of the quality of care being given by agency care provides. An agency can choose to use the standards of care set forth by the providers, professional organization such as the ANA nursing standards or the agency can use the nursing process and apply it to the activities of the nurses as the activities correspond to the procedures of care defined by the agency. The primary approaches for process evaluation include the peer review committee and the client satisfaction survey. The techniques included are direct observation, questionnaire, and interview, written audit and videotape of client and provide encounter. The evaluation of outcome standards reveals the end results of nursing care. To be able to identify the net changes in the client‘s health status as a result of nursing care will give nursing profession data to show the contributors of nursing to the health care delivery system. Research studies using the tracer method or the sentinel method to identify client outcomes and client satisfaction surveys are approaches that may be used to evaluate 121
outcome standards. Technique used in client classification systems that are admission data of the clients, level of dependence or problems and discharge data that may show changes in the level of dependence. 3) Select measurement needed to determine degree of attainment of criteria and standards: Measurements are those tools used to gather information or data, determined by the selections of standards and criteria.The approaches and techniques used to evaluate structural standards and criteria are, nursing audit, utilization‘s reviews, review of agency documents, self studies and review of physicals facilities. The approaches and techniques for the evaluation of process standards and criteria are peer review, client satisfactions surveys, direct observations, questionnaires, interviews, written audits and videotapes. The evaluation approaches for outcome standards and criteria include research studies, client satisfaction surveys, client classification, admission, readmission, discharge data and morbidity data. 4) Make interpretations: The degree to which the predetermined criteria are met is the basis for interpretation about the strengths and weaknesses of the program. The rate of compliance is compared against the expected level of criteria accomplishment. 5) Identify Course of Action: If the compliance level is above the normal or the expected level, there is great value in conveying positive feedback and reinforcement. If the compliance level is below the expected level, it is essential to improve the situations. It is necessary to identify the cause of deficiency. Then, it is important to identify various solutions to the problems. 6) Choose action: Usually various alternative course of action are available to remedy a deficiency. Thus it is vital to weigh the pros and cons of each alternative while considering the environmental context and the availability of resources. In the recent findings if more than one cause of the deficiency has been identified; action may be needed to deal with each contributing factor. 7) Take Action: It is important to firmly establish accountability for the action to be taken. It is essential to answer the questions of who will do. What? By when? This step then concludes with the actual implementation of the proposed courses of action. 8) Reevaluate: The final step of QA process involves an evaluation of the results of the action. The reassessment is accomplishment in the same way as the original assessment and begins the QA cycle again. Careful interpretation is essential to determine whether the course of action has improved the deficiency or the deficiency was remedied, positive reinforcement is offered to those who participated and the decision is made about when to again evaluate that aspect of care. If the deficiency is not remedied, the problem solving process is repeated Developing quality indicators: A quality indicator is a quantitative measure of an important aspect of service that determines whether the service conforms to established standards or requirements. The 122
quality indicator is the focus for the quality improvement program, with the staff monitoring criteria that will show whether indicator standards have been met. There are three types of indicators- Structure, process and outcome. Structure Indicators: Evaluate the structure or systems for delivering care .An example is adherence in checking if emergency casts are adequately stocked or if forms documenting restraint use are completed correctly. Process Indicators: Evaluate the manner in which care is delivered (E.g. the process of pain assessment, recovery of clients from sedation and client‘s referral to community services). Outcome indicators: Evaluate the end result of care delivered E.g.: incidence of noos cromial infection and adherence to medication therapy. Outcomes are the most important in any quality improvement program, but structural and process indicators cannot be ignored. Processes of care are obviously closely related to outcomes and the structure, in which a process occurs, enhances or hinders the effectiveness of care (Donabedian 1988). When a unit-based team selects a quality improvement indicator, it is important that the indicator be relevant. It is often appropriate to measure a process as well as the expected outcome, to know if standards of care are being met. E.g.: In a medicine unit, staff may choose to measure their success in implementing the process of diabetes Instructions early while also measuring the outcome of whether clients learn to administer insulin correctly. When a unit based team sits-together to select quality indicators for a quality project, it helps to ask what processes and related outcomes are in need of improvement and are most likely to make a significant contribution to how nursing care is being practiced. Processes to improve may include the following. A weak process that is causing problems (E.g.: poor pain management for clients with sickle cell anemia). A stable process that is adequate, but that can benefit for improvement (E: calculating time for ambulatory surgery clients). A process linked to negative outcome (E.g.: care of intravenous access sets with the occurrence of phlebitis. Establishing Thresholds for Evaluation: After selecting a quality indicator, staff members must determine ways to quantitatively measure the indicator. The occurrence of an indicator or the percentages of times the indicator is observed (E.g.: the number of clients having surgery who can successfully explain their discharge instructions) is a common measure. A threshold is a standard for determining whether a problem exists. A measurement that falls below the threshold indicates problems. Staff will then thoroughly review the factor interfering with successful client education and adherence. When quality is an ongoing process staff continuously work to improve outcomes or performance by raising thresholds. It is important to understand that almost all processes have variation. For e.g.; consider the process of diabetic instruction and the associated outcome of clients administering insulin. Possible variations in the process might include the time when teaching begins, materials used in instruction and learner motivation. 123
Outcome variations might include accuracy in injections site selection and proficiency in preparing the insulin in a syringe. Setting specific thresholds may not always be achievable. The intent in any quality improvement program is to seek ways to continuously improve. This includes defining the acceptable level of performance and allowing for normal variability. Data collection and Analysis: The process of data collection and analysis can be simple or complex. The importance however is in obtaining accurate results that help in making appropriate decisions regarding quality issues. Many organizations have made quality improvement so important that formal research studies are conducted. In this case the process of data collection and analysis is very formal and well designed. Statistical techniques are used to determine if problems that have been identified are significant. Similarly if a quality improvement project involves the introduction of a new practice or procedure, statistics can show whether the improvement made a significant difference in outcomes. When formal research is not conducted, staff may become involved in simple evaluation studies involving the collection of data on frequencies and percentages for a predetermined number of clients or cases. Evaluation studies offer valuable information on practice trends and whether problems are evident. What is important in data collection is to collect data on the right criteria and to then have adequate data from which to make decision. Quality improvement teams usually have access to resources within three organizations that can help determine how much information is needed for QI analysis. Evaluation of Care: Monitoring of quality indicators evaluates whether a specifically defined process reaches desired outcomes. If results exceed or meet a threshold or if performance is within controls for a process, no problem has been identified and process is performing well. When thresholds for satisfactory care are not met or when performance is below the control limits set, staff must try to find the cause of problems. When a process is not working well, one of the models for QI (E.g. FOCUS PDCA) may be used. This allows the staff to find the aspect of process to improve, organize an expert team who knows the process, clarify knowledge about the process, understand any sources of variation and select an improvement or solution. The process may take several team meetings before the group can agree on the actions to take. In the case of diabetic instruction, it would be important to have staff nurses, dieticians, diabetes nurse specialists and pharmacists involved as a part of QI team. Once the problem is identified, additional team members may be needed. The team collaborates to discover what are the factors associated with practice problems. Eventually the team recommends approaches for improving the process with the goal of achieving desired outcomes. Resolution of Problems: After evaluating quality problems, staff develop action plans to improve the process and outcomes. It is important to establish actions that will be successful. E.g. the action of merely notifying staff that a problem exists is unlikely to change practice or improve outcomes. An action plan should be more direct. In FOCUS PDCA, staff plans the action or improvement to make do or implement the change, check or analyze results of change and then act on the findings. 124
E.g. The Q.I team may discover that clients are not administrating insulin correctly because they do not have all of the necessary information (Staff are not beginning teaching as soon as clients learn that insulin will be a form of therapy. Staff is also found to have trouble acquiring necessary teaching materials for instruction). In this case the team may recommend having the pharmacy send instructional materials when insulin is sent to the unit and having a clinical pharmacist assist with instruction on insulin therapy. The staff nurses and nurse specialist may develop a practice protocols that outlines specific content to teach until the client learns to administer injections. Collectively the team may develop innovational approach that is designed to get appropriate information to clients more quickly and efficiently so that learning can take place. Evaluation of Improvement: After implementing an action plan, the staff must reevaluate its success. In the E.g. Staff members may repeat monitoring of the teaching process and the results of client testing to see if improvement has been made. The change may be positive or negative. Communication of Results: The results of QI activities must be communicated to staff in all appropriate organizational departments. If findings and results are not communicated, practice changes will likely not occur. Regular discussions of QI activities through staff meetings, newsletters and memos are examples of communication strategies. Often a QI study reveals information requiring organization wide change. In this case the organization must be responsible for responding to problem with the resources needed to make changes. Revision of policies and procedures, modification of standards of care and implementation of system changes are examples of ways that an organization may respond. Factors affecting Quality Assurance in Nursing Care: 1) Lack of Resources: Insufficient resources, infrastructures, equipment, consumables, money for recurring expenses and staff make it possible for output of a certain quality to be turned out under the prevailing circumstances. 2) Personnel problems: Lack of trained, skilled and motivated employees, staff indiscipline affects the quality of care. 3) Improper maintenance: Buildings and equipment‘s require proper maintenance for efficient use. If not maintained properly the equipment‘s cannot be used in giving nursing care. To minimize equipment down time it is necessary to ensure adequate after sale service and service manuals. 4) Unreasonable Patients and Attendants: Illness, anxiety, absence of immediate response to treatment, unreasonable and uncooperative attitude that in turn affects the quality of care in nursing. 5) Absence of well informed population: To improve quality of nursing care, it is necessary that the people become knowledgeable and assert their rights to quality care. This can be achieved through continuous educational program.
125
6) Absence of accreditation laws: There is no organization empowered by legislation to lay down standards in nursing and medical care so as to regulate the quality of care. It requires a legislation that provides for setting of a stationary accreditation / vigilance authority to a) Inspect hospitals and ensures that basic requirements are met. b) Enquire into major incidence of negligence c) Take actions against health professionals involved in malpractice 7) Lack of incident review procedures: During a patient‘s hospitalizations reveal that incidents may occur which have a bearing on the treatment and the patients‘ final recovery? These critical incidents may be a) Delayed attendance by nurses, surgeon, physician b) Incorrect medication c) Burns arising out of faulty procedures d) Death in a corridor with no nurse / physician accompanying the patient etc. 8) Lack of good and hospital information system: A good management information system is essential for the appraisal of quality of care. a) Workload, admissions, procedures and length of stay b) Activity audit and scheduling of procedures. 9) Absence of patient satisfaction surveys: Ascertainment of patient satisfaction at fixed points on an ongoing basis. Such surveys carried out through questionnaires, interviews to by social worker, consultant groups, and help to document patient satisfaction with respect to variables that are a) Delay in attendance by nurses and doctors. b) Incidents of incorrect treatment 10) Lack of nursing care records: Nursing care records are perhaps the most useful source of information on quality of care rendered. The records. a) Detail of the patient condition. b) Document all significant interaction between patient and the nursing personnel. c) Contain information regarding response to treatment. d) Have the dates in an easily accessible form. 11) Miscellaneous factors: a) Lack of good supervision. b) Absence of knowledge about philosophy of nursing care. c) Lack of policy and administrative manuals. d) Substandard education and training. e) Lack of evaluation technique. f) Lack of written job description and job specifications. g) Lack of in-service and continuing educational program. Quality assurance model in india: Nurses who are trained as per Indian nursing council regulations and registered with state nursing registration councils are safe to provide care Inc has developed a quality assurance program for nurses in India. The program is expected to develop mechanisms for ensuring quality of nursing practice. 126
Quality assurance model in nursing: Quality assurance model in nursing is the set of elements that are related to each other and comprise of planning for quality development of objectives setting and actively communicating standards developing indicators, setting thresholds, collecting data to monitor compliance with set standards for nursing practice and apply solutions to improve care Philosophy of Quality Assurance Model In Nursing: Indian nursing council believes that nurse will: Do good for person /receiver of care, do no harm, maintain respect for life and human dignity, believe in human justice and fairness to individuals in terms of access to resources and care and protect the vulnerable Have moral obligation to provide services as per the prescribed of the regulatory body / health care system/ organization /institution even if it is in conflict with her personal beliefs and values Be responsible and accountable for providing quality care in line with set standards. Be committed to understanding of dynamic nature of her / her role in interdisciplinary health team Be obliged to create public awareness and consider social expectations before making decisions for providing nursing care Be obliged to include receiver in making choices in planning and implementation of care Work in conjugation with legislation, accreditation and political system Have obligation to promote education of self and others Be committed to advancement of profession Nurse is expected to practice in adherence to existing health care delivery system at national / state and institutional level within the framework of QUALITY ASSURANCE MODEL in nursing Purpose of quality assurance model: To ensure quality nursing care provided by nurses in order to meet the expectations of the receiver, management and regulatory body It also intends to increase the commitment of the provider and the management Goals of quality assurance model: Develop confidence of the receiver that quality care is being rendered as per assurance. Develop commitment of the management towards quality care. Increase commitment of providers to adhere to set standards for nursing practice and strive for excellence. Strengthen documentation of nursing care. Promote optimum utilization of resources in providing cost effective nursing care Quality assurance setting standards For more than 100 years, an author has written about the evaluation of nursing practice as a process with minimal elements of:1. Setting standards. 2. Comparing nursing practice to such standards. 3. Instituting changes to increase the adherence to the standards. 127
Evolution of standards: The first to write about standards in English language was Florence Nightingale whose notes on nursing what it is and what it is not was first published in England in December 1859. In it she frequently called for change to achieve high standards. Nightingale developed a multitude of standards of nursing care in the 19th century whether a family member as someone far such service provided the care. Notes on nursing have standards regarding. Noise and its control around sick. Consistency of food and when it should be served. Type of bed and mattress to be used, as well as prospects about the bed linens Position of the bed in relation to windows so that the patient can look out. Cleanliness of the room. Personal cleanliness. Though Nightingale made no comparison between her standards and the existing conditions, within 6 months she reduced the mortality to 2%. In other words a quality assurance as quality control process was used. Much has been done since that time to isolate the concept of setting standards from the larger process of evaluation. Establishing schools of nursing after 1873 was quite an indirect approach in terms of setting standards for practice and meaning improved compliance. Almost two decades after schools of nursing has been established. Efforts were again made to set standards for them. This in turn improved the care of side in the hospitals, because schools of nursing were intimately associated within the hospitals. Elbridge addressed the quality of nursing care in 1932 predominantly in terms of the quality of care given by students in hospitals. She defined quality of nursing care in terms of the quality of care given by students in hospitals. She defined quality of nursing care in terms of outcomes of nursing practice although not in the measurable outcomes used today. After the World War II the attention was again focused on establishing standards and upgrading nursing care. In the 1950‘s as the nursing process emerged, as an identifiable entity with the specific elements evaluation of care was almost always included as a step in nursing process. Orlando identified function, process and principles of professional nursing. She stressed on the evaluation of nursing process. Carrier and Sitzman in 1971 included evaluation as the final point in the six-step process of the nursing care plan. In 1973 the ANA legitimized the nursing process. Thus started the era for the evaluation of the nursing profession for better quality care of the patient and quality assurance of the profession itself. STANDARDS: Definition: Standard is an established rule as basis of comparison in measuring or finding capacity, quality context and value of objects in the same category. Standard is a broad statement of quality. It is a definite level of excellence as adequately required, aimed at or possible. Standard is a predetermined baseline condition as level of excellence that comprises a model to be followed and practiced. It is used as a measurement tool. Professional Standards of Nursing Practice: Professional standards of nursing practice as established by professional nursing organization exist to guide the nurse in providing case. 128
A standard in a model of established practice, which has general recognition and acceptance among, registered professional nurses and is commonly accepted as correct standards of practice, are agreed on levels of competence as determined by the ANA and specially nursing organizations [ANA, 1996].
Standards are defined as authoritative statements that describe a common level of care as performance by which the quality of practice can be determined or measured. Standard help define professional practice (Hubes 1996). Importance of standards in Nursing: It is an authoritative statement by which the quality of nursing practice, service and education can be judged. In nursing practice, standards are established criteria for the practice of nursing. It is a guideline and a guideline far is a recommended path to safe conduct an aid to professional performance. It provides a baseline for evaluating quality of nursing care, increase effectiveness of care and improve efficiency. Standard, help supervisors to guide nursing staff to improve performances Standards may help to clarify nurses, Area of accountability Standards may help nursing to clearly define different levels of care Standard is a device for quality assurance as Quality control. Purposes of standards: The purposes of publishing, circulating and enforcing nursing care standards are to Improve the quality of nursing Decrease the cost of nursing Determine the nursing negligence Characteristics of standards: 1. Statement must be broad enough to apply a wide variety of settings. 2. Must be realistic, acceptable and attainable. 3. Members of the nursing profession must develop nursing care. 4. Must be understandable and stated in unambiguous term. 5. Must be based on current knowledge and scientific practice. 6. Must be reviewed and revised periodically. 7. Must be directed towards an optimal standard. NURSING CARE STANDARDS can be divided into ends and means standards 1. End Standards: The end standards are patient oriented; they describe the change as desired in a patient‘s physical status or behavior. 2. Mean Standards: The mean standards are nursing oriented, they describe the activities and behavior designed to achieve end standards. End standards require information about the patients. A mean standard calls for information about the nurses‘ performance. NURSING CARE STANDARDS can be classified according to frame of references, relating to nursing structure, process and outcome.
129
1. Structure standard: A structural standard involves the setup of the institution. The philosophy, goals and objectives, structure of the organizations, facilitates and equipment and qualifications of employees are some of the components of the structure of the organization. Example, recommended relationship between the nursing department and other departments in a healthy agency are structural standards, because they refer to the organizational structure in which nursing is implemented. It includes people, money equipment, staffing policies etc. The use of standards based on structure implies that if the structure is adequate, reliable and desirable, standard will be met as quality care will be given. 2. Process Standard: Process standards describe the behaviors of the nurse at the desired level of performance. A process standard involves the activities concerned with delivering patient care. These standards measure nursing action or of actions involving patient care. The standards are stated in action verbs that are in observable and measurable terms. E.g.: the patient demonstrates. The focus is on what was planned, what was done and what was communicated as recorded. In process standard there is an element of professional judgment i.e. determining the quality as the degree of skill. It includes nursing care technique, procedures, regimens, and processes. 3. Outcome Standards: Descriptive statements of desired patient care results are outcome standard, because patients‘ results are outcome of nursing intervention. An outcome standard measures changes in the patient health status. This change may be due to nursing care, medical care or as a result of variety of services offered to the patient. Outcome standards reflect the effectiveness and results rather than the process of giving care. Thus structural standards are agency or group oriented, process standards are nurse oriented and outcome. NURSING AUDIT Introduction: Quality in product services, is the demand of the day as per a famous statement .You cannot insert quality into the product; quality must be built into the product as service. The level of quality is determined at the point of service, which is experienced and perceived by the clients and reflected through the audit process. History of Nursing Audit: Before 1955 very little was known about the concept of Nursing Audit. George Groward a physician was the first one to pronounce the term medical audit in 1918. Ten years later Thomas. R. Pondon HD established a method of Medical Audit based on procedures used by financial account. The 18th report of Nursing Audit of the hospital published in 1995. Definition: According to Ganong & Ganong; Nursing audit is a method for assuring documentation of the quality of nursing care in keeping with the standards of the agency, the nursing department, and the professional, governmental and accrediting groups. According to Phaneuef (1976). 130
A method for evaluating quality of care through appraisal of nursing process as it is reflected in the patient care records for discharged patients. According to Eclison: Nursing audit refers to assessment of the quality of clinical nursing. Purposes of Nursing Audit: 1. Necessitating adequate documentation of nursing care provided to the client through the entire nursing process. 2. Directing attention to the design and utility of the charting record. 3. Encouraging the use of the problem oriented nursing system. 4. Supporting and becoming an integral part of nursing by objective program 5. Facilitating the co-operative planning and delivery of client care by physicians and nursing employees. 6. Increasing the priority for results oriented performance evaluation program for nursing service employees. 7. Enriching and providing direction to in service education effects. 8. Providing a specific management technique in carrying out evaluation and control function. 9. Identifying ways to improve patient care. 10. Providing a meaningful ways for nursing staff members to participate and achieve career growth. Concept Of Nursing Audit: Nursing Audit mainly comprises of 1) Debit 2) Credit I. Debit: Debit is all negative activities in nature e.g. Hospital infection. II. Credit: Credit mainly involves all positive activities in nature E.g. Satisfactions of care. Debit Items of Nursing Audit: 1. Death of the client not justifiable as otherwise could have been prevented. 2. Complications due to the neglect of nursing care. 3. Complications of diseases leading to morbidity. 4. Hospital infection. 5. Errors in treatment. 6. Clients discharged against medical advice. 7. Absence of total client care. 8. Lack of application of nursing process. Credit Items in Nursing Audit: i) No. of recovered patients. ii) Shortens stay in the hospital. iii) Expansion of health knowledge in client population. iv) Research as need for problem oriented care approach. v) Regular follow up in the community. vi) Measures to improve the public image. 131
vii) Well maintained nursing audit AUDIT CYCLE: Set standards Implement Audit Cycle Observe practice Change Compare with standard 2. Measurement of Actual Practice against Criteria This means to secure the charts from medical records (possibly by random selection, collect the necessary data, measure the result against set standards. 3. Evaluation of the results 4. Action taken to correct deficiencies 5. Follow up and reassessment 6. Report to nursing service administration and needed staff Types Of Nursing Audit: The nursing audits are mainly of two types 1. Concurrent audit 2. Retrospective audit 1. Concurrent Audit: The concurrent audit has also been called as the open chart audit because it is done while the patient is receiving care. It is a process audit that evaluates the quality of ongoing care being perceived by clients by looking at the nursing process. 2. Retrospective Audit: Refers to an in-depth assessment of the quality, after the client has been discharged, having the client chart as a source of data. Focuses on 2 factors: Discharge status and complications .The 3 components of discharge status are: Heath, Activity, Knowledge. Other Types of Nursing Audits: (i) Structure audit: The inspection of the management process as carried out and documented by the nurse manager. (ii) Process audit: In this type of audit inspection of the nursing process, as carried out and documented by staff nurses to evaluate competence with established standards of nursing care. (iii) Outcome audit: It mainly identifies client outcomes (satisfactory and unsatisfactory and the patterns of nursing care that appears to be responsible. Example Of An Audit Summary: To: Ward or unit: Date: From: Audit Committee Signed Chairman. Re: Audit Topic. Quality Control Check of Nursing Process. - Number of open charts audited. - Number of clients observed / interviewed. - Number of personnel observed / interviewed. 132
Advantages Of Nursing Audit: - Method of measurement. - Functions are easily understood. - Scoring system is fairly simple. - Results are easily understood. - Assess the work of all those involved in recording case. - May be useful tool as part of a quality assurance program in area where accurate records of case are kept. Disadvandages Of Nursing Audit: - It is not so useful in areas where the nursing process has not been implemented. - Many components overlap making analysis difficult. - It is time consuming. - Requires a team of trained auditors. - Deals with a large amount of information. - Only evaluates record keeping.
133
BIBLIOGRAPHY: Barbara Cherry, Contemporary nursing issues trends and management, Mosby publication. 2nd Edition Page 419. Basavanthappa B.T, Nursing Administration, 1st Edition 2000, Jayper Brothers Page: 161, 435 - 438. Ganong J.M and Ganong W.L, Nursing Management 2nd Edition 1980, Aspin Publication Page 96 - 97: 194, 207. Laura Mae Dongla. The effective nurse leader and manager, 4th edition, Page 193 196. Stanhope (1988), Community Health Nursing Process and Practice for promoting health Mosby publication. Page 233, 347, 447-448. Schroeder Patricia S and Maibusel Regena M, Nursing quality Assurance, 1984, Aspen Publication, London Page 193 - 199. Stevens J Nursing Management 1996, Mosby Publications New York. JOURNALS: Andrades, Christine, 2000 Importance of Clinical audit in the prevention and control of hospital acquired infection? Asian Journal of Cardio Vascular Nursing 10 (2): 9 13. Brar A, 1989 and evaluation of patient cax, The Nursing Journal of India. New Delhi Vol. LXXX No. 10: 268, 269. Khan G. August 1999, Factors affecting quality assurance in nursing care Nursing Journal of India Vol. LXXXX No. 8, Page 173, 174. Moree K, what nurses learn from nursing audit, Nursing outlook, January 1988, 26 (1) 48. S.Sridhar. Quality assurance in nursing Indian Journal of Nursing and Midwifery Vol. 2 Sept 1988. Indian Nursing Council (2006), Teaching Material For Quality Assurance Model: Nursing Edition 1ST, Indian Nursing Council Publications Page 8,9
134
FUTURISTIC NURSING Introduction: Many new trends in nursing are likely to develop in the near future. Some can predicted with certainly while others may be unexpected these trends of the future will result from very rapid changes take place in all areas of life. You will have to make a constant effort to keep informed through all available sources. It is the only way which will help you to know what is happening at present and what may come in the near future. Modern Nursing: The art of using the latest technology and science to promote quality of life as defined by patients and families throughout their life experiences from birth to the end of life. Aspects of future of Nursing: Nursing Education Nursing Services NURSING EDUCATION: Future directions for nursing Education: In 1993, three major organizations issued statements and reports about nursing education for the twenty first century. Their reports addressed the new directions of nursing education needed to take in the future. Although the three organizations advocated somewhat different approaches and strategies, several common themes emerged in their reports common emphasis included the following eight points. These eight areas of emphasis remain as important today as they were first identified in 1993. 1. Schools should recruit diverse students and facilities that reflect the multicultural nature of society. 2. Curricula and learning activities should develop student‘s critical thinking skills. 3. Curricula should emphasize student‘s abilities to communicate from interpersonal families and inter disciplinary colleagues. 4. The number of advanced practice nurses should be increased and curricula should emphasize health promotion and health maintenance skills for all nurses. 5. Emphasis should be placed on community–based care increased accountability state of the art clinical skills and increased information management skills. 6. Cost effectiveness of care should be focus in nursing curricula. 7. Faculty should develop programmed that facilitate programmed articulation and career mobility. 8. Continuing faulty development activities should support excellence in practice teaching and research. Future direction for medical education: The University of Queensland hosted the first Australian National Medical Education Colloquium in August 2005. The priority directions for medical education identified by plenary speaker were:1 Student centered learning. Adaptivecurriculum. TeachingInnovations. System approach. Finless to practice. MedicalEducation. 135
Student centered learning: Harden highlighted the importance of student centered learning as being pivotal to thinking about learning and teaching the suggested that medical institutions includes a bank of learning objects (e.g. x-ray images, videos) curricula maps, virtual patients and guided learning that is responsive to the learning needs of individual students. Adaptive Curriculum: An adaptive curriculum modifies and personalizes learning by designing teaching and learning experiences in response to the specific needs of the individual students. Harden explained that concepts of ―just for me learning‖ and ―just in time learning‖ are accommodated by technology when the learner is ready the teacher will appear via technology. Teaching Innovations: Innovations in medical education extend to curriculum technology assessment and professionalism. The curriculum model of the future should be student centered problem or task based, inter professional, community based and elective driven with core and student selected components. System Approach: Aretz stressed the need for medical education programs to prepare gradates who are responsible to both the needs to the health system in which they will function and needs of patients they will treat currently medical students spend most time in teaching hospitals but they will eventually work in the community, where most patients present and are treated. Fitness to practice: According to Walton, fitness to practice is an issue with which all medical schools are currently grappling overall we are probably handling the issues of knowledge and clinical skills quite well. There is still debate about what it really means what its components are and what we need to do much better. Medical Education Research: In order to validate the effectiveness of new teaching approaches medical education research must emphasis appropriate methodology. Parideaux said that very little research is undertaken of our teaching programs in medical schools. He challenged to make medical education research in integral part of their school service. NURSING SERVICES By the year 2020- less than 15 years from now a study from occupational Health and Safety Administration predicts that the need for registered nurses in nursing homes will increase 66% for licensed practical and vocational nurses by 72% and the need for certified nursing assistants will increase by 69%. For nurses working in home health settings which include ‗managed care‘ nursing home settings- those numbers are even higher will above 250% increase at every level of licensing. On site Nurse in Senior Housing: Many senior don‘t need round the clock nursing care, but do need some nursing supervision. Senior housing communities often have an onsite nurse who is available in case of an emergency. The nurse on site will also often consult with doctors to help and manage any medical care that they need. 136
Regents Blue Ribbon Task Force on the future of Nursing: In April 2001, New York State Board of Regents named a Blue Ribbon Task Force on Future of the Nursing, chaired by Regent Diane. The Regents Blue Ribbon Task Force has a critical role in addressing the current nursing shortage, solutions to the problem and the long term future of nursing. The leaders from education, health care government were the members of the Task Force. The task force has released their findings and recommendations for resolving those looming health care crises. The task force recommends the following solutions to the nursing shortage. Recruitment: Expand the nursing workforce by recruiting additional numbers of men, non-practicing nurses and recent high school graduates. Education: Provide additional academic and financial support systems to increase and pool of nursing school graduates and creates career leaders. Technology: Increase the application of labor saving technology to eliminate unnecessary, duplicative paper work and communication of patient information, thereby improving workplace conditions. Data Collection: Develop a reliable central source of data on the future need for nurses in the workforce upon which employers, policy makers, researchers and legislators may base public policy and recourse allocations. Clarify existing laws and regulations: Scope of practice for Nurses: Issue practice guidelines to clarify the legal scope of practice of nursing including those tasks which do not require licensure. These guidelines will reaffirm the individual practitioner‘s responsibility for patient care. Future of Nursing Career: Predications are that in 10 or 20 years it will look nothing like it does today! With new technologies and drugs, changes in insurance and health care policies and the shortage in nurses, the profession will have to reinvest itself. Many nursing functions will be automated such as documentation and updating patient records, smart beds to monitor vital signs and voice activated technology. This would give nurses more time to provide a human touch to their patients. As results of nursing shortages: Health care facilities will be forced to use their nurses judiciously nurses will spend more time at the bedside as educators and care coordinators to refocus on the patient. They will need to know how to access knowledge and transfer it to the patient and their loved ones. The changes in technology will possibly attract more men and minorities into the profession. Greater emphasis must be placed on supporting teaching careers and recruiting educators to relieve the serious shortage of nursing school faculty. More loans and scholarships for master‘s and PhD‘s would have to be in place. As technology and research progresses nurses would focus more on preventing the illnesses rather than treatment. The nursing shortage and rising health care costs will also 137
put pressure on the health care system to change from an illness model to a wellness and prevention model. If the nursing shortage continues: Hospitals may have to be reserved only for the very sickest. They will also serve more prominent roles in clinics, consulting firms, insurance companies. Nurses would probably to much more population based or community Health care. They will provide community education and work with employers and insurance payers to develop programs that save money as well as promote health. TECHNOLOGICAL ADVANCEMENT Technology Changed The Nursing: Technology has facilitated change and improvements in health care at a more rapid pace than ever before with each passing year, the pace of that change and accumulation of knowledge increase exponentially. Nurse now tends to be specialists rather than generalists because the equipment they use is so specialized. In addition, computers have helped tremendously because they have taken away the need for nurses to remember so much information. They also allow nurses to check information against orders, which makes providing health care safer advanced monitoring tools have improved efficiency. Technology can make it more challenging to make sure the art of nursing in not overshadowed by science. If we merely take care of the physical person and miss the target in the spirit of the person we fail as a profession. Telemedicine: The concept of telemedicine was introduced more than 30 yrs ago through the use of telephone and slow-scan games. The term telemedicine in short refers to the utilization of telecommunication technology for medical diagnosis, treatment and patient care. Telemedicine is a rapidly developing application of clinical medicine where medical information is transferred via telephone, the internet or other networks for the purpose of consulting and sometimes remote medical procedures or examinations. Telemedicine enables a physician or specialist at on one site to deliver health care, diagnose patients, give intra-operative assistance, provide therapy or consult with another physician or paramedical personnel at a remote site. Telemedicine system consists of customized medical software integrated with computer hardware, along with medical diagnostic instruments. The great impact of telemedicine may be in fulfilling its promise to improve the quality, increase the efficiency and expand the access of the health care delivery system to the rural population and developing countries. Telehealth Nursing: Telehealth Nursing is generally not a separate nursing role. Few nurses use telehealth exclusively in their practices. Nurses have always used the telephone to communicate with physicians, patients and other health care providers. Today's technologies have evolved far beyond the telephone to include computers, interactive audio and video linkages, teleconferencing. Telehealth is defined as "the removal of time and distance barriers for the delivery of health care services and related health care activities through telecommunication technology". 138
The goals of healthy people 2010 include eliminating health disparities among population & improving quality of life and life expectancy. Many health disparities occur because of barriers such as geographic location e.g. rural population‘s experiences greater health disparities, age that creates health disparities because of limited health care access, home bound status & transportation issues. The use of telehealth expands access to health care for underserved populations and individuals in both urban and rural areas. It also serves to reduce the sense of professional isolation experienced by those who work in such areas and may assist in attracting and retaining health care professionals in remote areas. Impact of Telehealth on Patient outcomes: Telehealth use in home health care opens the door for direct communication between the patient and the provider by integrating information and technology to facilitate health care delivery. Telehealth essentially removes time and distance barriers via videophones, video camera and sensory monitoring devices. The telehealth contributes to positive outcomes in terms of self management and compliance. Robot Nursing: Human nurses can have peace of mind. Their jobs are secure but little helper has come to rescue to do most of the boring nursing tasks for them. Robot-Nurse helps nurses in hospitals. Her body is developed by Samsung and her brain by Robot-Hosting.com. The nursing school and the psychology departments of the University of Auckland are creating her nurse knowledge base. She has face recognition (Camera), voice recognition (Microphone), arms and hands. She talks (Speaker) with the Patients, Doctors and Nurses in 8 human languages. Another responsibility is talking with those patients who do not have any visitor Her to keep their company, just carry the conversation to make them happy. Therefore they will not feel lonely. Futuristic Cyber Nursing: In Future: When you arrive at work, your I.D. tag is automatically detected and you are clocked in as you walk through the door. The patient is being monitored by automatic vital signs. You do your assessment verbally into your hand held device that converts it to readable notes on the computers' main system. At patient‘s bed side, you can get chemistry, hematology with a small hand held device that requires no blood drawn. You just place the sensor on the patient‘s skin and you have auto results. You verbalize your order into the hand held which goes directly to pharmacy which fills the orders automatically directly to patient's room. Most diagnosis will have a system for auto care plans upon patient admission. Patients have a bedside computer to access educational tools and progress of their recovery or stay. Nurses getting laptops and using intranet to do their jobs. This is a way to spend more time with patients and less time for doing paperwork.
139
BIBLIOGRAPH (REFERENCES): 1. Chitty Kay Kittrell ―Professional Nursing concepts and challenges‖ Ed 4th Pp 53. 2. Zwemer Ann J ―Professional Adjustment and Ethics for Nurses in India‖ Ed 6th Published by K. V. Mathew Pp 275-277. 3. Official Journal ―Nursing Outlook‖ July-August 2008 Pp152-156. 4. WWW.Google. Com. 5. WWW.Pubmed. Com.
140
UNIT-II
141
SYLLABUS Unit
Hours
II
5
Content Health care delivery: �Health care environment, economics, constraints, planning process, policies, political process vis a vis nursing profession. �Health care delivery system- national, state, district and local level. �Major stakeholders in the health care system-Government, non-govt, Industry and other professionals. �Patterns of nursing care delivery in India. �Health care delivery concerns, national health and family Welfare programs, inter-sectoral coordination, role of nongovernmental agencies. �Information, education and communication (IEC). �Tele-medicine.
142
HEALTH CARE ENVIRONMENT DEFINITION OF HEALTH: According to W.H.O., ―Health is a state of complete physical, mental and social well being and not merely the absence of disease or infirmity.‖ The health of an individual as an integrated system within the context of the environment is termed holistic health. Environmental Health refers to the state of all substances, forces and conditions in an individual's surroundings that may exert an influence on health and well being. When environmental conditions are favorable, health status is enhanced. However adverse biological, chemical, physical and sociological forces in the environment, separately or in combination may disrupts healthy life-style and impede a person's ability to cope with environmental stimuli. Florence Nightingale’s Environmental Theory of Nursing: The core concept that is most reflective of nightingale‘s writings is that of environment. Although she tends to emphasize the physical more than the psychological or social environment, this needs to be viewed in the context of her time and her activities as a nurse leader in a war-torn environment. The environment is viewed as all the external conditions and influences affecting the life and development of an organism and capable of preventing, suppressing or contributing to disease or death. Nightingale‘s writing speaks of providing such things as ventilation, clean air and water, cleanliness and warmth, so the reparative process that nature has instituted will not be hindered
Medical practice is not viewed as a curative process but as having the function of assisting nature. Thus, nursing is also a non-curative practice in which the patient is put in the best condition for nature to act. This condition was seen by her as enhanced by providing an environment conducive to health promotion. At this point, it is helpful to think of a patient who has had surgery and relate what Nightingale proposes. Medicine is seen as functioning to remove the diseased part, whereas nursing places the patient in an environment in which nature can assist post operative patient to reach their optimal health condition. Nightingale’s Environmental Concepts: Major Areas of Concentration Examples 1. Ventilation Fresh air, which is of primary importance, can be achieved through open windows. An outlet is needed for impure air. Drafts caused by open windows and doors are to be avoided. 2. Light Second only to the need for fresh air is the value of light. Beds should be placed in such a position as to allow the patient to see out the window – the sky and sunlight. 3. Warmth Guarding against the loss of vital heat is essential to the patient‘s recovery. Chilling is to be avoided. Hot bottles and drinks should be used to restore lost heat. 143
4. Effluvia (smells)
Sewer air is to be avoided and care is needed to get rid of noxious body odor caused by disease. Fumigations and disinfectants should not be used but the offensive substance removed. 5. Noise Intermittent sudden noise causes greater excitement than continuous noise, especially during patient‘s first sleep. Whispering, or discussing a patient‘s condition just outside his or her room is cruel. To Nightingale the environment of the patient was quite encompassing. Although she did not specifically distinguish among the physical, social or psychological environments as such, she speaks of all three in the practice of nursing. View Of The Theory Created By Nightingale: The key point is diagrammed in the center of the triangle- patient condition and nature. Here the thrust of environment is on the patient and nature functioning together to allow the reparative process to occur. The three components – physical, social and psychological – need to be viewed as interrelating rather than a separate distinct part. PHYSICAL ENVIRONMENT
CLEANLINESS VENTILATION AIR LIGHT NOISE
COMMUNICATION ADVICE
WATER PATIENT CONDITION BEDDING & NATURE DRAINAGE
PSYCHOLOGICAL VARIETY
WARMTH
ENVIRONMENT
DIET
144
MORTALITY DATA PREVENTION OF DISEASE SOCIAL ENVIRONMENT
Physical Environment: The basic environmental components are physical in nature and relate to such things as ventilation and warmth. These basic factors affect one‘s approach to all other aspects of the environment. A patient‘s bed must be clean, aired, warm, dry and free from odor. One should provide an environment in which patient can be easily cared for by others or self. The entire room should be well ventilated. Psychological Environment: the effect of mind on the body was fairly well accepted in Nightingale‘s time. Nightingale recognized that a negative environment could cause physical stress thereby affecting the patient‘s emotional climate. Therefore emphasis on placed on offering the patient a variety of activities to keep his or her mind stimulated. Communication: Communication with the patient is viewed in the context of the total environment. Communication should not be hurried. When speaking with patients, it is important to sit down in front of them. The place one communicates with the physician and family about the patient is in the context of environment of the patient. Advice: One should not encourage the sick by false hopes and advice about their illness. Rather the emphasis here is on communicating about the world around them that they miss or about good news that visitors can share. Again, patients are viewed in the context of their total environment. Social Environment: Observation of the social environment, especially as related to specific data collections relating to illness, is essential to preventing disease. Thus, each nurse must use observational powers in dealing with specific cases rather than be comfortable with data addressing the ‗average‘ patient. The patient‘s total environment not only includes the patient‘s home or hospital room but the total community influencing that specific environment. Environmental Health Hazards: It falls into 4 general categories: Biological. Physical. Chemical. Psychosocial. Biological: Disease producing infectious agents in the environment that are capable of entering the human body such as viruses, bacteria or other micro-organisms are environmental hazards of biological nature. Transmission by direct contact, contaminated water, vectors (rodents and arthropods such as flies, mosquitoes, fleas, ticks, mites) Chemica: These include toxic agents such as polychlorinated biphenyls (PCBs), asbestos, lead and pesticides such as insecticides (DDT, hydrocarbons), herbicides and rodenticides, industrial waste, emissions From motor vehicles. Results of experimental studies with animals indicate that these chemicals cause severe chronic health problems, thus posing a serious threat to human health. Physical: Natural disasters such as earthquakes, volcanoes and accidents, noise, heat, vibration, radiations, insects, rodents and certain type of equipment fall into the category of physical hazards. For e.g. air temperature and humidity may be adversely affected in industries that use 145
blast furnaces, laundry equipment contributing to health problems such as respiratory disorders, dermatitis, GI disturbances and eye inflammation. Psychosocial: Many of the stressors violence, stress, substance abuse and dependence are known threat to health of individuals, families and communities. Additionally feelings of well-being may be altered by factors such as high level of noise, overcrowding or isolation, lack of adequate sources or opportunities for economic advancement. Environmental Influences on Health: Toxic Agents: 1. Asbestoes: It has been linked to diseases such as lung and GI cancer and mesothelioma. 2. Lead: Lead biologically interferes with blood formation often resulting in anemia. It can also cause kidney damage, birth defects, and injury to the CNS, poor memory, hair loss, hypertension, mental retardation, convulsions, coma and death. 3. Pesticides: Pesticide residues are contact poisons and tend to accumulate in fatty tissues in living organisms and remain in the body indefinitely. Air Pollution: The effects of air pollution on the health of individuals depend on the chemical properties of the pollutant and size of particle, which in turn affects the site of deposition in the respiratory tract, adverse health effects from air pollution may range from mild to severe. For e.g. mild irritation of respiratory tract can occur when larger particles are entrapped in the upper respiratory tree. On the other hand, severe respiratory problems and even asphyxiation may occur as a result of direct absorption of a pollutant such as carbon monoxide, from the alveoli into the blood. The risk of developing cancer or a chronic pulmonary disease increases with prolonged exposure to air pollutants. Water Pollution: The most pressing health problems related to water quality involve contamination of waterways with the microbial pathogens found in human body wastes, a problem directly related to lack of or faulty sewage disposal facilities. Swimming facilities such as swimming pools, hot tubs and natural bathing areas like lakes, rivers and ponds are sometimes dangerously polluted and provide a medium to vectors to flourish. NOISE POLLUTION: It can be defined as any unwanted or undesirable sound in the environment. Its effects can range from mildly annoying to psychologically and physically debilitating. The most severe health problem resulting from noise pollution is temporary or permanent hearing loss. It also affects an individual's psychological and physical health because it disrupts communication, sleep, leisure and work activities. Accidents: Unintentional injuries like due to falls, drowning and fires kill more than 100,000 people each year and incapacitate millions of others with many lifelong disabilities. Of these approx. 46,000 deaths are motor vehicle related injuries. Social And Hazardous Wastes: Wastes are being generated at an alarming rate. The amount of solid waste continues to soar, partly as a result of today's ‗Throwaway' attitude where many products are used once and then discarded. In addition to solid wastes, the disposal of hazardous waste is a critical issue.
146
Emerging Environmental Issues: A. Major Issues: Seven major environmental issues which will directly or indirectly affect health have been identified; 1. Population: There was little change in population growth rates by the year 2000.The estimated world population by the end of century will be 6.3 billion. 2. Food Production: Worldwide food production is projected to increase by 90% between 1970 &2000.However, the largest increase of food will occur in richer countries and the countries of Middle East. Africa and Southern Asia will continue to have inadequate amount of food for their people, 3. Natural Resources: Non fuel resources appear sufficient to meet demands through the year 2000, but discoveries and investments will be needed to maintain reserves. 4. Water: Shortages will become more severe, over pumping of ground water, poor land use practices and pollution of existing water supplies will reduce the availability of water at a time of rising need. 5. Forests: Loss of forests will continue over the next 20 years. 6. Wild Life: Rates of extinction will increase sharply resulting in loss of hundreds of thousands of species, especially in the tropical forest regions. 7. Pollution: Increased emissions of carbon dioxide and chlorofluorocarbons in the atmosphere are threatening to alter the world's climate and upper atmosphere significantly by 2050. Acid rain from the burning of fossil fuels is affecting increasingly wider areas with damage to lakes, soil and crops. B. Global Warming: As a result of increased burning of fossil fuels, deforestation and the production of certain synthetic chemicals, there is dramatic increase in heat trapping gases in the atmosphere. Carbon dioxide is the major offender, allowing energy from the sun to pass through, while absorbing radiation from the earth and creating a planetary hothouse. NASA (National Aeronautics and Space Administration) has reported that the atmospheric ozone layer, which protects life from harmful ultraviolet radiations, has begun to think globally. As ozone layer diminishes in the upper atmosphere, the earth receives more ultraviolet radiations, which promotes skin cancers and cataracts and depresses the human immune system. C. Acid Rain: Acid rain is caused by emission of sculpture dioxide and nitrogen oxides. Nitrogen oxides, formed when fuel is burnt at high temperature, come principally from motor vehicle exhaust, electric utilities and industrial boilers that burn coal or oil. Once released into the atmosphere, these compounds can be carried long distances by prevailing winds until they return to the earth as acidic rain, snow, fog or dust. Fish and wildlife suffer harm, lakes are contaminated, buildings and statues deteriorate and people experience health problems such as respiratory impairment. The Environmental Protection Agency (EPA): Legislation establishing regulations and policy occurs at national level. The EPA is an independent agency formed to coordinate environmental programs related to air and water pollution, solid and hazardous waste management, noise, public water supplies, 147
pesticides and radiation. The agency also administers the municipal sewage treatment construction grant program authorized by congress in the 1972 Clean Water Act.
ECONOMICS Economics represents the study of allocating scarce resources among competing needs. Allocating resources refers to how each good produced is distributed to its consumers. Simply stated, economics becomes the intellectual liaison between nature and technology on the SUPPLY side & the preferences and desires of consumers and overall society on the DEMAND side. The economics involved with health care is important on both sides of the SUPPLYDEMAND equation. Economics provides a systematic mechanism to obtain information about the availability, potential and results of health care system. Also, economics can be used to trace relationships among the health of the population, the size and productivity of work force, and the demand for health care. Economic Indicators Of Health Care: 1. Consumer Price Index (CPI): CPI measures the average changes in prices of all types of consumer goods and services purchased by urban wage earners and clerical workers. This index is computed monthly by the Federal Government. 2. Hospital Status: Admissions, Cost per inpatient day, Length of stay, Outpatient visits, Occupation rates and Staffed beds indicate consumption and cost of consumption for hospital care. 3. National Health Expenditur: It includes both public and private expenditures for personal health care, medical research, the construction of medical facilities, program administration, insurance costs and Government sponsored public health programs. 4. Personal Consumption Expenditure (PCE): PCE represents private payments for medical care. 5. Personal Health Care Expenditure (PHCE): It indicates expenditures for consumers whether insured or not. Included are expenses for non-prescribed drugs and medicines, household supplies and other items not covered by insurance? 6. Professional Status: Office Visits- indicate the number of office calls consumers make to a physician. Physician Fee reflects charges for office and other physician visits. Surgical Charges indicate the fee for common surgical procedures and emergency medical procedures. Economic Concepts In Health Care: The three basic concepts of SUPPLY, DEMAND & COST are intricately related in economics. The SUPPLY of health care refers to the amount of resources currently available for delivering health services. Resources include health care facilities, manpower and financing. Supply levels are constantly changing because of technological discoveries, costs for services, consumer demands, and effect of Government regulations. The DEMAND for health care refers to the amount and type of health care the consumer requires and is willing to purchase. (Feldstein, 1983). The demand level revolves around consumer needs and desires, costs of health care, treatment selections ordered by health care providers, and general societal needs. 148
The COST of health care refers to the amount a provider pays to produce health related goods and services, as well as the amount a consumer pays to purchase these goods and services. Factors influencing the cost of health care are numerous, ranging from consumer demands to advancements in medical technology to the nation‘s economy.
PLANNING PROCESS PLANNING is a process of analyzing and understanding a system, formulating its goals and objectives, assessing its capabilities, designing alternative courses of action or plans for the purposes of achieving these goals and objectives, evaluating the effectiveness of these plans, choosing the preferred plan, initiating the necessary action for its implementation and monitoring the system to ensure the implementation of the plan and its desired effect on the system. Health Planning: is an orderly process of defining community health problems, identifying correct needs and surveying the resources to meet them, establishing priority goals that are realistic and feasible and projecting administrative action to accomplish the purpose of the proposed programmed. Characteristics Of Planning: 1. Planning is essential for the entire job. Planning leads to more effective and rapid achievement because everyone involved is clear about what is to be done, how, when and why. 2. Good planning should focus on the purpose i.e. every programmed including health programmed has their own purpose or objectives e.g. RCH programmed. 3. Although planning is a continuous process, there should be a provision for flexibility to some extent according to changes due to event or situation. 4. Planning should not be based on high ideals and be blind to social and political conditions in the environment. 5. Planning of health programmers must be precise in its objectives, scope and the nature. 6. Planning should be documented because it serves as a blue-print for implementation. Steps of Planning Process: Analysis of the health situation. Establishment of objectives and goals. Assessment of resources. Fixing priorities. Write up the formulated plan. Programming and implementation. Evaluation.
149
PLANNING CYCLE: Planning cycle may be considered in eight steps as follows:ASSESSING PLANNING ENVIRONMENT
DATA COLLECTION & DATA ANALYSIS
EVALUATION & REPLANING
STRATEGY FORMULATION & TARGET SETTING
MIDTERM APPRAISAL & MAKING CORRECTION
TAKE ADOPTION AND PLAN IMPLEMENTATION
PARTICIPATORY PLAN FORMULATION
PLAN EUTHENTICATION
150
POLICIES Introduction: A policy is an established course of action determined to achieve a desired outcome. Government and institutions create policies to achieve their missions. However, policy development and implementation are not limited to Government and institutions. Any health care providing agency, professional organization, non profit organization or family may make policies for members to follow. Policy formation takes place at many levels in society at family, community, institution, and state, national and international level. Policies can be major or minor. Definitions: POLICY is defined as principles that govern actions directed towards given ends; policy statements set forth a plan, direction or goal for action. Policies may be laws, regulations or guidelines that govern behavior in the public arena, such as in Government or in the private arena such as in workplaces, schools, organizations and communities. Policies are formalized procedures that are followed by persons responsible for delivering Governmental or institutional services. (Stanhope, 1996) HEALTH POLICY refers to the public or private rules, regulations, laws or guidelines that relate to the pursuit of health and the delivery of health services. Implied And Expressed Policies: Implied: Implied policies are neither written nor expressed verbally, have usually developed over time and follow a precedent. For example a hospital may have an implied policy that employees should be encouraged and supported in their activity in community, regional and health care organizations. Expressed: Expressed policies are donated verbally or in writing. Most organizations have many written policies that are readily available to all people and promote consistency of action. It may include a formal dress code, policy for sick leave or vacation time and disciplinary procedures. Before any action is taken, an issue should be put on the public agenda. Placing an issue on the public agenda requires actions that bring a concern to the attention of the policy makers and the public, people other than those affected by the situation are aware of the issue and its consequences. Policy Decisions: According to Mason, Leavitt, Chaffee, 2002 Policy decisions (e.g. laws or regulations) reflect the values and beliefs of those making the decisions. As the values and beliefs change, so do policy decisions. Types of Policies: Distributive Policies: Distributive policies extend goods and services to members of an organization, as well as distributing the costs of goods or services amongst the members of organization. Examples include Government policies that impact sending for welfare, public education, highways and public safety or a professional organization‘s policy on membership training. Regulatory Policies: Regulatory policies limit the discretion of individuals and agencies or otherwise complete certain types of behavior. These policies are 151
generally thought to be best applied in situations where good behavior can be easily defined and bad behavior can be easily regulated and punished through fines. Constituent Policies: These create executive power entities or deal with laws. Miscellaneous Policies: Policies are dynamic; they are not just static list of goals or laws. Policy blueprints have to be implemented, often with unexpected results. SOCIAL POLICIES are what happens ‗on the ground‘ when they are implemented as well as what happens at the decision making or legislative state. Other Types Of Policy: Domestic Policy: It presents decisions, laws and programs made by Government which are directly related to issues in the country. Economic Policy: It refers to the actions that Governments take in the economic field. It covers the systems for setting interest rates and Government deficit as well as the labor market and many other areas of Government. Education Policy: It refers to the collection of laws or rules that govern the operation of education system. Education occurs in many forms for many purposes through many institutions. Education policy can directly affect the education people engage in at all levels. Environmental Policy: It is an action deliberately taken to manage human activities with a view to prevent, reduce or mitigate harmful effects on nature and natural resources and ensuring that man made changes to the environment do not have harmful effects on humans. Health Policy Analysis: It is the process of assessing and choosing among spending and resource alternatives that affect the health care system, public health system. Foreign Policy: It is also called the ‗INTERNATIONAL RELATIONS POLICY‘ is a set of goals outlining how the country will interact with other countries economically, politically, socially and military. Human Resource Policy: These are systems of codified decisions, established by an organization, to support administrative personnel functions, performance management, employee relations and resource planning. Public Policy: It is the body of fundamental principles that underpin the operation of legal systems in each state. This addresses the social, moral and economic values that tie a society together, values that vary in different cultures and change overtime. Social Policy: It relates to guidelines for the changing, maintenance or creation of living conditions that are conducive to human welfare. Thus social policy is that part of public policy that has to do with social issues. Social policy aims to improve human welfare and to meet human needs for education, health, housing and social security. Impact of Policy on Nursing: Public policy has significant impact on the practice of nursing. The ability of the individual nurse to provide care is affected by public policy decisions. State licensure of a registered nurse (RN) derives from legislation that defines the scope of nursing practice. The defined scope determines what a nurse legally can and cannot do.
152
Regulations that are developed to implement legislation also affect practicing nurses and their work environments. For e.g., the rules for administering and documenting the administration of narcotic drugs are promulgated by a regulatory agency of the Federal Government, the Federal Drug Administration, under the department of Health and Human Services. The way in which such regulations are written can greatly affect nurse's ability to practice. If nurses do not actively participate in developing regulations, policy outcomes are likely to restrict rather than enhance nursing authority for regulated activities. Spheres of Nursing Influence: The nurse has an opportunity to make an impact on policies in four aspects of influence as identified by Talbot and Mason (1988). These spheres are: Government. Organizations. Workplace. Community. Since the community encompasses the other three spheres, only Government, organizations, and workplace will be discussed here. Government: Laws, with their accompanying rules and regulations, control nursing practice and health care. Nurses have been more involved in federal and state Governments, although local Governments provide many health care services. Local Governments control school health programs, local public hospitals and home and community health care. In general, the nurse first must be a registered voter. Nurses can join collective actions by working with PACs (Political Action Committees). These committees support deserving candidates who support nursing and health care issues. Most states have state nurses association PACs for state and local candidates. Workplace – Over 66% of nurses work in hospitals and should be influential in setting hospital policies, especially regarding patient care. Nurses can influence how quality care is delivered with controlled costs. Most hospitals currently require that many non nursing tasks be done by nurses. Through collective action, nurses serving on committees in the institution can help eliminate these tasks. Nurse can even serve on the board of trustees of the institution. Nurses who successfully practice the politics of change in their place of employment can influence the type and quality of patient care. Organizations: Important influences include professional organizations such as ANA and many specialty organizations. The organizations work in coalitions with other health groups to support or oppose issues. By joining and being active in a professional organization, an individual nurse has access to a wider range of tools and information to use in order to influence health care policies.
153
POLITICAL PROCESS IN NURSING PROFESSION Politics: Merriam Webster‘s Collegiate Dictionary (1994) defines politics as “the art or science concerned with guiding or influencing guiding policy‟ and „the art or science of winning and holding control over a government”. Policies are the decisions; Politics is the influence of those decisions. Politics And Nursing: Broader issues affecting the nursing profession are political in nature. Issues of pay equity or equal pay for the work of comparable value are of concern to nurses, because they have historically been underpaid for their services. One of the earliest case demonstrating the inequality of nursing salaries involved public health nurses in Colorado. They were paid considerably less than city tree trimmers and garbage collectors. The nurses demanded just compensation for their work by demonstrating that nursing requires more complex knowledge and is of greater value to society than these other occupations. As a result of this suit, recognition of nurse‘s low pay was brought to public attention, this in turn mobilized public support for increasing nursing salaries. This is an example of political action by nurses that resulted in both policy and professional outcomes. More recently, the nursing shortage has caused concern amongst the public that the number of nurses available to provide care in hospital and other agencies is inadequate. Nurses in California mobilized the public and other constituency groups to get the first legislation requiring specific nurse to patient ratios passed in 1999. Unfortunately nursing profession was not well organized politically during the time of expanding health care capacity and access in the early 1960s. Times have changed. Nurses have increased their political savvy. Through the efforts of American Nurses Association (ANA), other professional organizations, constituent member associations, political action committees (PACs), nurses are now participating much more effectively in both Governmental and Electoral politics. Levels Of Politics In Nursing: Three levels of political involvement in which nurses can participate are:1. Nurse Citizens: A nurse citizen brings the perspectives of health care to the voting booth, to public forums that advocate for health and human services. Nurses tend to vote for candidates who advocate for improved health care. Here are some examples of how the nurse citizen can be politically active: Register to vote. Vote in every election. Keep informed about health care issues. Speak out when services on working conditions are inadequate. Join politically active nursing organizations. Join a political party. Once nurses make a decision to become involved politically, they need to learn how to get started. One of the best ways is to form a relationship with one or more policymakers. 2. Nurse Activists: The nurse activist takes a more active role than the nurse citizen. Nurse activists can make changes by: 154
Joining politically active nursing organizations. Contacting a public official through letters, Emails or phone calls. Registering people to vote. Contributing money to a political campaign. Working in a campaign. Writing letters to the editor of local newspapers. Inviting legislators to visit the workplace. 3.Nurse Politicians: Once the nurse realizes and experiences the empowerment that can come from political activism, he or she may choose to run for office. No longer satisfied to help others get elected, the nurse politician desires to develop the legislation, not just influence it. Nurse politicians use their knowledge about people, their ability to communicate effectively and their superb organizational skills in running for office. The nurse politician can: Run for an elected office. Seek appointment to a regulatory agency. Be appointed to a governing board in the public or private sector. Use nursing expertise as a front line policymaker who can enhance health care and the profession. FLORENCE NIGHTINGALE, the founder of modern nursing was the first nurse politician. Current Political Issues Affecting the Practice Of Professional Nursing And Health Care: 1. The patient safety act of 1997: It aims to ensure safe patient care in hospital and other health care institutions. Each health care institution would have to make the following information available to the public: Number of RNs and UAP (Unlicensed Assistive Personal) providing direct patient care. The mean number of patients per RN who is providing direct patient care. Patients‘ mortality rates. Number of adverse patient care incidents. Methods used to determine and adjust nursing personnel staffing levels according to patient care needs. 2. The Genetic Information Nondiscrimination in Health Insurance Act of 1997: This legislative act would protect American consumers from being denied health care insurance coverage based on high risk genetic information. Advances in genetic research provide critical information for effective screening for diseases for persons at high risk for terminal and chronic illnesses, especially cancer. 3. The HIV Prevention Act of 1997: It includes the following provisions: Mandatory HIV testing of all sex offenders. Mandatory partner notification of persons testing positive for HIV. Allowing health care professionals to perform HIV testing without informed consent on any person undergoing an invasive medical procedure. 155
4. Victims of Abuse Protection Act of 1997: This bill would prohibit the use of information by insurers for refusing to ensure persons or for charging higher premiums based on previous history of or high risk for domestic violence. (Gonzales, 1997). As client advocates, nurses must support any legislation that prohibits access to, or increases the cost of health care for, any specified population. 5. The Tele health Bill of 1997: Tele health is the use of computer technology to link rural and underserved areas to large medical centers. This bill would provide loan and grant funding to establish tele health networks in rural areas and renames the Joint Working Group on Telemedicine as the ‗Joint Working Group on Tele health. 6. Working Families and Flexibility Act: It has been introduced to assist parents meet family and work obligations. This bill proposes that employers compensate hourly rate employees for overtime by offering them a choice of overtime pay or compensatory time off at a rate of 1.5 times the hourly wage. This bill would increase the flexibility of hourly waged employees. CONCLUSION: This is to conclude that nurses need power commensurate with their knowledge and expertise as the care givers closest to patient and proportionate to their numbers. They need power and politics to provide competent, humanistic and affordable care to people and also enormous decision making power within the health care system for improve nursing profession in health care and health policy.
156
BIBLIOGRAPHY: Kay Kittrell Chitty, ―Professional nursing concepts & challenges, Ed 4th, Published by Elsevier, pp- 580-598 Susan Leddy, Mae Pepper J., ―Conceptual Basis of Professional Nursing‖ Ed 4th, Published by Lippincott, pp- 277, 290-292 Joan Creasia L., Barbara Parker, ―Conceptual foundations of Professional Nursing Practice, Published by Mosby, pp- 107-125, 225-239 BT Basavanthappa, ―Nursing Administration,‖ Ed 1st, Published by Jaypee Brothers, pp- 50-51 George Julia B., ―Nursing Theories The Base for Professional Nursing Practice,‖ Ed 3rd, published by Appleton & Lange, pp- 32-36 www.google.com.
157
HEALTH CARE DELIVERY SYSTEM – NATIONAL STATE, DISTRICT AND LOCAL LEVEL Organization of Health: System in India: India is a union of 28 states and 7 union territories under the constitution of India, the states are largel y independent in matters relating to the delivery of health care to the people. Each state therefore, has developed its own system of health care delivery, independent of the central government. The central responsibilit y consist of mainl y policy, planning, guiding, assisting, evaluating and coordinating the work of state health ministry‘s so that health services cover every part of the country, and no states lags behind for want of these services. The health care services organization in the country extends from the national level to village level from the total organization structure, we can slice the structure of health care system at national, state, district, communit y, PHC and sub -centre level.
158
Deputy Nursing Advisor: Union Ministry of Health and Family Welfare: The Union Ministry of Health and famil y welfare is headed by: Cabinet Minister (A minister of State) Deput y Health Minister There are political appointments The Union Health Ministry has two departments: 1) Department of Health: Secretary (i.e. Executive Head) Joint Secretary Deput y Secretary Administrative Staff 2) Department of Family Welfare: The Department of famil y welfare was created in 1966 within the ministry of health and famil y welfare. The secretary to the Govt. of India in the ministry of Health and famil y welfare is in overall in charge of the department of famil y welfare. He is assisted by the additional secretary and commissioner and one joint secretary. 3) Functions: The functions of Union Health Ministry are set-out in the seventh schedule of Article 246 of the constitution of India unde r (a) Union list. (b) Concurrent list (A) Union List: 1) International health relations and administration of post quarantine. 2) Administration of central institutes such as the All India Institute of Hygiene and Public Health Kolkata, National Institute for the control of Communicable Diseases, Delhi, etc. 3) Promotion of research through research centers and other bodies. 4) Regulation and development of medical, pharmaceutical dental and nursing professions. 5) Establishment and maintenance of drug standards. 6) Censuses and collection and publication of other staticall y data. 7) Immigration and emigration. 8) Regulation of labor in working of mines and oil fields. 9) Coordination with states and with other ministries for promotion of health. B) Concurrent List: The Concurrent list includes:1) Prevention of extension of communicable disease from one unit to another. 2) Prevention of adulteration of foodstuffs. 3) Control of drugs and poisons. 4) Vital statistics. 159
5) Labor welfare 6) Ports other than major 7) Economic and social planning 8) Population control and famil y planning. 2) Directorate General Of Health Services : a) Organization: The director general of health services is the principal advisor to the union Government in both medical and public health matters. He is assisted by an add itional director general of Health services, a team of deputies and a large administrative staff. The directorate comprises of three main units, e.g. medical care and hospitals, public health and general health administration. b) Functions: The Specific functions are :1) International health r elations and quarantine: All major posts in the country and international airports are directl y controlled by the directorate general of Health Services. All matters relating to the obtaining of assistance from inte rnational agencies and the coordination of their activities in the country are undertaken by the directorate general of health services. 2) Control of drug standards: The drugs control organization is port of Directorate general of Health Services, and is headed by the drug controller. Its primary function is to lie down and enforce standards and control the manufacture and distribution of drugs through both central and state government officers. 3) Medical Store Depots: The Union Government runs medica l Store depots at Mumbai, Chennai, Kolkata, Karnal, Gauhati and Hyderabad. These depots suppl y the civil medical requirement of the central Government and of various state Governments. These depots also handle supplies from foreign agencies. The Medical st ore organization endeavors to ensure the highest qualit y, cheaper bargain and prompt supplies. 4) Post Graduate Training: The Directorate General of Health Services is responsible for the administration of national institutes, which also provide post -graduate training to different categories of health personnel. Some these institutes are:The all India Institute of Hygiene and Public Health at Kolkata, All India Institute of Mental Health at Bangalore, College of Nursing at Delhi, National Tuberculosis, Institute at Bangalore, National communicable disease at Delhi, etc. 5) Medical Education: The central directorate is directl y in charge of the following medical college in India. 160
The lady Hardinge The Maulana Azad The Medical College at Pondicherry and Goa 6) Medical Research: Medical research in the country is organized largel y through the Indian council of Medical Research, founded in Loll in New Delhi. The council plays a significant role in aiding, promoting and coordinating scientific research on human diseases, their causation, prevention and cure. The research work is done through the council's several permanent research institutes, research units, field surveys and a large no of ad -hoc research enquiries financed by the council. It maintains canc er research centre, Tuberculosis chemotherapy centre at Chennai, Virus research centre at Poona, National institute of Nutrition at Hyderabad and blood Group reference centre at Mumbai. The funds of the council are wholl y derived from the budget of Union ministry of Health. 7) Central Govt. Health Schemes : 8) National Health Programmed: The various national healths‘s programmed for the eradication of malaria and for the control of tuberculosis, filarial, leprosy, AIDS and other communicable disease invo lve expenditure of corers of rupees. 9) Central Health Education Bureau: An outstanding activit y of this bureau is the preparation of education material for creating health awareness among the people. The bureau offers training courses in health educatio n to different categories of health workers. 10) Health Intelligence: The central bureau of health intelligence was established in 1961 to centralize collection, compilation, anal ysis, evaluation and dissemination of all information on health statistics for the nation as a whole. 11) National Medical Library: The central Medical Library of the Directorate General of Health services was declared the national medical library in 1966. The aim is to help in the advancement of medical, health and related scie nces by collection, dissemination and exchange of information. CENTRAL COUNCIL OF HEALTH: The central council of health was set up by a Presidential order on a August, 1952 under article 263 of the constitution of India for promoting coordinated concerted action between the centre and the states in implementation of all the programmed and measures pertaining to the health of the national. The union health minister is the chairman and the state health ministers are the members. Functions: 1) To consider and recommended broad outline of policy in regard to matters concerning health in all its aspects such as the provision of 161
remedial and preventive care, environmental hygiene, nutrition, health education and the promotion of facilities for training and resea rch. 2) To make proposals for legislation in fields of activit y relating to medical and public health matters and to lay down the pattern of development for the country as a whole. 3) To make recommendations to the central Government regarding distribution of available grants-in-aid for the health purpose to the states and to review periodicall y the work accomplished the different areas through the utilization of these grants -in-aid. 4) To establish any organization or organizations invested with appropriate functions for promoting and maintaining cooperation between the central and state Health Administration. PLACEMENT OF NURSES AT THE CENTRAL LEVEL:
STATE LEVEL: At present there are 28 states in India, with each state having its own health administration. In all states, the management sector comprises the state ministry of health and a Directorate of Health. STATE MINISTERY OF HEALTH AND FAMILY WELFARE: (a) Organization: The state ministry of Health and family welfare is headed by cabinet Minister Deput y Minister. The minister of Cabinet rank is the political head of the department of Health and FW. The Health Minister has to perform both the activities, i.e. Political as w ell as administrative as follow:-
162
Functions: 1) As a member of the state legislature , it is his dut y to support and safeguard the total policies of the Govt. because of the collective responsibilit y of the cabinet. 2) As a member of ministry, he brings all the bills pertaining to his department for approval of the legislature. 3) As political head of the health department, he acts as an executive & administrator. He has to see the policies approved by the legislature are faithfull y implemented. 4) He is the custodian of the interests of the people in general and his constituency in particular. 5) As a member of Govt. he performs Ceremonial duties. Health Secretariat Organization: In order to keep a record of the policies framed by the political heads and to watch over their implementation he has to seek the help of an office which is known as "Secretariat" Health Secretariat is the official organ of the state Health Ministry. The secretary of the state Govt. is a senior officer of the Indian Administrative services, is the administrative head and is assisted by Addition Secretary, Deput y Secretary Etc. The main duties of Health department are as follow:Functions: 1) Assisting the Minister in policy making in modifying policies from time to time and in the discharge of his legislative responsibilit y. Framing draft legislation and rules and regulati ons. 2) Coordination of policies and programmers‘, supervision and control over their execution and review of results. 3) Budgeting and control of expenditure. 4) Maintaining contact with Govt. of India and other state Govts. 5) Overseeing the smooth and efficient running of administrative machinery. State Health Directorate Organization: The Director of health and famil y welfare is the principal advisor to the state Govt. on all matters relating to medicine and public health as he is technicall y qualified person in the field, may be called as technical head of the Department of health and famil y welfare. He is assisted by joint Director, Regional joint Director and Deput y and Assistant Directors of major wing. Functions: 1) To provide adequate medical care through h ospitals, dispensaries, health centers and mobile domiciliary units both in rural and urban areas. 2) To make proper arrangement for medical education and research. In order to improve the functioning of the medical education the state health department is to take following steps: Increase the out turn of Para-medical staff in view of large expansion of rural services. 163
Reorientation of medical education with a view to progressivel y making training of medical students more communit y based. To make good the efficiency in nursing / paramedical / ministerial and other services staff in accordance with the norm prescribed by the Inc. To improve and expand common facilities like hospital, p harmacy, blood bank, emergency services, intensive care unit and rehabili tation services in the hospitals. Continuing encouragement to research activities in Medical colleges. 3) Proper implementation of National Health Programmers. The national health programmers‘ are planned, guided, directed and financed by the union Ministry of health and family welfare only operational cost of these schemes are born by the state. 4) To make previsions for personal and impersonal health services. The following are the personal and impersonal health services : a) Immunization services . b) Nutrition. c) School Health. d) Industrial Health. e) Famil y planning. f) Rural & Urban Sanitation . g) Control of Fairs & Festivals . h) Drugs and food control . i) Production of vaccines and carryi ng out mass immunization programmed. j) Emergency health services during flood, famine, eart hquake, refugee influx etc. 5) Control of food and drug administration state health department has responsibilit y to control adulteration of food and drugs and enforce minimum standards of food and drugs laid down by the state. 6) Collection and Dissemination o f Health information state health Department of collects and transmits information of health and vital statistics for the states. 7) Control over ES I scheme. State health department supervises the ESI Scheme. The expenditure on this scheme is shared in the ration of 1:7 by the Govt. and ESI Corporation. 8) Enforcement of Professional Ltd. The dept. determines and maintains the standards of professional education, research and practice through statutory bodies like the universit y, state medical council, state Nursing Council, state pharmacy council etc. 9) Promotion of Indigenous s ystems of medicine. The dept. encourages the Indigenous system of medicine. 10) Setting up of laboratories. 11) Supervision and control over the local bodies. 12) Preparation for the enactment o f Health legislation. 164
13.) Provision of Integrated famil y welfare services. PLACEMENT OF NURSES AT STATE LEVEL: ............................................................................................................ ................................. ........................................................................... ............................................................................................................ ......................................................................... ................................... REGIONAL LEVEL: In the state of Bihar, Madhya Pradesh, Uttar Pradesh, Adnhra Pradesh, Karnatka, and others, Zonal or regional or divisional set -ups have been created between the state Directorate of Health Services and D istrict Health Administration. Each regional, zonal set -up covers three to five districts and acts under authorit y delegated by the state Directorate of Health services. The status of officers/incharge of such regional/zonal organizations differs, but they are known as additional/joint/Deput y Directors of Health Services in different States. District Level: The Major unit of administration in India is the District for administration purpose the country is divided into 28 states and 67 union territories which in turn are divided into 432 administration districts. Each district is divided into sub -districts or taluks, under which are situated the Communit y Development Blocks at present there are 600 communit y development Blocks in India. Functions of health organization at District leve l or local level: 1) Coordinate health Planning. 2) Investigate communicable disease. 3) Maintain free clinics for the earl y diagnosis of Communicable disease. 4) Provide laboratory services to assist doctors. 5) Conduct clinics for adm inistration of vaccines. 6) Collect vital statistics 7) Provide MCH services 8) Maintain a Public health nursing service. 9) Supervise water supply and sewage disposal 10) Supervise qualit y and safet y to meat and other foods. 11) Inspect and supervise the production, pasteurization and distribution of milk. 12) Investigate and supervise general sanitary conditions in public eating places. 13) Provide preventive and rehabilitative services in chronic disease control. 14) Conduct health education programmed . 15) Promulgate rules and regu lations. 16) Provide mental health services. 17) Provide famil y planning services.
165
MAJOR STAKEHOLDERS IN HEALTH CARE SYSTEM Health Care System: The health care system intended to provide services and resources for better health. This system includes hospitals, clinics, health centers, nursing homes and special health programmed in school, industry and community. Health system operates in the context of socioeconomic and political framework of the country. Introduction: Stakeholder encompass a wide sector of society, they include consumer or patients, community health care professionals, hospital health care professionals, pharmacists nongovernmental organizations, supplier etc. Stakeholder: Stakeholder is a person, group, organization or system who affects and can be affected by an organizational action.
TYPES OF STAKEHOLDERS
EXTERNAL STAKEHOLDERS
INTERFACE STAKEHOLDER
INTERNAL STAKEHOLDER
External Stakeholder: A health care organization must respond to large number of external stakeholders. They fall into three categories in their relationships to the organization. Those that provide inputs to organization Those that compete with it Those that have particular special interest The first category includes suppliers, patients and financial community. The relationships between the organization and these external stakeholders are a symbiotic one, as organization depends on them for its survival. In turn these stakeholders depend on the organization to take their outputs. The relationships between the organization and 166
the stakeholders that provide necessary input are one of mutual dependence. As such the both two parties cannot, or do not want to, do without one another. The competitor stakeholder seeks to attract the focal organization dependents. The competitor may be direct competitor for patients (e.g. other hospital) or they may be competing for skilled personnel. Competitor does not need one another to survive, while co-operation between hospitals and their competitor has increased in recent years. External stakeholders in third category are special interest group. These are the government regulatory agencies, private accrediting association, professional associations, labor union, the media and political action group. Because of special interest conflict most often occur. Compromise and, in some cases, overt collaboration generally resolves the conflicts. Interface Stakeholders: Some stakeholders function on the interface between the organization and its environment. The major categories of interface stakeholders include the medical staff, the hospital board of trustees. The organization must provide sufficient inducements to continue to make appropriate contribution. The organization may offer professional autonomy institutional prestige or political contacts, special services and benefits etc. Internal stakeholders almost entirely within the organization and typically include management, professional and non professional staff. Management attempts to provide internal stakeholders with sufficient inducements to gain continual contribution from them. The stakeholders determine whether the inducements are sufficient for the contribution that they are required to make partly on the basis of alternative contribution offer received from competitive. Stakeholders In Health Care System: 1. Government. 2. Public. 3. Providers. 4. Hospital administrator and governing boards. 5. Non governmental. 1. Government: The role of government in the administration of health care can not be overestimated. Many federal government health care efforts are headed by a cabinet-level officer, the secretary for health and human services, who runs the department of health and human services. The federal government makes budget and other planning related to expenditure in health care. As the major payer, the federal government has been active in regulating the health care industry. Therefore, hospital have great incentive to comply with regulations promulgated by federal government, because they can be fined or ―decertified‖ as a provider of care to Medicare clients if they do not. Noncompliance can results in the loss of lot of money & income for the hospital. Government regulation is frequently opposed by the health care industry because it often affects the health care practitioner‘s autonomy. 2. The Public: The public has a stake in health care from several perspectives. As consumers of health care services or as patients, the public is concerned with quality, cost and access to care. Many people believe that health care is a right and should be universally available 167
to all citizens, regardless of the cost. Paradoxically, however, most do not want to pay these costs. Patients want compassion as well as skill with clear communication. They expect an employer to offer a wide variety of option for health coverage that can be customized to their specific needs. They also look for the employs to fund the majority of cost of health insurance. Overall, public values regarding health care are changing. People are interested in receiving quality care at a reasonable cost. In addition, the public has a more positive view of health promotion and illness prevention than in past.. Health care resources remain focused on illness, however, with only 1% of health care expenditures going to public health. 3. The providers: Community health care professional Hospital health care professional Hospital Health Care Professional Physicians: The role of physicians in the health care system is important one. Physicians provide direct medical services to clients in variety of settings, including offices, clinics, hospitals and freestanding centers. In addition, physician control 60% to 70% of hospital costs through their decisions regarding the use of resources. Physicians decide which client to admit, where to admit, the length of stay, the ancillary services, whether to perform surgery, when to initiate and to discontinue treatment regimens, and which medications to prescribe. Nurses: An individual who provides care to clients. The extent of participation varies from simple patient care tasks to the most expert professional technique necessary in acute life threatening situations. The ability of nurse to function independently and making self directed judgment will depends on his or her professional development. Nurses provide a unique perspective on the health care system. The greatest impact and the most frequently discussed aspect of nursing has been the recurring shortage of nurses. Pharmacists: The roles of the pharmacist are changing. Some can now prescribe as well as dispense medicine. They are more interested in meeting the requirements of pharmaceutical industry. 4. Hospital administrators and governing boards: The chief executive, chief financial officer, chief nursing officer, and governing boards of hospitals strongly influence health care delivery in their institutions. In addition most hospitals are members of some association which represents the industry‘s efforts to influence legislation, regulation, judicial decisions, and health policy. 5. Non governmental stakeholders: The voluntary agencies occupy an important place in community health care system. These organizations directly or indirectly act as stakeholder. These organizations are administered by autonomous boards which hold meetings, collect funds from private sources and spend money for providing health services and health education to individual, family and Community. There are many NGO‘S in India which serves to society. Some of these organizations are given below:
168
Indian Red Cross Society: It was established in 1920 and has over 400 branches all over India. It has been executing programmed for the prevention of diseases and promotion of health. Its activities are: Relief work. Milk and medical supplies. Armed forces. Maternal and child welfare services. Family planning. Blood bank and first aid. Hindu Kusht Nivaran Sangh: It was founded in 1950 with its headquarters in New Delhi. Its precursor was the Indian council of British Empire Leprosy Relief Association (B.E.L.R.A) which was renamed as LEPRA in 1950. The programmed of work of the sangh include rendering of financial assistance to various leprosy homes and clinics, health education, training of medical worker and physiotherapists conducting research and field investigation. The Sangh has branches all over India and work in close cooperation with the Government and other voluntary agencies. Indian council for child welfare: It was establish in 1952. It is affiliated with international union for child welfare. The services of I.C.C.W are devoted to secure for Indian children those ―opportunities and facilities, by law and other means‖ which are necessary to enable them to develop physically, mentally, morally, spiritually and socially in a healthy and normal manner and in conditions of freedom and dignity. Tuberculosis Association of India: It was formed in 1939. It has branches in all states of India. The activities of this association comprise organizing T.B campaign every year to raise funds, training of doctors, health visitors and social workers in ant tuberculosis work, promotion of health education conferences. Bharat Sevak Samaj: The Bharat Sevak Samaj which is non-political and nonofficial organization was formed in 1952.One of the prime objective of the Bharat sevak is to help people to achieve health by their own actions and efforts. The B.S.S. has branches in all the states and nearly all the districts. Improvement of sanitation is one of the important activities of the B.S.S. The Kastubra Memorial Fund: Created in commemoration of Kastubra Gandhi, after her death in 1994, the fund was raised with the main objective of improving the status of women, especially in the villages, through gram-savikas. The trust has nearly one crore of rupees and is actively engaged in various welfare projects in the country. All India Women’s Conference: It is the only women‘s welfare organization in the country. Established in 1962, it has now branches all over the country. Most of branches running M.C.H. clinics, Medical centers, and adult education centers, milk centers and family planning clinics. The All India Blind Relief Society: It was established in 1946 with a view to coordinate different institutions working for the blind. It organizes eye relief camps and other measures for the relief of the blind. 169
Professional bodies: The Indian Medical Association, All India Dental Association, The Trained Nurses Association Of India of all men and women who are qualified in their respective specialties and possess register able qualifications. These professional bodies conduct annual conferences, publish journals, arrange exhibitions, foster research, set up standards of professional education and organize relief camps during periods of natural calamities. Management Of Stakeholders Relationship: The stakeholder relationships can be managed by following certain steps. These are given below:-
Diagnose of stakeholder relationship: Stakeholder potential for threat. Stakeholder potential for co-operation. Stakeholder potential for threat: A health care organization‘s manager needs to anticipate and evaluate systematically the actual or potential threats in its relationship with stakeholder. These threats may focus on obtaining inducements from the organization that may or may not be provided. The desired inducement may include financial resource, participation in decision making. Stakeholder power and its relevance for any particular cause confronting the organizations manager determine the stakeholder‘s potential for threat. Power is primary 170
a function of the dependence of the organization on stakeholder. Generally, the more dependent the organization, the more power full the stakeholder. Stakeholder’s potential for cooperation: The stakeholder‘s dependence on the organization and its relevance for any particular issue facing the organization determine the stakeholder‘s co-operative potential. Generally the more dependent the stakeholder on the organization, the higher the potential for co-operation. Types of stakeholder relationship: Mixed blessing stakeholder relationship. Supportive stakeholder relationship. Non supportive stakeholder relationship. Marginal stakeholder relationship. Stakeholder’s Potential To Threaten The Organization: High
Type 1: With the mixed blessing stakeholder relationship‘s the health care executive faces a situation in which the stakeholder rank high on both type of potential: threat and cooperation. Physicians-hospital relationships probably are the clear example of this type of relationship. Although physicians can and do provide many services that benefit hospitals, physicians also can threaten hospital because of their general control over admissions, the utilization and provision of different services, and the quality of care. Type 2: The ideal stakeholder relationship is one that supports the organization‘s goals and actions. Managers wish all their relationships were of this type, such a stakeholder is low on potential threat but high on potential co-operation for e.g. the relationships of well managed hospital with its board of trustees, its manager, its staff employees, local community and nursing homes. Type 3: The most distressing stakeholder relationship for an organization and its manager‘s are non supportive ones. They are high on potential for threat but low on potential for cooperation. Typical non supportive relationships for hospitals include competing hospitals, 171
employee unions, the federal government, other govt. regulatory agencies the news media. Type 4: The marginal stakeholder relationships are high on neither threatening nor co-operative potential. This type of relationships include professional associations for employees, volunteer groups in community etc, for a well run hospital. Stakeholder’s Potential To Reduce Stakeholder Threat:
Collaborate cautiously in the mixed blessing relationship: The best way to manage the mixed blessing relationship, high on the dimensions of both potential threat & potential co-operation may be cautious collaboration. The goal of strategy is to turn mixed blessing relationship into supportive relationships. Involve trustingly in the supportive relationship: As the supportive stakeholder poses a low potential for threat, they are mostly ignored by organization. However for maximizing the co-operation from this type of stakeholder, the health care executives can delegate authority to manager, involve in decision making and other plans. With this the manager will more likely to committed to achieve organizational objective. Defend proactively in the non supportive relationship: Stakeholder relationship with high threatening potential, but low co-operative potential is best managed by a proactive defensive strategy. Relationships with the federal govt. and indigent patients are non supportive stakeholder relationship for most health care organization. In stakeholder terms, a defensive strategy involves proactively preventing the stakeholder from imposing cost or other disincentives on the organization. Monitor efficiently in the marginal relationship: Monitoring helps to manage this marginal relationship in which the potential for both threat and co-operation is low. The marginal relationships are unstable; they can move into any one of the other three types of relationships.
172
Strategy implementation and outcome: The fifth step of management of stakeholder relationship is implementation of planned and articulated strategies. With conscious, consistent relationship and implementation of strategies, a quite fully organized health care system can be developed.
173
PATTERNS OF NURSING CARE DELIVERY Introduction: Nurses provide care to clients while working under a variety of care delivery models. A care model is a philosophy of care delivery and a system for organizing the relationship and roles of all nursing care personnel. Historically several delivery of care models have been used in nursing. Each differs in regard to the types of responsibilities assumed by registered nurses and other nursing personnel. The models also differ in the extent to which a registered nurse directly coordinates the care of all clients need is matched with staff abilities. Providing care to groups of patients rather than to individuals required nurses to be efficient and use their time effectively. An organizing structure was needed, and various types of care delivery systems were designed to meet the goals of efficient and effective nursing care. The model of nursing care used varies greatly from one set of patient circumstances to another. Types of Patient Care Delivery System: Several types of patient care delivery systems have been used in acute care settings. Four systems are as follows: 1. Functional nursing. 2. Team nursing. 3. Primary nursing. 4. Case management nursing. 1. Functional Nursing: The functional approach to care grew out of a need to provide care to large number of patients. It focused on organizing and distributing the tasks, or functions, or care. Trained nurses provide care that requires high skill levels and untrained workers with little skill or education performed many less complex tasks. In functional nursing, personnel worked side by side, each performing the assigned task. The goal of functional nursing was efficient management of time, tasks and energy. Although this practice saved hospitals money, patient care was fragmented and patients had to relate to many different people. There was no one person they could call ―My Nurse‖ Advantages of functional nursing: Efficient – can complete many tasks in a reasonable time frame. Workers do only tasks they are educated to do and become very efficient. Promotes organizational skills – each worker must organize his own work Promotes worker autonomy. Disadvantage of functional nursing: Lack of holistic view of patient – emphasis on task, not person. Lacks- continuity – patients often do not know who their nurse is. Registered nurses have little time to talk with patients or render personal care. 2. Team Nursing: In response to the frustration some nurse felt when using the functional approach to patient care, Lam bertson (1953) designed team nursing. She envisioned nursing teams as 174
democratic work group with different skill levels represented by different skill levels represented by different team members. They were assigned as a team to a group of patients. The intent of team nursing is to provide patient centered care. The patients nursing care needs are identified and met through nursing diagnosis and prescriptions. The ward clerks and unit manager perform the non nursing function of the unit. The process requires planning, with the objective of taking nursing personnel to the bedside so that they can focus on nursing care of patients. The team leader ultimately responsible for all the care provided, delegates (assigns responsibility for) certain patients to each member. Each member of the team provides the level of care for which he or she is best prepared. The least skilled and experienced members care for the patients who require the least complex care, and most skilled and experienced members care for the most seriously ill patients who require the most complex care. Implementing team nursing requires study of the literature on team plan, development of a philosophy of team nursing, planning for appropriate utilization of all categories of nursing workers and planning for team conferences, nursing care plans and development of team leadership. The team plan gives priorities to the development of leadership potential – leadership in the practice of nursing – leadership that is creative and that encourages improvement of communication among team members, patients and leadership, the nursing of cooperative effort and free expression of ideas of all team members. It gives priority to motivation of people to grow to this self approved or maximum level of performance. Through the team plan the contribution of all team members in improving patient care are recognized. Priority is given to strengthening of their weakness. Patient centered care employs effective supervision and recognizes that personnel are the media by which the objectives are met in a cooperative effort between team leaders and team members. Through supervision the tem leader identifies nursing care goals:1.Identifies team members needs 2.Focuses on fulfilling goals and needs 3.Motivating team members to grow as workers and citizens 4.Guide team members to help, set and meet high standards of patient care and job performance. Advantages of team nursing: Involves all team members in planning patients nursing care through team conferences and written nursing care plans. Provides best care at the lowest cost. Each workers ability is used to the fullest. Provides comprehensive care. Decrease non professional duties of registered nurses. Promotes job satisfaction. Disadvantages of team nursing: Constant need to communicate among team members is time consuming. Difficult to find time for team conferences and care plans. 175
Team composition varies from day to day which can be confusing and disruptive and decreases continuity of care. Allows RN who I steam leader to have the only significant responsibility and autonomy. The disadvantages of team nursing can be overcome by educating competent team leaders is the principles of nursing team leadership. Team nursing organization: HOSPITAL ADMINISTRATION NURSING SUPERDENTENT DEPUTY NURSING SUPERINDENTENT ASSISTANT NURSING SUPERDENTENT WARD SISTER Staff nurses clerk’s dietician attendant class IV Students. 3. Primary Nursing: Primary nursing was designed to promote the concept of an identified nurse for every patient during the patient‘s stay on a particular unit. The goal of primary nursing is to deliver consistent, comprehensive care by identifying one nurse who is responsible, has authority, and is accountable for the patients nursing care outcomes for the period during which the patient is in a unit. In primary nursing, each newly admitted patient is assigned to a primary nurse. Primary nurses assess their patients, plan their care, and write the plan of care. While on duty, they care for their patients and delegate responsibility to associate nurses when they are off duty. Associate nurses may be other RNs or LPN. The primary nurse accepts total 24hours responsibility for a patient‘s nursing care. Nursing care is directed towards meeting all the individualized patients‘ needs. The primary nurse is responsible and accountable for involving the patient and family directly in all facets of care and has autonomy in making decisions in this regards. The primary nurse communicates with other members of health care team regarding the patient‘s health care. This process promotes continuity of care and collaborative efforts directed toward quality patient care. The characteristics of primary nursing modality are:1.The primary nurse has responsibility for the nursing care of the patient 24 hours a day from hospital admission through discharging. 2.Assessment of nursing care needs, collaboration with the patient and other health professionals and formulation of plan of care are all in the hands of primary nurse. 3.Execution of nursing care plan is delegated by the primary nurse to secondary nurse during other shifts. 4.The primary nurse consults with nurse manager. 5.Authority, accountability and autonomy rest with primary nurse. 176
6.Associate nurses carry out plan of care when the primary nurse is not on duty 7.Usually implemented as an all-RN model Advantages of primary nursing: Provides increased autonomy on the part of nurse, thus increasing motivation, responsibility and accountability It ensures more continuity of care as the primary nurse gives or direct care throughout hospitalization It makes available increased knowledge of the patients psychosocial and physical needs, because the primary nurse does the history and physical assessment, develops the care plan and act as liaison between the patient and other health workers. It leads to increased rapport and trust between nurse and patient that will allow formation of therapeutic relationship. It improves communication of information to physicians. It frees the charge nurse to assure the role of operational manager to deal with staff problems and assignments and to motivate and support the staff. Promotes job satisfaction and sense of accomplishment for nurses. Disadvantages of primary nursing: Difficult to hire all registered nurse staff. Expensive to pay all registered nurse staff. Nurses do not know other patients, difficult to ‗cover‘ for each other. May create conflicts between primary and associate nurses. Heavy responsibility, especially for new nurses. 4. Case Management Nursing: The most recent evolution in nursing care delivery system is case management. In many ways, it is a return to the type of nursing practiced before patients were cared for primarily in hospitals. Case management can be defined as a collaborative process which assesses, plans, implements, coordinates, monitors and evaluates options and services to meet an individual‘s health and needs through communication and available resources to promote quality and cost effective outcomes (Case Management Society Of America, 2003) Two models of case management nursing have evolved over time. These are characterized by either an ―internal‖ focus in which the case manger works, within a treatment facility, or an ―external‖ approach, in which the case manager oversees patients and the delivery of services over the continuum of an illness or long term disease. Although different in scope, these two models share the same principles. Key functions of the case manager role include:ASSESSOR
ADVOCATE
NURSE CASE MANAGER
FACILITATOR
177
PLANNER
A) Assesssor: Gather all relevant data and obtains information bay interviewing patient/family and performing careful evaluation of the entire situation. Evaluates all information related to the current treatment plan objectively and critically to identify barriers, clarify or determine realistic goals and objectives and seek potential alternatives. B) Planner: Works with patient/family to develop a treatment plan that enhances the outcomes and reduces the payee‘s liability. Includes the patient/family as a primary decision maker and goal setting. Incorporates contingency plans for each step in the process to anticipate treatment and service complications Initiates and implements plan modifications as necessary through monitoring and reevaluation to accommodate changes in treatment and progress. C) Facilitator: Actively promotes communication among team members, patient, family, health care providers and all parties involved. Collaborates between the patient and health care team to maximize outcomes. Coordinates the health delivery process by eliminating unnecessary steps and by promoting timely provision of care. D) Advocate: Incorporates the patients individualized needs and goals throughout the case management process. Supports and reduces the patient to become empowered and self reliant in self advocacy. Obtains consensus of all parties to achieve optimal outcomes. Promotes early referral to provide optimum care and cost outcomes. Represents the patient‘s best interest through advocacy for necessary funding, treatment alternatives, coordination of health services and frequent revaluation of programs and goals. Key skills for nurses in these roles include critical thinking, communication, advocacy, negotiation, holistic planning and evaluation and the ability to set both long term and short term goals. Advantages of Case Management: Promotes interdisciplinary collaboration. Increase quality of care. Cost effective. Eases patient‘s transition from hospital to community services. Disadvantages of Case Management: Nurse has increased responsibility. Requires additional training. Requires nurses to be off the unit for period of time. Time consuming. Is most useful only with high-risk/high-cost/high-volume patients.
178
THE NURSE’S ROLE ON THE HEALTH CARE TEAM: Whatever the setting, nurses fulfill a number of roles on the health care delivery system changes, the evolving role of registered nurse requires new competencies and skills in each of the roles described below: 1. Provider of care: Nurses provide direct, hands on care to patients in all health care agencies and settings. As provides, they take an active role in illness prevention and health promotion and maintenance. They offer health screenings, home health services, and an array of health care services in schools, workplaces, churches, clinics, physician‘s offices and other settings. Their breadth and depth of knowledge, their ability to care holistically for patients, and their natural partnership with physicians are making them some of the most sought after care providers. 2. Educators: Nurse educators teach patients, families, the communities, other health care team members, students and business. In hospital settings as patient and family educators nurses provide information about illness and teach about medications, treatment and rehabilitation need. In community settings, nurses after classes in injury and illness prevention and health promotion. Nurses also have a responsibility to understand and teach how a healthful or unhealthful environment may affect both the short term and long term health of community. Nurses also serve as teacher of next of next generation nurses. Nursing students need educator who set high standards and ideals and who helps students to understand ethical choices that all health care providers must make. Nurses are often the key educators on health care team. They teach other members about the patient and family and why different interventions may have varying degrees of success. Nurses help other team members find cost-effective, quality intervention that are desired and needed by the patient rather than wasting resources on ineffective, inefficient, unneeded services. 3. Counselor: People who experience illness or injury often have strong emotional responses. It is clear that emotional that the relationships among the emotions, the mind and the body are critical to promotion of and restoration to health. As counselors, nurses provide basic counseling and support to patients and their families. Using therapeutic communication techniques, nurses encourage people to discuss their feelings, to explore possible options and solutions to their unique problems, and to choose for themselves the best alternatives for action. 4. Manager: The effective management of nursing resources is essential. Nurse Manager must have strong leadership, financial, marketing, system design, outcome research and organizational behavior skills. Nurse executives must ensure the quality of nursing care with in financial, regulatory and legislative constraints. In their daily work, all nurses are managers. The bedside staff nurse must manage the care of group of patients and decide priorities, which staff members to assign to patients, and how to accomplish all the activities during an 8 or 12 period. 179
5. Researcher: Nurse researchers investigate whether current or potential nursing actions achieve their expected outcomes, what options for care may be available, and how best to provide care. Nursing research looks at patient outcomes, the nursing process, and the system that support nursing services. 6. Collaborator: The collaborator role is vital one for nurses to ensure that everyone agrees on the same patient outcomes, collaboration requires nurse understand and appreciate what other health professionals have to offer. They must also be able to interpret to others the nursing needs of patients. 7. Change agent: The role of change agent is one that requires a combination of tact, energy, creativity and interpersonal skills, most professional nursing education programs include change theory as part of their management courses and graduates are prepared to become change agents in their work settings. 8. Entrepreneur: Nurse entrepreneurs provide consultation and educational services to nurses and other health team members. They provide services to business by conducting work site wellness programs and advising human resource staff on how to provide high quality health benefits to employees while reducing costs. 9. Patient Advocate: Patient advocate are nurses who realize that policies are important and govern most situations well but occasionally can and should be broken
Fig.: role of nurse in health care team
Bibliography: ................................................................................................................................................ ............................................................................................. 180
HEALTH CARE DELIVERY CONCERNS,NATIONAL HEALTH AND FAMILY WELFARE PROGRAMMES, INTER-SECTORAL COORDINATION, ROLE OF NONGOVERNMENTAL AGENCIES Introduction: Community health nursing occurs in the context of health care delivery system and the characteristics of that system profoundly influence community health nursing practice. For instance, the lack of emphasis on health promotion in the health care delivery system increases the need for health promotion efforts by community health nurses. Health and health care concerns throughout the world, and each jurisdiction (community, state or nation) has developed a system for addressing these concerns. A health care system is all of the societal services and activities designed to protect and restore the health of individuals, families, groups, or communities, and these should cover full range of preventive, curative and rehabilitative services. Health care delivery concerns: Throughout the world, approximately 4.5 million children die each year from diarrheal diseases, while communicable diseases of all kinds remain a serious problem despite raising immunization levels for the childhood diseases from 5% to 50% of the world‘s population in the last 10 years. An assessment of the health status is required to make a plan for the health care delivery services. The assessment will bring out major health problems. And these health problems are the major health care concerns. HEALTH CONCERENED AREAS: 1. Communicable Disease Problems: – Malaria, TB, diarrheal diseases, Acute respiratory infections, Leprosy, Filaria, AIDS, Kala Azar, meningitis, Viral Hepatitis, Japanese Encephalitis, Enteric fever, Helminthes infections. – Immunization Problems. 2. Nutritional Problems: – Protein- Energy Malnutrition. – Nutritional Anemia. – Low Birth Weight. – Exophthalmia. – IDD. – Endemic fluorosis. 3. Environmental Sanitation Problems: – Lack of safe water. – Primitive method of excreta disposal. – Global concern over radiation. – Destruction of ozone layer. – Air pollution. – Lead poisoning. – Chemical contamination of food supplies. 181
4. Medical Care Problems: – Lack of medical care professionals. – Over-crowding in hospitals as a result of migration of people from rural areas. – Scarcity of resources. – Inequitable distribution of Services. – Chronic Diseases and Mental health problems. – Adolescent Pregnancy. 5. Population Problems: The population explosion has inevitable consequences in all aspects of development, especially employment, education, housing, health care, sanitation and environment. The country‘s growth rate is 1.93% and the Govt‘s goal is to reduce it to 1%. 6. Human Response to Disasters: Natural and manmade disasters are affecting large numbers. E.g. Toxic chemical leak in Bhopal in 1985. International efforts coordinated by WHO and the International Red Cross have led to the development of disaster planning groups throughout the world. “Past experience has indicated that international cooperation and effort can make a difference in the health status of the population of the world. The classic example of the benefits of such cooperation is the eradication of smallpox”.
NATIONAL HEALTH AND FAMILY WELFARE PROGRAMMES Since India became free, several measures have been undertaken by the National Government to improve the health of people. Prominent among these measures are the NATIONAL HEALTH PROGRAMMES, which have been launched by the Central Government for the control of communicable diseases, improvement of environmental sanitation, control of population etc. National Health Programmed: 1. National Anti-Malaria Programmed(NMCP): It was launched in India in April 1953.In 1999, the Government of India changed the term ― National Malaria Eradication Programmed‖ and renamed it ― National Anti-Malaria Programmed‖. 2. National Filarial Control Programmed (NFCP): It has been in operation since 1955. 3. National Leprosy Eradication Programmed (NLCP): It has been in operation since 1955.In 1983, the Leprosy control Programmed was redesignated as National Leprosy Eradication Programmed. 4. National Tuberculosis Programmed (NTP): It has been in operation since 1962.In 1992, the Government of India, WHO, and World Bank together reviewed the NTP and this programmed is called as Revised National Tuberculosis Control Programmed. 5. National AIDS Control Programmed: It was launched in 1987. In April 2002, National AIDS Prevention and Control Policy were approved by Government of India. 6. National Programmed for Control of Blindness: It was launched in 1976. 7. Iodine Deficiency Disorders Programmed: It is in operation since 1962. 8. Universal Immunization Programmed: It was launched in 1974 by WHO. 9. National Cancer Control Programmed: It was started by Government of India in year 1975-1976. 10. National Water Supply and Sanitation Programmed: It was initiated in 1954. 182
11. Minimum Needs Programmed: It was introduced in 1974-78. 12. 20-Point Programmed: It was initiated in 1975 by Government of India. 13. National Mental Health Programmed: It was launched in 1985. NATINAL FAMILY WELFARE SCHEMES The Ministry of Health and Family Welfare has a number of schemes to cover the under-privileged sections of society and help them with maternity, post and neo-natal healthcare and family planning. These include the Janani Suraksha Yojana, Rehabilitation of Polio Victims and several financial assistance schemes for surgery and other health problems. Counseling centers are also available across the country as part of the government sponsored family welfare schemes. 1. National Family Welfare Programmed: India launched the National Family Welfare Programmed in 1951 with the objective of "reducing the birth rate to the extent necessary to stabilize the population at a level consistent with the requirement of the National economy. The Family Welfare Programmed in India is recognized as a priority area, and is being implemented as a 100% centrally sponsored programmed. 2. National Population Policy: The National Population Policy, 2000 affirms the commitment of government towards voluntary and informed choice and consent of citizens while availing of reproductive health care services and continuation of the target free approach in administering family planning services. 3. National Rural Health Mission: The National Rural Health Mission (2005-12) seeks to provide effective healthcare to rural population throughout the country with special focus on 18 states, which have weak public health indicators and/or weak infrastructure. The mission aims at effective integration of health concerns with determinants of health like sanitation and hygiene, nutrition and safe drinking water through a District Plan for Health. 4. Urban Family Welfare Schemes: This Scheme was introduced following the recommendation of the Krishnan Committee in 1983. The main focus was to provide services through setting up of Health Posts mainly in slum areas. The services provided are mainly outreach of RCH services, preventive services, First Aid and referral services including distribution of contraceptives. 5. A Scheme for reservation of Sterilization beds in Hospital run by Government, Local Sterilization Beds Scheme Bodies and Voluntary Organizations was introduced as early as in the year 1964 in order to provide immediate facilities for tubectomy operations in hospitals where such cases could not be admitted due to lack of beds etc. But later with the introduction of the Post Partum Programmed some of the beds were transferred to Post Partum Programmed and thereafter the beds were only sanctioned to hospitals run by Local Bodies and Voluntary Organizations. 6.Reproductive and Child Health Programmed: The Reproductive and Child Health Programmed was launched in October 1997 incorporating new approach to population and development issues, as exposed in the International Conference in Population and Development held at Cairo in 1994.The programmed integrated and strengthened in services/interventions under the Child Survival and Safe Motherhood Programmed and Family Planning Services and added to the basket of services, new areas on Reproductive Tract/ Sexually Transmitted infections (RTI/STI). 183
The "Jansankhya Sthirata Kosh" (JSK) (National Population Stabilization Fund) has been registered as an autonomous Society established under the Societies Registration Act of 1860. JSK has to promote and undertake activities aimed at achieving population stabilization at a level consistent with the needs of sustainable economic growth, social development and environment protection, by 2045.
INTERSECTORAL COORDINATION: The Health Care System is intended to deliver health care services. It operates in context of socio-economic and political framework of the country. In India, it is represented by 5 major sectors which differ from each other. These are:• Public Sector. • Private Sector. • Indigenous System of Medicine. • Voluntary Agencies. • National Health Programmers‘ Intersect oral coordination is the basis of primary health care.Intersect oral coordination is a crucial component for promotion of intersect oral linkages which is required for the effective implementation of health services throughout the country. Intersect oral Coordination ensures convergence of basic social services in order to bring all health sector service providers into closer and more responsive working relationships for the benefit of the society. This will enable better equity and wider coverage
184
―The pulse polio drives have demonstrated that effective mobilization of civil society can achieve remarkable results hence forging of partnerships with the government departments, NGOs, the corporate sector, trade unions, human rights commission, police, legal bodies, political parties, media and academic institutions will be promoted aggressively”. Health is not everything but everything else is nothing without health: It requires enthusiastic and sustained participation of all the citizens of the country in taking responsibility for their own health as well as that of their communities. An integrated multisectoral approach is appropriate to ensure coordination between ranges of activities. Strategy for Community Participation and Intersect oral Coordination: The responsibility of seeking community participation and ensuring intersect oral coordination, which have been identified as key factors for the success of any program, can be integrated together. This responsibility can be shouldered by a single committee, which will be headed by the Project Officer. The Community Mobilization and Coordination Units and Neighborhood Councils will be important components of this Committee. Health Care as a Priority Sector: To encourage increased participation by the private sector in providing secondary and tertiary health care, the government should announce health care as a priority sector and accord it all the benefits that accrue from being accorded a priority sector such as cheaper sources of funding. Develop Inter-sectoral Linkages, Especially in Primitive and Preventive Services: There are several factors, which impact on the health of a community such as water, sanitation and sewage disposal. There are several agencies operating at different levels from the central government to the panchayat, operating individually on addressing these issues. There should be a massive effort in health education in the entire country, through school teachers, panchayat members, youth clubs, Mahila Mandals and health workers to help people inculcate a more rational and scientific understanding of health. Develop Intersect oral linkages in meeting finance and manpower requirements: India, considering its diversity, cannot have a single solution across the country. Our country would need a host of financing mechanisms to improve our health infrastructure. They have initiated schemes to encourage private sources of finance to augment constrained government spending. Multiple Financing Options to Provide for Health Care: The current system of individual spending should migrate to collective spending on health care. The government should facilitate this migrate though introducing multiple healthcare financing schemes targeted at different socio-economic segments of the population. This should be through a mix of private and public sources. Voluntary Sector in Primary Health Care: The voluntary sector should be involved in providing primary health care in a more effective manner, particularly in the neediest areas. A special fund like CAPART (Centre for Advancement of People‘s Action and Rural Technology) should be set aside for this purpose. 185
Enhanced Private Sector Participation for Increased Coverage: The government should enlist private providers to deliver preventive care through local delivery channels for specific preventive and primitive services. This would enhance the reach of the health delivery system and also reduce the need for extensive infrastructure to be established by the government. Separate Purchase and Delivery Functions: The government plays the roles of financier, purchaser and provider. These functions should be separated and the government should allow private providers to cover these roles in conjunction with the government agencies in providing better health services to the people. ADVANTAGES OF INTERSECTORAL COORDINATION: • To provide sustainable basic health services to the community and to integrate these services with other health services provided by other health sectors. • Early detection, treatment of patients within the community itself. • To promote cooperation and mutual understanding among various sectors. • To take pressure off the one sector alone. • For attaining the goal of ―Health for All‖. • To make the services available to people with early and easy access.
NON-GOVERNMENTAL AGENCIES Non-Governmental agencies arose because there was an unmet health need. They are the organizations that are formed by groups of people because of their interest in a particular health concern, such as diabetes, child abuse or, environmental pollution. Voluntary agencies are funded by donations. They are accountable to their supporters and their activities are determined by supporter‘s interest, rather than legal proceedings. Non-Governmental health agencies are of five types: 1. Voluntary Agencies. 2. Professional Agencies. 3. Philanthropic Agencies. 4. Service, Social and Religious Organizations. 5. Corporate Agencies. 1. Voluntary Agencies: Voluntary agencies play an important role in research and education, although they may provide a few direct health services. In the field of health, their role is in promotion of health, creation of awareness among people about various measures to prevent illness and provision of welfare services for victims of different types of diseases. Since official efforts alone are not sufficient to meet the health needs of the country, it is essential to have voluntary agencies to support and guard the work of official agencies. Indian red Cross Society, Hind Kusht Nivaran Sangh, Indian Council for Child Welfare, Tuberculosis Association of India, Bharat Sewak Samaj, Central Social Welfare Board, Kasturba Memorial Fund, Family Planning Association Of India, All India Women‘s Conferences, The All India Blind Relief Society are all the examples of Voluntary Agencies.
186
Role of voluntary agencies: They perform eight basic functions within the scientific health care subsystem. • Pioneering: Voluntary agencies explore areas that are underserved by the other components of the health care system e.g. research that culminated in the development of a vaccine was the early focus of the March of Dimes. And now, Polio Immunization is largely a function of official agencies. • Demonstration of Pilot Projects: in Health care Delivery • Education: Educating public and health professionals is the function of voluntary agencies. • Supplementation: Supplementation of services provided by the official health agencies. For instance, some voluntary health agencies provide transportation to clinics, respite care, special equipments and other services. • Advocacy for Public Interests: They advocate for the public health. E.g. a voluntary health agency may campaign against reduction of health care services due to budget cuts. • Legislation: Promoting legislation related to health is a closely related function Health Planning and Organization: Voluntary agencies often assist official agencies in determining health care needs in the population and in planning programs to address those needs. • Assisting Official Agencies: Voluntary agencies assist official agencies in developing well-balanced community health programmed. E.g. Voluntary agencies often provide services that fill gaps in services available from official agencies. 2. Professional health organizations: Professional agencies are made of health professionals who have completed specialized education and have met the standards of registration, licensure for their respective field‘s .e.g. American Nursed Association, INC, PNRC etc. Role of Professional Agencies: • Promoting high standards of professional practice for their specific profession, thus improving health of society. • Certification of continuing- education programmed for professional renewal. • Lobbying: for example, INC has a powerful lobby nationally. Their purpose is to affect legislation in such a way as to benefit their membership and their profession. 3. Philanthropic Foundations: These foundations support community health throughout the world by funding programmed and research on the prevention, control and treatment of many diseases. E.g. Rockefeller Foundation funds the international health projects. ―The development of vaccine for yellow fever by a scientist funded by the Rockefeller foundation is an example of one such long- range project”. Other such foundations are: • Commonwealth Fund( contributes to community health in rural communities) • Ford Foundation( contributes to family planning efforts throughout the world) Service, Social and Religious Organizations: • These play an important role in community health e.g. Rotary clubs. Lions Club • Members enjoy social interactions with people of similar interests in addition to fulfilling the needs of communities. 187
• Though their specific mission is not health, but they make important contributions in that direction by raising money and funding health- related problems. • Religious groups donate money for missions. It should be noted that some religious groups have hindered the work of community health workers. • Almost every community in the country can provide an example where a religious organization has protected the offering of a school district‘s sex education programmed. 4. Corporate Agencies: These agencies support health related programmed both at and away from the worksite. Worksite programmers aimed at trimming employee medical bills. Away worksite, the activities go beyond traditional sponsorship of youth and may include community health fairs, screening programmers for specific health problems.
188
INFORMATION, EDUCATION AND COMMUNICATION (IEC) I) Introduction: The importance of health education as been increasingly realized during last three decades so much so that health education has emerged as a specialty in itself. The aim of the health education is to bring about a change in health behavior of the people in such a manner that the harmful health practices given up while good ones are reinforced. II) Objectives: General Objective: On completion of class group will have in depth knowledge regarding information education and communication. Specific objective: After completion of the session the group will be able to 1. Explain the definition of IEC. 2. List down Principles of health education. 3. Describe the Objectives. 4. Enumerate the steps and developing materials of IEC. 5. Explain counseling and role of Counselor 6. Describe major components of IEC. III) Terminologies: 1. Information - resource, message, Facts. 2. Education - Knowledge, learning processes. 3. Communication – interactions. 4. Essential – necessary. IV) Definition And Concepts: INFORMATION Defined as to describe it as one (or) more statement or fact that is received by a human which have some form of worth to him. Information affects the perspective of the recipient person. The facts and figures that are received by human have to be true and factual to be labeled as information. Lays, fare hood counterfactual information is not information itself but is called Misinformation. Building Information Base SERVICE INFORMATION DISEASE INFORMATION Where facilities are available What are the skills available? What is the cost of services?
causes of disease Symptom of disease Consequences of disease Benefit of treatment EDUCATION It is the process by which behavioral changes takes place in an individual as a result of experience which he has undergone. Education in a learning process or a series of learning experience through which as individual inform and orients himself to develop skills and intelligent action.
189
COMMUNICATION Communication is the process of attempting to change the behavior of other. The communication job is chiefly helping people learn to look at things in a new way by sharing ideas and information. When people exchange idea and information they can work together better, sharing entails parting with information that gives. Power communication is a general term for the flow of information linking people or place. It is therefore the process of exchanging news forts opinion and massagers individual. V) The essentials of IEC: Information, education and communications (IEC) combines strategies, approaches and methods that enable individuals, families, groups, organizations and communities to play active roles in achieving, protecting and sustaining their own health. Embodied in IEC is the process of learning that empowers people to make decisions, modify behaviors and change social conditions. Activities are developed based upon needs assessments, sound education principles, and periodic evaluation using a clear set of goals and objectives. IEC activities should never be developed or implemented independently from a broader reproductive health program me that is being designed and executed in the country. IEC activities not only need to have an appropriate context in which they are shaped, but it is crucial that health services providers be prepared to respond to any demand that may be created as a result of effective IEC activities. The influence of underlying social, cultural, economic and environmental conditions on health are also taken into consideration in the IEC processes. Identifying and promoting specific behaviors that are desirable are usually the objectives of IEC efforts. Behaviors are usually affected by many factors including the most urgent needs of the target population and the risks people perceive in continuing their current behaviors or in changing to different behaviors. Health information can be communicated through many channels to increase awareness and assess the knowledge of different populations about various issues, products and behaviors. Channels might include interpersonal communication (such as individual discussions, counseling sessions or group discussions and community meetings and events) or mass media communication (such as radio, television and other forms of oneway communication, such as brochures, leaflets and posters, visual and audio visual presentations and some forms of electronic communication). Good communication between users and providers of any service is essential; but it is especially important when providing RH services, given the sensitive nature of some of the issues that are addressed (such as sexual violence. female genital mutilation, and providing contraceptives to adolescents). Accordingly, IEC approaches must be carefully and appropriately designed and selected. Although good ―one - to - one‖ communication at the point of service provision is essential for transmitting information and building trust the client, communication with other individuals and groups within the community is also vital. It is through such communication networks that service providers can obtain information about users‘ needs, priorities and concerns; such informal information gathering is the first step in assessing needs (which can be supplemented by other more formal means-see section below). 190
It also helps providers better understand the specific setting and context in which they are working, which will be useful in the later development of IEC approaches, messages and materials. These types of conversations, or passing on information by ―word - of - mouth‖, has been shown to be one of the most effective communication channels for acquiring knowledge and promoting desired changes in behavior. Evidence of this is the speed with which rumors spread and the force of their impact. Field staff should not ignore these informal opportunities to educate the public through casual conversation with the people in the community. Once a refugee situation stabilizes, it becomes appropriate to consider the development of more elaborate and formal IEC strategies. This requires serious thought and significant allocation of time and resources. The steps involved in the development of IEC are outlined here, but this is not intended to be an exhaustive guide. Whatever materials and format program me is developed, it is important to ensure that the different aspects are coordinated and that the content of any messages and the media used to convey those messages are complementary. It is also vital to ensure that people are provided with the necessary support and resources to act in the manner advised. III) Information Education Communication (IEC) Training Scheme: The information education and communication training scheme was launched by the Ministry of Health and Family Welfare, with financial assistance from USAID on 17th November 1987 in four Hindi speaking states of UP, MP, Rajasthan and Bihar in phased manner. Thus the Ministry of Health and Family Welfare abroad the scheme to continue as a plan scheme under the 8th plan and made budgetary provision as part of the IEC division of the Ministry. Objectives of IEC: 1. Increase the reach of services by making visit of worker and supervisor more predictable and regular. 2. Improve the quality of services through knowledge and skill development of worker. 3. Make supervision more oriented towards problem solving. 4. Link supervision with training at various levels. 5. Concentrate on local field problems both for development of training material and their users. 6. Combine interpersonal communication strategy with mass media approach. 7. Improve performance level through continuous with village community volunteers. Major Component of IEC: 1. Visit schedules 2. Training 3. Supervision 4. Monitoring and Evaluation Visit Schedules: Under IEC scheme the tour programs of health worker one drawn as a weekly schedule rather than date wise calendar schedule, new system attempts to make the visit regular, week days in a fortnight of a particular village. To establish a link between villager and workers. The Village is divided into units of twenty households. 191
Training: Training should not only cover technical aspect of program but also focus on problem solving skills of workers. This is possible only when the worker is given training in the work situation by their immediate supervisor at regular intervals. Training in this project in conducted at sector PHC level and district level according to a predetermined schedule. Supervision: Each supervisor during visit 1. Records. 2. Target achievements. 3. New Instruction. Monitoring and Evaluation: Success of any program depends of ability to monitor and evaluate program adequately and accurately and to take corrective action if necessary. IV. Steps in Developing IEC activities: The Information gathered through the needs assessment provides the framework for the development of suitable IEC activities and materials must always be culturally sensitive and appropriate. These are the major steps you should follow when designing an IEC activity. 1. Conduct a needs assessment: Set the goal. This is a broad statement of what you would like to see accomplished with the target audience in the end. 2. Establish behavioral objectives that will contribute to achieving the goal: Develop the IEC activities and involve as many other partners as possible. After their successful implementation, you should be able to have a significant impact on achieving the behavioral objectives. 3. Identify potential barriers and ways of overcoming them. 4. Identify potential barriers and ways of overcome them. 5. Establish an evaluation plan. The indicators should determine the level of achievement of the behavioral objectives. Having such specific indicators makes evaluating and monitoring the progress and impact of the activities much easier. Additionally, process indicators could be established to track to what extent and how well the planned activities have been carried out. V. IEC Messages: Develop IEC messages A good message is short accurate and relevant. It will make, at the most 3 points. It should be disseminated in the language of the target audience and should use vocabulary appropriate for that audience. The message tone may be humorous, didactic, authoritative, and rational of emotionally appealing. It may be intended as a one-time appeal or as repetitive reinforcement. It is often necessary to develop several versions of a message depending on the audience to whom it is directed. For example, differing information about contraceptive services will be relevant to women who already have three or four children already, from that which would be appropriate for adolescents who are just beginning to be sexually active. Their needs and priorities are different, so the IEC materials used with each group must also differ. Find out of materials already exist in the host country or country of origin and if appropriate, use these instead of developing new ones. 192
Pre-testing by trying out the materials with small groups from your target audience is an essential part of developing messages and educational materials. It is through pre-testing that you will ensure that people understand the message as intended. Pre-testing may need to be repeated frequently until you are sure your information is being conveyed as desired. Determine suitable methods and channels of action and communications. Once the target audience is identified and researched and the key message have been chosen, it is time to decide which media and combinations of information channels will reach the target group. Both formal and informal groups can be targeted. Different channels do different jobs. Each has its own strengths and weakness, depending the role it will take in the communication program me. The choice of messages and media will be influenced by many factors: cost, literacy levels; artistic style within the community; familiar with, and extent of penetration of a particular medium of both service providers and users; and availability of the medium in the target population‘s community. The development and refinement of messages and the choice of the communication channel or medium are inseparable. Very different messages will be developed for different media, for example radio, stories, poems, songs, posters of flip charts, for the nature of the medium affects what message can be successfully used. The skills of those using the materials must also be considered, it may be necessary to provide training to those using the materials. For example, it is important to recognize that placing a picture or poster on a clinic wall at which people may or may not look is quite different from using a series of pictures in the form of a flip chart as an educational tool in a group setting. Thus to train the people in healthy living or to impart health education one has to motivate them to do things conductive to health or to adopt health practices. VII) Objectives Of Health Education And Promotion: It may be recalled that according to the definition adopted by the National Conference on Preventive Medicine. Health education is a process that inform motivates in helps people to adopt and maintain healthy practices and life styles. There are two objectives. 1. Informing people: Information is a basic right. It is also a prerequisite to proper awareness and assessment of once duties and rights. Human is a basic right of all human beings and health information help problem become aware of their health problems in developing proper perception about them is seeking appropriate solution for same. 2. Motivating People: More information is not sufficient. The knowledge that tobacco and alcohol are harmful to health does not, in itself, ensure that people will give them up i.e. Motivation of the people to adopt a certain behavior. This motivation must be developed in them by a process of change of behavior. Ex: Before people voluntarily practice family planning they must be motivated and mentally planning they must be motivated or mentally prepared and willing to adopt the small family norm. 193
VIII) Principles of Health Education: 1. The aim of health education is to bring about a change in health behavior: Health education must 1st create a need in the mind of the people and also stimulates interest in them to fulfill that need. Only then will health education succeed such situation call for a proper educational diagnosis about different factors influencing the community such as beliefs prejudices resources perception, attitude. 2. Health education is not an artificial teaching learning exercise: Health educator should start not by demolishing the present attitudes and values but by building upon those that the community already has slowly trying to bring about change but guiding peoples thinking towards the desired change. 3. Health education should involve free discussion: There should be a free flow of communication between the people and the health educator. The health problem their possible solution and the good and bad points of the solution should be thoroughly and honestly discussed, without trying to conceal anything. This helps in clearing all doubts in the minds of the people. Health education should remember his job is not to instruct people about certain do‘s and do not‘s but rather to let them assess and compare themselves the new and old ideas on the basis of past experience so that they may take their own decision that appear beneficial. 4. Tell only what is needed: It is important that the health educator especially if he in an expert, should not start telling all that he knows about the subject he should clearly understand the health problem. He should then limit the content of health education to telling only that which is necessary important and relevant using simple language. 5. Do not give conflicting information: Health educator should be consistent in what he tells the people. Different health worker should not give contradictory message regarding a particular problem. 6. Try to change only what needs to be changed: Health education should focus attention on health behavior which is undoubtedly harmful. An example of the latter in the practice of not giving clearly vegetables to pregnant women in some part of India. Harm belief and practices: 1. For the first 3 days the child should not be breastfed and colostrums should be discarded. • No liquids should be given to infant when they suffer from diarrhea • Weighing the children at young age will cast and evil eye on them • Eruption fever like measles chicken pox, small pox are due to the anger of some Goddess who needs to be appeared through prayer and offering. 7. Educator should make himself acceptable: The health educator should always remember that he in to assume the role of a professor but of an enabler his task in to use the ability of the people to understand their health problem to find solution for the same to put that solution into practice. a) He should be friendly and sympathetic. b) He should be knowledgeable. c) He should be praise what he teaches. d) He should talk the language of the people. 194
e) He should employ all possible method of education. 8. Use audiovisual aids wherever possible: Such aids make the topic more lively, interesting and comprehensible. They may be essential to explain certain technically complex messages. Knowledge depends upon perception is directly proportional to the number of some organ involved on perception. 9. Choose a proper medium of communications: The medium will vary depending upon the nature of the target clientele for the health message. 10. Communication must be good: Health educator has to communicate with people so as to get this message across to them. This is obvious that these cannot be good health education 11. Health education should be planned properly: It is always desirable to plan any activity or program properly. This is especially so in case of health educator unplanned health education may be good as wasted. 12. Health education should be provided in graded loses: It is futile to try to give too many health messages to the community at the same time. People have limited power for comprehending what a technical expert may think to be very simple themes. 13. The health educator should put into practice the principles of community organization: The health educator should put into practice the principles of community organization. IX) Communication in Health education and training: Communication deals with transmission of information or ideas and sharing and exchanging the same. Since education implies transfer of knowledge. Communication in an essential component of education. Three essential part of a communication system are the communicator or sender. The three dimension of message are the code (the symbols e.g. the alphabet in which it is transmitted the content 9th subject matter) and the treatment. Treatment of a message refers to the manner in which the message is prepared. Principles of communication: 1. The sender’s and receiver’s perception should be as close as possible: Very often two people though find it difficult to understand each other because of their different perception 2. The message should be of good quality a good messages should be: a) Simple. b) Accurate. c) Adequate. d) Clear. e) Specific. f) Significant. g) Applicable h) Appropriate and timely attractive or appealing. In accordance with the laid down objectives. In time with the metal and socioeconomic level of audience. 195
3. Communication should involve as many sense organs as possible: Communication is one of the effective when more than one sense organ is involved when a message in delivered on radio only auditory and visual senses of involved. 4. Communication should be two ways: Unilateral communication from the sender to the receiver is not fully effective. It does not allow for any feedback from the receiver of the communication. Hence it is not possible for the communicator to improve and modify his message and technique of communication according to needs of receiver. 5. Direct Communication is more effective: Is most effective when it is face to face. In this situation more sense organ are involved and constant immediate feedback is available enabling expert communicator to modify his own perception and message according to the need of the communicate. X) The Role of the Counselors of IEC: The counselor‘s role is to provide accurate and complete information to help the user make her/his own decision about which, if any, part of the services (s) he will use. The role of the counselor is not to offer advice or decide on the service to be used. For example, the counselor will explain the available family planning methods, their side effects and for whom they are considered most suitable. The user then makes a decision, based on the information given, about which method she/he wishes to use. Effective counseling requires understanding one‘s own values and not influencing the user‘s by imposing, promoting or displaying them, particularly in cases where the provider‘s and the user‘s values are different.
196
TELEMEDICINE ― Watson, come here I want you‖ said Alexander Graham Bell on March 20, 1876, when he inadvertently spilled battery acid on himself, while making the world‘s first telephone call. Little did Bell realize that this was indeed the world‘s first telemedical consultation? We have come a long way since then. Today even tele surgery is a reality. Introduction: Secondary and tertiary medical expertise is not available in several areas of the world. Quite often, many patients are sent elsewhere at considerable expense. In a number of these cases the treatment could have been carried out by the local doctor with advice from a specialist. Even within a country there is a tendency for specialists to concentrate in the big cities making medical care in suburban and rural areas sub optimal Using a PC, a scanner, a digital camera networking, appropriate software and telecommunications it will be possible to transfer clinical data from any part of the world to any other part. Offering medical advice remotely, using state of the art telecommunication tools is now a regular feature in several parts of the world. Telemedicine is becoming an integral part of health care services in several countries including the UK, USA, Canada, Italy, Germany, Japan, Greece, and Norway and now in India. Several studies have shown telemedicine to be practical, safe and cost effective.. Telemedicine hinges on transfer of text, reports, voice, images and video, between geographically separated locations. Success relates to the efficiency and effectiveness of the transfer of information. Telemedicine is primarily focused on providing support towards curing an illness. Today we have expanded the scope of telemedicine to include the preventive and promotive aspects of healthcare. This new avatar is called Telehealth, Tele-Health, E Health or EHealth. Basics: The term 'telemedicine' has been derived from the Greek 'tele' meaning 'at a distance' and 'medicine' which is from the Latin word 'mederi' meaning 'healing'. Time magazine called Telemedicine ―healing by wire‖. Though initially considered ―futuristic‖ and ―experimental‖ Telemedicine is today a reality and has come to stay. This phrase was first coined in the 70s by Thomas Bird. The European Commission's health care telematics programmed defines telemedicine as: "rapid access to shared and remote medical expertise by means of telecommunications and information technologies, no matter where the patient or relevant information is located." .A major goal of telemedicine is to eliminate unnecessary travelling of patients and their escorts. Image acquisition, image storage, image display and processing, and image transfer represent the basis of telemedicine. In plain speak, telemedicine is a process by which a patient is able to communicate his problems (along with, if necessary, details of medical investigations) to a doctor many miles away and receive necessary and relevant medical advice. In a lighter vein, when your doc, on the phone, told you to 'take an aspirin and call me in the morning' he was actually practicing telemedicine! 197
The terms e-health and tele health are at times wrongly interchanged with telemedicine. Like the terms "medicine" and "healthcare", telemedicine often refers only to the provision of clinical services while the term tele health can refer to clinical and nonclinical services such as medical education, administration, and research. The term ehealth is often, particularly in the UK and Europe, used as an umbrella term that includes tele health, electronic medical records, and other components of health IT. Definition: Telemedicine can be defined as, ―the use of modern information technology, especially two- way interactive audio/video telecommunications, computers, and telemetry to deliver health services to remote patients and to facilitate information exchange between primary care physicians and specialists at some distance from each other.‖ (Telemedicine: Theory and Practice). Telemedicine is a rapidly developing application of clinical medicine where medical information is transferred via telephone, the Internet or other networks for the purpose of consulting, and sometimes remote medical procedures or examinations. Telemedicine is a method, by which patients can be examined, investigated, monitored and treated, with the patient and the doctor located in different places. In Telemedicine one transfers the expertise, not the patient. Hospitals of the future will drain patients from all over the world without geographical limitations. Telemedicine may be as simple as two health professionals discussing a case over the telephone, or as complex as using satellite technology and video-conferencing equipment to conduct a real-time consultation between medical specialists in two different countries. Telemedicine generally refers to the use of communications and information technologies for the delivery of clinical care. Specialties: Telemedicine covers a growing number of medical specialties such as: Cardiology. Home Care. Radiology. Emergency Care. Surgery. Dermatology. Psychiatry. Oncology. Pathology. Ophthalmology. Hematology. E.N.T. Nephrology. Pre hospital Care. Growth of Tm Applications: • 2001: Tele-radiology –still images. • 2002: Tele-cardiology – Moving images. • 2003: Tele-pathology, Tele-ophthalmology. • 2004: Tele-oncology, Tele-surgery. 198
• 2005: Mobile Tele Health – augmentation. • 2006 : Telemedicine for Primary healthcare --VRC History of Telemedicine: Care at a distance (also called in absentia care), is an old practice which was often conducted via post; there has been a long and successful history of in absentia health care, which - thanks to modern communication technology - has metamorphosed into what we know as modern telemedicine. In its early manifestations, African villagers used smoke signals to warn people to stay away from the village in case of serious disease. In the early 1900s, people living in remote areas in Australia used two-way radios, powered by a dynamo driven by a set of bicycle pedals, to communicate with the Royal Flying Doctor Service of Australia. The idea of performing medical examinations and evaluations through the telecommunication network is not new. Shortly after the invention of the telephone, attempts were made to transmit heart and lung sounds to a trained expert who could assess the state of the organs. However, poor transmission systems made the attempts a failure. 1906: ECG Transmission Einthoven, the father of electrocardiography, first investigated on ECG transmission over telephone lines in 1906! He wrote an article ―Le tele cardiograms‖ at the ―Archives Internationals Physiologies‖ 4:132, 1906 1920s: Help for ships Telemedicine dates back to the 1920s. During this time, radios were used to link physicians standing watch at shore stations to assist ships at sea that had medical emergencies. 1924: The first exposition of Telecare Perhaps it was the cover showed below of "Radio News" magazine from April 1924. The article even includes a spoof electronic circuit diagram which combined all the gadgets of the day into this latest marvel! (Information and photo by courtesy of Dennis J. Streveler Ph.D. Health care IT Consultant). 1955: Telepsychiatry The Nebraska Psychiatric Institute was one of the first facilities in the country to have closed-circuit television in 1955. In 1971 the Nebraska Medical Center was linked with the Omaha Veterans Administration Hospital and VA facilities in two other towns. 1967: Massachusetts General Hospital This station was established in 1967 to provide occupational health services to airport employees and to deliver emergency care and medical attention to travelers. 1970s: Satellite telemedicine Via ATS-6 satellites. In these projects, paramedics in remote Alaskan and Canadian villages were linked with hospitals in distant towns or cities. 1971, Japan: First time implemented in two areas: Nakatsu-mura and Kozagawa-cho, Wakayama using telephone line for voice and Fax transmission and CATV system for image transmission.
199
1972, Japan: Between Aomori Teishin Hospital and Tokyo Teishin Hospital over 4 Mhz TV channel and several telephone lines. Other systems came up for tele radiology in several places in Japan like, Nagasaki, Tokai etc. Applications In Different Forms: Information exchange between Hospitals and Physicians. Networking of group of hospitals, research centers. Linking rural health clinics to a central hospital. Videoconferencing between a patient and doctor, among members of healthcare teams. Training of healthcare professionals in widely distributed or remote clinical settings. Instant access to medical knowledgebase, technical papers etc. Types Of Telemedicine: Telemedicine is practiced on the basis of two concepts: Real time (synchronous) Store-and-forward (asynchronous). Real time telemedicine could be as simple as a telephone call or as complex as robotic surgery. It requires the presence of both parties at the same time and a communications link between them that allows a real-time interaction to take place. Video-conferencing equipment is one of the most common forms of technologies used in synchronous telemedicine. There are also peripheral devices which can be attached to computers or the video-conferencing equipment which can aid in an interactive examination. For instance, a tele-otoscope allows a remote physician to 'see' inside a patient's ear; a tele-stethoscope allows the consulting remote physician to hear the patient's heartbeat. Medical specialties conducive to this kind of consultation include psychiatry, family practice, internal medicine, rehabilitation, cardiology, pediatrics, obstetrics, gynecology, neurology, and pharmacy. Store-and-forward telemedicine involves acquiring medical data (like medical images, biosignals etc) and then transmitting this data to a doctor or medical specialist at a convenient time for assessment offline. It does not require the presence of both parties at the same time. Dermatology (cf: teledermatology), radiology, and pathology are common specialties that are conducive to asynchronous telemedicine. A properly structured Medical Record preferably in electronic form should be a component of this transfer. Telemedicine is most beneficial for populations living in isolated communities and remote regions and is currently being applied in virtually all medical domains. Specialties that use telemedicine often use a "tele-" prefix; for example, telemedicine as applied by radiologists is called Teleradiology. Similarly telemedicine as applied by cardiologists is termed as telecardiology, etc. Telemedicine is also useful as a communication tool between a general practitioner and a specialist available at a remote location. Monitoring a patient at home using known devices like blood pressure monitors and transferring the information to a caregiver is a fast growing emerging service. These remote monitoring solutions have a focus on current high morbidity chronic diseases and are mainly deployed for the First World. 200
In developing countries a new way of practicing telemedicine is emerging better known as Primary Remote Diagnostic Visits whereby a doctor uses devices to remotely examine and treat a patient. This new technology and principle of practicing medicine holds big promises to solving major health care delivery problems in for instance Southern Africa because Primary Remote Diagnostic Consultations not only monitors an already diagnosed chronic disease, but has the promise to diagnosing and managing the diseases a patient will typically visit a general practitioner for. Technology Trends In Telemedicine: The concept of telemedicine was introduced more than 30 years ago through the use of telephone, facsimile machine, and slow-scan images. However, the enabling technology has grown considerably in the past decade. The term telemedicine, in short refers to the utilization of telecommunication technology for medical diagnosis, treatment and patient care. Telemedicine enables a physician or specialist at one site to deliver health care, diagnose patients, give intra-operative assistance, provide therapy, or consult with another physician or paramedical personnel at a remote site. Telemedicine system consists of customized medical software integrated with computer hardware, along with medical diagnostic instruments connected to the commercial VSAT (Very Small Aperture Terminal) at each location or fiber optics. Although, telemedicine could potentially affect all medical specialties, the greatest current applications are found in radiology, pathology, cardiology and medical education. Perhaps the greatest impact of telemedicine may be in fulfilling its promise to improve the quality, increase the efficiency, and expand the access of the healthcare delivery system to the rural population and developing countries. Third-generation wireless cellular systems will offer video telephony that can facilitate the transfer of real-time images to help with communications between a patient or a caregiver and a health-care professional. Interestingly, this technology offers exactly the kind of cost effective solutions for the specific needs arise in rural area situation. Being cost effective, it opens an innovative way to connect rural areas to the cities that already have connectivity to the Internet or have resources available on LAN. Thus, it enables to bridge the digital divide and provides a channel for communication to the rural mass. It also makes it possible to get a timely feedback of the health problems taking place in remote areas. In situations of epidemic outbreaks such timely information can save a significant number of lives. As wireless technology becomes more ubiquitous and affordable, applications such as video-telephony over POTS will gradually migrate towards third-generation wireless systems. These techniques promise to greatly improve the cost and convenience associated with long-term outpatient monitoring, and could potentially extend monitoring to the broader healthy population for preventative diagnostics and alerts. Virtual reality as most of us are aware of is the ultimate simulation, like entering the rabbit hole in Alice in Wonderland. Applications in virtual reality for medicine pertain to the planning of surgeries and use of data fusion, i.e., to fuse virtual patients onto real patients as navigation aid in surgery. While research into tele-surgery helps to jump-start robotics in the operating room, 201
distant operations have remained an elusive application. However, it may eventually prove to be one of the most significant uses of robotic surgery. Telemedicine In Defense: In early times, following a battle, the opposing forces retired or the day, leaving the surgeons to go to the battlefield and attend to the wounded. The focus of casualty care turned toward first aid with rapid evacuation to the surgeon and hospital, rather than upon immediate advanced medical care to the individual soldier. Regrettably, many soldiers did not arrive for treatment within this golden hour for trauma surgery. They never lived to receive the benefit of the sophisticated combat medical system in the rear echelons. Modern technology may make it possible to reduce mortality at the front lines by utilizing that golden hour and placing emphasis upon sending the surgeon back to the front lines in real time –- but with telepresence. Medical efforts within the defense services show growing acceptance of telemedicine technologies. Surveying the leading edges of technology in remote sensing and medical informatics reveals an opportunity to fundamentally change the way battle-field casualty care is provided. The keys are remote monitoring of every soldier‘s location and vital signs with Personal Status Monitor (PSM) assistance at the casualty side to the medic from a remote physician with Telementoring, providing immediate surgical care on the battlefield with Telepresence surgery, monitoring en route therapeutics and transportation of casualties in a Trauma Pod, simulation of battle wounds for surgical practice and medical forces planning and training with virtual reality. However, defense services place particular emphasis on encryption and other security measures for telemedicine. Computer based telemedicine systems for military or commercial customers can offer strong safeguards to keep unauthorized eyes and ears from sensitive information. The core technologies of medical informatics and networking are in existence today, but major commitment will be required to integrate them into a system for the medical battlefield of the coming century. First application of telemedicine was made in disasters during the mid-1980s. There are number of types of disasters such as earthquakes, nuclear/hazardous chemical accidents, civil disorder/riots, bomb threats/terrorist attacks, bio-wars etc. In such situations, the existing terrestrial infrastructure could be damaged. The space systems then suitably complement partly destroyed terrestrial infrastructure to answer the requirements of emergency healthcare services such as fast deployment of the management of logistic and medical means or remote medical expertise. Appropriate new telemedicine applications can improve future disaster medicine outcomes, based on lessons learned from a decade of civilian and military disaster (widearea) telemedicine deployments. Emergency care providers must begin to plan effectively to utilize disaster-specific telemedicine applications to improve future outcomes. As telemedicine technologies and processes gradually mature, the extent and breadth of medical specialties where telemedicine technologies could prove clinically useful should expand. Indeed, reports of telemedicine implementations are appearing in orthopedics, dermatology, psychiatry, oncology, neurology, pediatrics, internal medicine, ophthalmology and surgery.
202
The price of the underlying technologies for telemedicine is dropping, and so is the number of available specialist. Those trends, combined with the increased availability of telecommunications facilities, indicate that telemedicine will grow more common. As it becomes more routine, you will not hear the term ‘telemedicine.‘ It won‘t be thought of as anything special. Medisoft telemedicine pvt. Ltd. Company: Med soft Telemedicine Pvt. Ltd. is a research based development company. Objective: To improve health care delivery by setting the highest standards in the field of public health with the help of telemedicine and ehealth. Goal: To provide accessibility of medical practitioners to the remotest regions through state of the art technologies with optimal economical outcomes. At Med soft, we firmly believe that quality healthcare is the right to all. Telemedicine In India: • Existing system limited only to private hospital. • APPOLO Group of Hospitals. • RN Tagore Cardiac Hospital, Calcutta. (Asia Heart Foundation). • No Telemedicine system for public health care. • Corporate Sectors Offering Telemedicine Systems. • APPOLO Group. • Online Telemedicine System, Ahmedabad. • WIPRO GE. • SIEMENS. Telemedicine At Apollo: Apollo Hospitals have been the pioneer in the field of telemedicine in India. It was the first to set up the rural telemedicine Centre in the village of Aragonda in the state of Andhra Pradesh. It has now evolved as the single most and largest solution provider for telemedicine in India. Telemedicine Services at Apollo: Telemedicine reduces the burden of inferior medicine access by utilizing technology, reducing time and cost for transportation of patients, incorporates direct clinical, preventive, diagnostic, and therapeutic services and treatment, consultative and follow-up services, remote monitoring of patients, services for rehabilitation and education for patients. The expertise at Apollo is widely appreciated throughout the world and brings in patients form all around to the Apollo clinics. Apollo telemedicine facilities can help the patients sitting outside India to consult the doctors at the Apollo and communicate with him through telephone, video conferences and other communication technologies. That way, the patients are equipped with knowledge and information prior to their medical tours. Even after the treatment is over and the patients go back, follow up and post treatment reviews and consultation can be done through telemedicine. Telemedicine in India can meet the challenges of health care delivery in an organized and cost efficient manner providing better exchange of information, medical expertise and health care access.
203
Telemedicine Technology Evolution in India: – Point to point. – Point to multipoint. – Multipoint to multipoint. – Tele-education. Requirement Specification:
Requirement Specification Nodal Nodal Hospital Hospital
• A patient getting treated
• A Doctor • A remote telemedicine console having audio visual and data conferencing facilities
POTS / ISDN
• An expert/ specialized doctor Referral Referral Hospital Hospital
• A central telemedicine server having audio visual and data conferencing facility
Sequence Of Operation:
Sequence of Operation PATIENT IN
Day One
Patient visits OPD Local Doctor checks up
Patient receives local treatment and not referred to telemedicine system
Patient referred to the Telemedicine system (some special investigations may be suggested) Patient visits Telemedicine data-entry console. Operator entries patient record, data and images of test results, appointment date is fixed for online telemedicine session Offline Data transfer from Nodal Centre
204
OUT
OUT
Day Two
Sequence of Operation
Patient 1 Patient 2 Patient 3 Patient 4 . . .
Online conference for the patient. IN
Patient, local doctors at the nodal hospital and specialist doctors at the referral hospital
Patient queue
The Data: • Data related to a patient‘s personal information. • Data related to a patient‘s medical information. • Data for patient management in Telemedicine. • Data related to the doctors. • Data for system management. Personnel Involved: Referral end: • A group of specialist doctors. • System Administrator. • Studio technician. Nodal end: • A group of general physicians. • System administrator. • Data entry operator. • Studio technician. • Patients. Patient’s Personal Information: • Patient ID • Name • Age • Sex • …… 205
OUT
Patient’s Medical Information: Textual. Plain Text. Structured Document. Image. Graphics. Video. Vector. Data Related To The Doctors: • Doctor‘s personal information. • Unique Identification key. Data for System Management: Users‘ list Password file Log files Advantages Of Telemedicine: Our research has shown that players in healthcare institutions can gain great benefits from telemedicine. In particular, telemedicine can provideCompetitive Advantages: better quality: e.g. faster treatments with lower level of contamination for the patient; reduction of cost: e.g. economies of scale and scope; information procurement; e.g. university-level diagnostic competence for small hospital standardization: e.g. organizational and administrative processes; specialization: e.g. telemedicine-based networks will support professionalization, and specialization (Gogan, 1999); IT competence: e.g. increasing number of digital modalities telemedicine will penetrate the local routine processes in hospitals and to sustain the IT competence required. availability of human resources: e.g. better coordination of Enlistment periods for radiologists across a teleradiology network; shared digital archives: e.g. digital archives are an expensive resource and build boundaries for new entrants; procurement: e.g. telematics-based networks change the bargaining power of healthcare institutions; Continued development of treatments: e.g. much better date base of patient records through telematics-based networks. Imagine the advantages it confers upon a patient who is miles away from the nearest medical aid post, in some cases this could even be life saving. For The Patient: Telemedicine is cutting edge technology which has the potential to enlighten YOUR life whatever your background. As a patient it makes life extremely comfortable and brings super-specialist services almost to your door step, where ever you live.
206
Availability of selected basic, intermediate and advanced medical facilities within 3 to 5 KMs of a patient's residence. Reduction in travel to distant referral medical centers. Reduction in cost of medicare. Better diagnoses of diseases due to availability of specialist opinions. Increased and better monitoring of chronic cases. Increased domiciliary care. Tele-counseling of selected psychiatric cases. Telemedicine can thus avoid unnecessary travel and expense for the patient and the family improve outcomes and even save lives. Once the ―virtual presence‖ of the specialist is acknowledged, a patient can access resources in a tertiary referral centre without the constraints of distance. Telemedicine allows patients to stay at home ensuring much needed family support. For The Gp: As a rural GP you find the 24 hr advice of specialists not only a great support but also a relief as it saves many of your patients‘ long trips to the nearest city hospital. Better diagnoses of diseases due to availability of specialist opinions. Reduction in nosocomial infections due to increased OPD and domiciliary care. Increased and better monitoring of chronic cases. Ability to update oneself. Ability to discuss cases with peers and request advice from specialists. The general practitioner in the rural/suburban area often feels that he would loose his. With Telemedicine the community doctor continues to primarily treat the patient to the city consultant. patient under a specialist‘s umbrella. With modern software/hardware at either end 90% of the normal interaction can be accomplished through Telemedicine. For The State: Better monitoring of disease patterns and trends. Reduction in diseases due to increased OPD and domiciliary care. Early notification of communicable diseases. Reduced cost of medicare. Reduction in urban migration from villages due to better medicare. Improved preventive health care measures. For The Corporate Hospital/Business Man: Increased profits from increased virtual specialist referrals. A profitable franchise . Increased utilization of specialists. Reduced requirement of superspecialists. Reduced cost of medicare. A positive public relations exercise. Tax write offs, as telemedicine schemes are generally encouraged by many states. To a Hospital Administrator or the CEO of a hospital it means extended reach, higher efficiency, greater patient satisfaction and higher profits. 207
An Insurance Agency sees it as a means to cover a larger group of people at lower costs. Others:
Advantages of telemedicine in India: Doctors licensed to practice all over India, Maximum utilisation of limited resources Saves travel, time and money, Makes Geography History!! International grand rounds, Web casting conferences, Motivation for computer literacy among doctors Useful in designing credits for re certification of doctor
It can make specialty care more accessible to underserved rural and urban populations. Video consultations from a rural clinic to a specialist can aggravate prohibitive travel and associated costs for patients. Video conferencing also opens up new possibilities for continuing education or training for isolated or rural health practitioners, who may not be able to leave a rural practice to take part in professional meetings or educational opportunities. India –the land of the future! 65% of 1100 million will be literate by 2005 60% of rural India has access to TV coverage. 60% of rural India has access to TV coverage. 650,000 existing PCOs ® internet kiosks,. 400,000 villages already have telephone connections. Internet users in India 2m Dec 2001, 8.5m 2003. Hardware, software and brain ware all available. Technical Issues Over Low Bandwidth: Problem Solution • Longer time for data transfer - Store and forward policy • Poor video quality - Transferring sequence of still images Barriers To Telemedicine: There are several barriers to the practice of telemedicine such as:-
208
The lack of procedural proficiency and unavailability of resources, High infrastructure costs. Many potential telemedicine projects have been hampered by the lack of appropriate telecommunications technology. Regular telephone lines do not supply adequate bandwidth for most telemedical applications. Many rural areas do not have cable wiring or other kinds of telecommunications access required for more refined uses, so those who could most benefit from telemedicine may not have access to it. Pressure on the appropriate government and legislative agencies will surely increase as more people realize the benefits of telemedicine. Disadvantages: Kokesh sees only one disadvantage to telemedicine—perhaps it might best be called too much of a good thing. ―It‘s really hard to match your capacity to do telemedicine with what can be an unpredictable growth rate,‖ he notes. ―When we started, we had two to three cases a week. Now, we have 80 to 90 cases a week.‖ McBeath cites the difficulty of reimbursement as a major obstacle to the growth and development of the Texas Tech program. Others: – Licensing across state lines. – Lack of standards. – Difficulty training users and maintaining equip. – Cost of telecom infrastructure. – ―Last mile‖. – Do rural homes have PCs?. – Patient confidentiality. CONCLUSION: Telemedicine will soon be just another way to see a health care professional, just as seeing friends and family while talking to them on the phone is becoming commonplace. Technology manufacturers and telecommunications companies are already vying with each other to produce the low–cost equipment and bandwidth needed. Distance education is common place and most educational institutions, and many companies allay travel costs for meetings by using video. Ten years or fifteen years ago we had no idea we would rely heavily on faxes, answering machines and e–mail, tools which are now low– tech and taken for granted. Since early 2000, the ramifications of E–Health (a general term encompassing health care delivery, administration and information dissemination) and its relationship to telemedicine are being analyzed.
209
BIBLIOGRAPHY: www.google.com www.telemed.com www.AMDTelemedicine.com www.medisoftTelemedicine.com www.telemedindia.org/ www.thamburaj.com/telemedicine
210
UNIT-III
211
SYLLABUS Unit
Hours
III
10
Content Genetics: �Review of cellular division, mutation and law of inheritance, human genome project, The Genomic era. �Basic concepts of Genes, Chromosomes & DNA. �Approaches to common genetic disorders. �Genetic testing – basis of genetic diagnosis, Pre symptomatic and predisposition testing, Prenatal diagnosis & screening, Ethical, legal & psychosocial issues in genetic testing. �Genetic counseling. �Practical application of genetics in nursing.
212
What is behavioral genetics? [Txt provided by Joseph McInerney] Sir Francis Galton (1822-1911) was the first scientist to study heredity and human behavior systematically. The term "genetics" did not even appear until 1909, only 2 years before Galton's death. With or without a formal name, the study of heredity always has been, at its core, the study of biological variation. Human behavioral genetics, a relatively new field, seeks to understand both the genetic and environmental contributions to individual variations in human behavior. This is not an easy task, for the following reasons. It often is difficult to define the behavior in question. Intelligence is a classic example. Is intelligence the ability to solve a certain type of problem? The ability to make one's way successfully in the world? The ability to score well on an IQ test? During the late summer of 1999, a Princeton molecular biologist published the results of impressive research in which he enhanced the ability of mice to learn by inserting a gene that codes for a protein in brain cells known to be associated with memory. Because the experimental animals performed better than controls on a series of traditional tests of learning, the press dubbed this gene "the smart gene" and the "IQ gene," as if improved memory were the central, or even sole, criterion for defining intelligence. In reality, there is no universal agreement on the definition of intelligence, even among those who study it for a living. Having established a definition for research purposes, the investigator still must measure the behavior with acceptable degrees of validity and reliability. That is especially difficult for basic personality traits such as shyness or assertiveness, which are the subject of much current research. Sometimes there is an interesting conflation of definition and measurement, as in the case of IQ tests, where the test scores itself has come to define the trait it measures. This is a bit like using batting averages to define hitting prowess in baseball. A high average may indicate ability, but it does not define the essence of the trait. Behaviors, like all complex traits, involve multiple genes, a reality that complicates the search for genetic contributions. As with much other research in genetics, studies of genes and behavior require analysis of families and populations for comparison of those who have the trait in question with those who do not. The result often is a statement of "heritability," a statistical construct that estimates the amount of variation in a population that is attributable to genetic factors. The explanatory power of heritability figures is limited, however, applying only to the population studied and only to the environment in place at the time the study was conducted. If the population or the environment changes, the heritability most likely will change as well. Most important, heritability statements provide no basis for predictions about the expression of the trait in question in any given individual. What indications are there those behaviors has a biological basis? [text provided by Joseph McInerney] Behavior often is species specific. A chickadee, for example, carries one sunflower seed at a time from a feeder to a nearby branch, secures the seed to the branch between its feet, pecks it open, eats the contents, and repeats the process. Finches, in contrast, stay at the 213
feeder for long periods, opening large numbers of seeds with their thick beaks. Some mating behaviors also are species specific. Prairie chickens, native to the upper Midwest, conduct an elaborate mating ritual, a sort of line dance for birds, with spread wings and synchronized group movements. Some behaviors are so characteristic that biologists use them to help differentiate between closely related species. Behaviors often breed true. We can reproduce behaviors in successive generations of organisms. Consider the instinctive retrieval behavior of a yellow Labrador or the herding posture of a border collie. Behaviors change in response to alterations in biological structures or processes. For example, a brain injury can turn a polite, mild-mannered person into a foul-mouthed, aggressive boor, and we routinely modify the behavioral manifestations of mental illnesses with drugs that alter brain chemistry. More recently, geneticists have created or extinguished specific mouse behaviors—ranging from nurturing of pups to continuous circling in a strain called "twirler"— by inserting or disabling specific genes. In humans, some behaviors run in families. For example, there is a clear familial aggregation of mental illness. Behavior has an evolutionary history that persists across related species. Chimpanzees are our closest relatives, separated from us by a mere 2 percent difference in DNA sequence. We and they share behaviors that are characteristic of highly social primates, including nurturing, cooperation, altruism, and even some facial expressions. Genes are evolutionary glue, binding all of life in a single history that dates back some 3.5 billion years. Conserved behaviors are part of that history, which is written in the language of nature's universal information molecule—DNA. How is behavioral genetics studied? [text provided by Joseph McInerney] Traditional research strategies in behavioral genetics include studies of twins and adoptees, techniques designed to sort biological from environmental influences. More recently, investigators have added the search for pieces of DNA associated with particular behaviors, an approach that has been most productive to date in identifying potential locations for genes associated with major mental illnesses such as schizophrenia and bipolar disorder. Yet even here there have been no major breakthroughs, no clearly identified genes that geneticists can tie to disease. The search for genes associated with characteristics such as sexual preference and basic personality traits has been even more frustrating. Genetics and molecular biology have provided some significant insights into behaviors associated with inherited disorders. For example, we know that an extra chromosome 21 is associated with the mental retardation that accompanies Down's syndrome, although the processes that disrupt brain function are not yet clear. We also know the steps from gene to effect for a number of single-gene disorders that result in mental retardation, including phenylketonuria (PKU), a treatable metabolic disorder for which all newborns in the United States are tested. In general, it is easier to discern the relationship between biology and behavior for chromosomal and single-gene disorders than for common, complex behaviors that are of considerable interest to specialist and no specialist alike. So the former are at the more informative end of a sliding scale of certainty with respect to our understanding of human 214
behavior. At the other end of the scale are the hard-to-define personality traits, while somewhere in between are traits such as schizophrenia and bipolar disorder—organic diseases whose biological roots are undeniable yet unknown and whose unpredictable onset teaches us about the importance of environmental contributions, even as it reminds us of our ignorance. What implications does behavioral genetics research have for society? [text provided by Joseph McInerney and Mark Rothstein] Researchers in the field of behavioral genetics have asserted claims for a genetic basis of numerous physical behaviors, including homosexuality, aggression, impulsivity, and nurturing. A growing scientific and popular focus on genes and behavior has contributed to a resurgence of behavioral genetic determinism—the belief that genetics is the major factor in determining behavior. Are behaviors inbred, written indelibly in our genes as immutable biological imperatives, or is the environment more important in shaping our thoughts and actions? Such questions cycle through society repeatedly, forming the public nexus of the "nature vs. nurture controversy," a strange locution to biologists, who recognize that behaviors exist only in the context of environmental influence. Nonetheless, the debate flares anew every few years, reigniting in response to genetic analyses of traits such as intelligence, criminality, or homosexuality, characteristics freighted with social, political, and legal meaning. What social consequences would genetic diagnoses of such traits as intelligence, criminality, or homosexuality have on society? What effect would the discovery of a behavioral trait associated with increased criminal activity have on our legal system? If we find a "gay gene," will it mean greater or lesser tolerance? Will it lead to proposals that those affected by the "disorder" should undergo treatment to be "cured" and that measures should be taken to prevent the birth of other individuals so afflicted? There are several scientific obstacles to correlating genotype (an individual's genetic endowment) and behavior. One problem is in defining a specific endpoint that characterizes a condition, be it schizophrenia or intelligence. Another problem is in identifying and excluding other possible causes of the condition, thereby permitting a determination of the significance of a supposed correlation. Much current research on genes and behavior also engenders very strong feelings because of the potential social and political consequences of accepting these supposed truths. Thus, more than any other aspect of genetics, discoveries in behavioral genetics should not be viewed as irrefutable until there has been substantial scientific corroboration. How do genes influence behavior? No single gene determines a particular behavior. Behaviors are complex traits involving multiple genes that are affected by a variety of other factors. This fact often gets overlooked in media reports hyping scientific breakthroughs on gene function, and, unfortunately, this can be very misleading to the public. For example, a study published in 1999 claimed that over expression of a particular gene in mice led to enhanced learning capacity. The popular press referred to this gene as "the learning gene" or the "smart gene." What the press didn't mention was that the learning enhancements observed in this study were short-term, lasting only a few hours to a few days in some cases. 215
Dubbing a gene as a "smart gene" gives the public a false impression of how much scientists really know about the genetics of a complex trait like intelligence. Once news of the "smart gene" reaches the public, suddenly there is talk about designer babies and the potential of genetically engineering embryos to have intelligence and other desirable traits, when in reality the path from genes to proteins to development of a particular trait is still a mystery. With disorders, behaviors, or any physical trait, genes are just a part of the story, because a variety of genetic and environmental factors are involved in the development of any trait. Having a genetic variant doesn't necessarily mean that a particular trait will develop. The presence of certain genetic factors can enhance or repress other genetic factors. Genes are turned on and off, and other factors may be keeping a gene from being turned "on." In addition, the protein encoded by a gene can be modified in ways that can affect its ability to carry out its normal cellular function. Genetic factors also can influence the role of certain environmental factors in the development of a particular trait. For example, a person may have a genetic variant that is known to increase his or her risk for developing emphysema from smoking, an environmental factor. If that person never smokes, then emphysema will not develop. Where can I learn more about the genetics of different behavioral traits? Online Mendelian Inheritance in Man (OMIM) is a large, searchable, up-to-date database of human genes, genetic traits, and disorders. Each OMIM record contains bibliographic references and a summary of the scientific literature describing what is known about a particular gene, trait, or disorder. The following behavioral traits are included in OMIM. The six-digit number MIM number is used to uniquely identify each record. Hand skill, relative (handedness): (139900) Hand clasping pattern: (139800) Arm folding preference: (107850) Ears, ability to move: (129100) Tongue curling, folding, or rolling: (189300) Musical perfect pitch: (159300) Novelty seeking personality trait: (601696) Stuttering: (184450) Tobacco addiction: (188890) Alcoholism: (103780) Homosexuality: (306995) You also may want to search OMIM for behavioral traits not included in the list above. For step-by-step instructions, see our OMIM Search Tutorial. For more detailed information, review the Help and FAQs pages. For information on other databases of human genes, see the Gene and Protein Database Guide available through Gene Gateway. Behavioral Genetics Links: General Information: University of Pennsylvania Behavioral Genetics Laboratory Virginia Institute for Psychiatric and Behavioral Genetics o Behavioral Genetics A downloadable book and special supplement from AAAS and the Hastings Center o Genetics and Human Behavior - Health feature from the BBC in the U.K. 216
o
DNA & Behavior: Is Our Fate in Our Genes? - An overview of the science and social implications of research in behavior genetics. From The DNA Files, last updated October 2001. o Personality Traits: Nature and Nurture - Audio file of a radio program from SoundVision Productions. From The DNA Files. o Genes, Environment, and Human Behavior -- Educational module targeted to teachers includes five student activities and extensive background information on the methods and assumptions of behavioral genetics (2000). Articles: o Toward Behavioral Genomics - Article from Science (February 2001). o Learning About Addiction From the Genome - Article from Nature (February 2001). o Caution urged for brain research on violence--from CNN (July 28, 2000) o Judging Molecular Biology of Murder, Addictive Disorders, and Dementia - Meeting proceedings, Human Genome News 11(1-2) o Genes and Behavior: A Complex Relationship - Article by Joseph D. McInerney, Judicature 83, 112 (November-December 1999). o The Impact of Behavioral Genetics on the Law and the Courts - Article by Mark A. Rothstein, Judicature 83, 116 (November-December 1999). o Recent Developments in Human Behavioral Genetics: Past Accomplishments and Future Directions - Am. J. Hum. Genet. 60, 1265 (1997 ASHG Statement). Associations: o Behavior Genetics Association o Society of Behavioral Medicine o International Society of Behavioral Medicine o International Society for the Study of Behavioral Development Books: Behavioral Genetics in the Post genomic Era, by Robert Plomin, John C. Defries, Ian Craig, and Peter McGuffin, eds., and Jerome Kagan. 2002, 608 pp. Behavioral Genetics: The Clash of Culture and Biology by Ronald A. Carson and Mark A. Rothstein. 1999, 224 pp. Behavioral Genetics by Robert Plomin (Editor), John C. Defries, Gerald E. McClearn, Peter McGuffin. 2000, 4th edition, 449 pp. Living With Our Genes: Why They Matter More Than You Think by Dean H. Hamer and Peter Copeland. 1999, 368 pp. Genetics of Mental Disorders: A Guide for Students, Clinicians, and Researchers by S.V. Faraone, M.T. Tsuang, and D.W. Tsuang. Guilford Press (1999), 272 pp. Send the url of this page to a friend Last modified: Tuesday, September 16, 2008 Home * Contacts * Disclaimer Base URL: www.ornl.gov/hgmis Site sponsored by the U.S. Department of Energy Office of Science, Office of Biological and Environmental Research, Human Genome Program
217
Behavioral genetics: Dictionary: behavioral genetics Sponsored Links B.Sc. - Medical Lab Tech. Industry Oriented Syllabi. Great Placement-Build A Rewarding Career www.amity.edu/AmityAdmission DNA Analysis Software Easy, Intuitive, and Integrated Try A Fully Functional Demo! www.clcbio.com Home > Library > Literature & Language > Dictionary n. The study of the genetic underpinnings of behavioral phenotypes such as eating or mating activity, substance abuse, social attitudes, violence, and mental abilities.
Answers.com ▼ Home Page Browse Personalize Print page Email page Translate page WikiAnswers.com ▼ Home Page Browse Recently Answered Recently Asked Unanswered questions Search Help Search unanswered questions... Browse: Unanswered questions | Most-recent questions | Reference library 5min Related Video: behavioral genetics Top o o o o o o o o o o o
218
Sci-Tech Encyclopedia: Behavior genetics Home > Library > Science > Sci-Tech Encyclopedia The study of the hereditary factors of behavior. Charles Darwin, who originated the theory that natural selection is the basis of biological evolution, was persuaded by Francis Galton that the principles of natural selection applied to behavior as well as physical characteristics. Members of a species vary in the expression of certain behaviors because of variations in their genes, and these behaviors have survival value in some environments. One example of such a behavior is curiosity—some organisms are more curious than others, and in some settings curiosity is advantageous for survival. The science of behavior genetics is an extension of these ideas and seeks (1) to determine to what extent the variation of a trait in a population (the extent of individual differences) is due to genetic processes, to what extent it is due to environmental variation, and to what extent it is due to joint functions of these factors (heredity-environment interactions and correlations); and (2) to identify the genetic architecture (genotypes) that underlies behavior. Traditionally, some of the clearest and most indisputable evidence for a hereditary influence on behavior comes from selective-breeding experiments with animals. Behavior genetic research has utilized bacteria, paramecia, nematodes, fruit flies, moths, houseflies, mosquitoes, wasps, bees, crickets, fishes, geese, cows, dogs, and numerous other organisms. Breeding of these organisms allows genetically useful types of relationships, such as half-sibs, to be produced easily. Artificial selection (selective breeding) can be used to obtain a population that scores high or low on specific traits. Inbred strains of many animals, particularly rodents, are readily available, and the study of various types of crosses among them can provide a wealth of information. An experimental design using the recombinant inbred-strain method shows great promise for isolating single-gene effects. This procedure derives several inbred strains from the F2 generation (grandchildren) produced by a cross between two initial inbred strains. Since it is possible to exert a great deal of control over the rearing environments, the experimenter can manipulate both heredity and environment. Other work has focused on the effects of the environment and genotype-environment interactions. For example, experiments with mice have shown that, with respect to several learning tasks, early environmental-enrichment effects and maternal effects were quite small, relative to the amount of normal genetic variation found in the strains of mice tested. Only a few genotype-environment interactions were found. Still other work has shown that early experiences affect later behavior patterns for some strains but not others (a genotype-environment interaction). An increasing role for animals in genetic research is to provide models of human genetic diseases, many of which have behavioral features. Such animal models may occur naturally or may be engineered in the laboratory. Animal models are available for many neurobehavioral disorders, including narcolepsy, various epilepsies, and alcoholism. The availability of animal models allows researchers to obtain information about the development of genetic disorders and the effects of different environments on this 219
development, as well as to explore treatment options. While it is not always prudent or desirable to generalize from animal results to humans, it is assumed that basic genetic systems work in similar ways across organisms, and it is likely that these types of animal studies will play a key role in elucidating the ways in which environment influences phenotypic variation. With advances in genetic technology, it is possible to observe genetic variation more directly by locating, identifying, and characterizing genes themselves. The effects of a single gene on behavior have been most extensively studied in the domain of mental retardation. Research has shown that there are a large number of metabolic pathways which have defects due to a single gene. Over 100 of these defects influence mental ability. One such single-gene defect is classic phenylketonuria (PKU), an autosomal recessive disorder, which also illustrates the role that environment can play in the expression of a trait. Individuals who are homozygous (having two copies of the PKU allele) are unable to make the enzyme phenylalanine hydroxylase, which converts the essential amino acid phenylalanine to tyrosine, a nonessential amino acid. Instead, the excess phenylalanine builds up in the blood and is converted into phenylpyruvic acid, which is toxic to the developing nervous system in large amounts. The main effect of untreated PKU is severe mental retardation, along with a distinctive odor, light pigmentation, unusual gait and posture, and seizures. Many untreated individuals with PKU show fearfulness, irritability, and violent outbursts of temper. See also Mental retardation; Phenylketonuria. Every organism develops in a particular environment, and both genes and environment control development. It is, therefore, not possible to state that a particular behavioral trait is either genetic or environmental in origin. It is possible, however, to investigate the relative contributions of heredity and environment to the variation among individuals in a population. With humans, it is possible to obtain approximate results by measuring the similarity among relatives on the trait of interest. Twins are often used in such studies. One method compares the similarity within pairs of both identical twins and fraternal twins reared together. Identical twins have all their genes in common by descent, since they arise from a single fertilized egg. Fraternal twins arise from two fertilized eggs and so share on average one-half of their genes. If it is assumed that the effects of the shared environments of the two types of twins are equal (a testable assumption), greater resemblance between identical twins than fraternal twins should reflect the proportion of genes they share, and the difference between the correlations of the two twin types should represent about one-half the genetic effect. A second type of twin study compares not only twins reared together but twins who have been reared apart. The degree of similarity between identical twins reared in the same home would reflect the fact that all their genes are identical and that they share a common family environment. On the other hand, if identical twins can be located who had been adopted by different families chosen at random (an unlikely event, since adopted children tend to be selectively placed), a measure of their degree of similarity would reflect only the effect of their common genes. If it were true that an individual's level on a measure (for example, extroversion) is determined in large part by the characteristics of his or her family and the opportunities that the family makes available to him or her, reared-apart identical twins should be no more alike than pairs of individuals chosen at random. If 220
they do exhibit some degree of similarity, it would reflect genetic effects alone. The existence of even very large genetic effects, however, would in no way imply that the environment was unimportant in the development of the trait; it would simply imply that environment was less important than genes in determining the variation among individuals on the trait in question at the time of measurement. That is, the individuals would differ more because of the genes they carry than because of the particular environments to which they were exposed. In another range of environments, the results might be different. See also Twins (human). Developmental psychologists are finding that differences in children's behavioral phenotypes are due more to their different genotypes than to their different rearing environments, as long as those environments are within a normal range of experiences. Identifying environmental variables from this normal range that have an important effect on the behavioral phenotype may be even more difficult than identifying contributing genes. Advances in theory and new technologies, combined with information from more traditional methodologies, will continue to provide insight into the contributions of genes and environment to behavior. Sponsored Links What's Synthetic Biology? Nanotech + Genetic Engineering? Learn and win a great prize! www.SynbioProject.org Articles on Genetics My Wire - current and archived articles from premier publications www.MyWire.com Britannica Concise Encyclopedia: behavior genetics Top Home > Library > Miscellaneous > Britannica Concise Encyclopedia The study of the interaction of heredity and environment insofar as they affect behavior. The question of the determinants of behavior, commonly called the "nature-nurture" controversy, was initially investigated by English scientist Sir Francis Galton. A balanced view that recognized the importance of both genetics and environment prevailed in the 1970s. Modern research is focused on identifying genes that affects behavioral dimensions, such as personality and intelligence, and disorders, such as depression and hyperactivity. Two quasi-experimental methods of study, the twin method and the adoption method, are used to quantify the genetic and environmental contributions to an individual's behavior. For more information on behavior genetics, visit Britannica.com. Sponsored Links Class VI to Class XII Free NCERT/CBSE Solutions, Tests, Videos, Animations and more www.meritnation.com
221
Jobs in Genetics Companies Hiring Experts in India & Submit Your Resume Free. Now! MonsterIndia.com Wikipedia: Behavioral genetics Top Home > Library > Miscellaneous > Wikipedia A significant amount of this article's content may actually relate to an entirely different subject. See coatrack articles and content forking for details. (May 2008) This article is in need of attention from an expert on the subject. Wiki Project Biology or the Biology Portal may be able to help recruit one. (April 2009) Behavioral genetics is the field of biology that studies the role of genetics in animal (including human) behavior. The field is an overlap of genetics, etiology and psychology. Classically, behavioral geneticists have studied the inheritance of behavioral traits.
Francis Galton Contents: [hide] 1 History 2 Contemporary behavioral genetics 3 Methods of human behavioral genetics 4 References 5 External links History: In 1869, Francis Galton published the first empirical work in human behavioral genetics, Hereditary Genius. Here, Galton intended to demonstrate that "a man's natural abilities are derived by inheritance, under exactly the same limitations as are the form and physical features of the whole organic world." Like most seminal work, he overstated his conclusions. His was a family study on the inheritance of giftedness and talent. Galton was aware that resemblance among familial relatives can be a function of both shared genes and shared environments. Contemporary behavioral genetics studies special 222
populations—in human research, twins and adoptees and in animal research, specially bred strains and lines—to separate genetic from environmental effects. The initial impetus behind behavioral genetic research was to demonstrate that there were indeed genetic influences on behavior. In psychology, this phase lasted for the first half of the 20th century largely because of the overwhelming influence of behaviorisms in the field. Later behavioral genetic research focused on quantitative methods, and today there is a large emphasis on applying techniques from molecular genetics to analyse individual genes that influence behaviour. Contemporary behavioral genetics: Currently, the largest branch of human behavioural genetics is psychiatric genetics which studies phenotypes such as schizophrenia, bipolar disorder, and alcoholism. Recent trends in behaviour genetics have indicated an additional focus toward researching the inheritance of human characteristics typically studied in developmental psychology. For instance, a major focus in developmental psychology has been to characterize the influence of parenting styles on children. However, in most studies, genes are a confounding variable. Because children share half of their genes with each parent, any observed effects of parenting styles could be effects of having many of the same genes as a parent (e.g. harsh aggressive parenting styles have been found to correlate with similar aggressive child characteristics: is it the parenting or the genes?). Thus, behaviour genetics research is currently undertaking to distinguish the effects of the family environment from the effects of genes. This branch of behaviour genetics research is becoming more closely associated with mainstream developmental psychology and the sub-field of developmental psychopathology as it shifts its focus to the heritability of such factors as emotional self-control, attachment, social functioning, aggressiveness, etc. Several academic bodies exist to support behaviour genetic research, including the International Behavioural and Neural Genetics Society, Behavior Genetics Association, the International Society for Psychiatric Genetics, and the International Society for Twin Studies. Behaviour genetic work features prominently in several more general societies, for instance the International Behavioral Neuroscience Society. Methods of human behavioural genetics: Human behavioural geneticists use several designs to answer questions about the nature and mechanisms of genetic influences on behaviour. All of these designs are unified by being based around human relationships which disentangle genetic and environmental relatedness. So, for instance, some researchers study adopted twins: the adoption study. In this case the adoption disentangles the genetic relatedness of the twins (either 50% or 100%) from their family environments. Likewise the classic twin study contrasts the differences between identical twins and fraternal twins within a family compared to differences observed between families. This core design can be extended: the so-called "extended twin study" which adds additional family members, increasing power and allowing new genetic and environmental relationships to be studied. Excellent examples of this model are the Virginia 20,000 and the QIMR twin studies. Also possible are the "children of twins" design (holding maternal genetic contributions equal across children with paternal genetics and family environments; and the "virtual 223
twins" design - unrelated children adopted into a family who are very close or identical in age to biological children or other adopted children in the family. While the classical twin study has been criticized they continue to be of high utility. There are several dozen major studies ongoing, in countries as diverse as the USA, UK, Germany, France, The Netherlands, and Australia, and the method is used widely in fields as diverse as dental caries, BMI, aging, substance abuse, sexuality, cognitive abilities, personality, values, and a wide range of psychiatry disorders. This is broad utility is reflected in several thousands of peer-review papers, and several dedicated societies and journals (See Twin study). REFERENCES: Carey, G. (2003) Human Genetics for the Social Sciences. Thousand Oaks, CA: Sage Publications. DeFries, J. C., McGuffin, P., McClearn, G. E., Plomin, R. (2000) Behavioral Genetics 4th ED. W H Freeman & Co. Scott, J.P. and Fuller, J.L. (1965) Genetics and the Social Behavior of the Dog. University of Chicago Press. Weiner, J. (1999) Time, Love, Memory : A Great Biologist and His Quest for the Origins of Behavior. Knopf Scott, J.P. and Fuller, J.L. (1965) Genetics and the Social Behavior of the Dog. University of Chicago Press. Pinker, S. (2002) The Blank Slate: The Modern Denial of Human Nature. van Abeelen, J.H.F., ed (1974). The Genetics of Behaviour. Amsterdam: North Holland. pp. 450. ISBN 0720471370. OCLC 1365968. External links: US Human Genome Project on Behavioral Genetics This entry is from Wikipedia, the leading user-contributed encyclopedia. It may not have been reviewed by professional editors (see full disclaimer) Donate to Wikimedia Sponsored Links Genetic Family Tree Software to draw genetic pedigree. Free Trial available, Download Now! genopro.com/family-tree-software Learn More: Boulder: Education and Research (city, Colorado) Model Organisms NIMH (National Institute of Mental Health) (intelligence) What is best after bsc genetics msc with genetics or mba? Read answer... Who is known as the father of genetics for his work in the feild of genetics? Read answer...
224
Give two problems that make the study of human genetics much more difficult than study of plant or animals genetics? Read answer... Help us answer these Are particularly important in genetics research that is the focus of behavioral genetics? Is there such an institution as the International College for Behavioral Genetics in Ogden Utah? Behavioral genetics have identified the DNA sequences for most psychological disorders? Post a question - any question - to the WikiAnswers community: Copyrights: Dictionary. The American Heritage® Dictionary of the English Language, Fourth Edition Copyright © 2007, 2000 by Houghton Mifflin Company. Updated in 2007. Published by Houghton Mifflin Company. All rights reserved. Read more Sci-Tech Encyclopedia. McGraw-Hill Encyclopedia of Science and Technology. Copyright © 2005 by The McGraw-Hill Companies, Inc. All rights reserved. Read more Britannica Concise Encyclopedia. Britannica Concise Encyclopedia. © 2006 Encyclopædia Britannica, Inc. All rights reserved. Read more Wikipedia. This article is licensed under the GNU Free Documentation License. It uses material from the Wikipedia article "Behavioural genetics". Read more
225
What is a gene mutation and how do mutations occur? A gene mutation is a permanent change in the DNA sequence that makes up a gene. Mutations range in size from a single DNA building block (DNA base) to a large segment of a chromosome. Gene mutations occur in two ways: they can be inherited from a parent or acquired during a person‘s lifetime. Mutations that are passed from parent to child are called hereditary mutations or germ line mutations (because they are present in the egg and sperm cells, which are also called germ cells). This type of mutation is present throughout a person‘s life in virtually every cell in the body. Mutations that occur only in an egg or sperm cell, or those that occur just after fertilization, are called new (de novo) mutations. De novo mutations may explain genetic disorders in which an affected child has a mutation in every cell, but has no family history of the disorder. Acquired (or somatic) mutations occur in the DNA of individual cells at some time during a person‘s life. These changes can be caused by environmental factors such as ultraviolet radiation from the sun, or can occur if a mistake is made as DNA copies itself during cell division. Acquired mutations in somatic cells (cells other than sperm and egg cells) cannot be passed on to the next generation. Mutations may also occur in a single cell within an early embryo. As all the cells divide during growth and development, the individual will have some cells with the mutation and some cells without the genetic change. This situation is called mosaicism. Some genetic changes are very rare; others are common in the population. Genetic changes that occur in more than 1 percent of the population are called polymorphisms. They are common enough to be considered a normal variation in the DNA. Polymorphisms are responsible for many of the normal differences between people such as eye color, hair color, and blood type. Although many polymorphisms have no negative effects on a person‘s health, some of these variations may influence the risk of developing certain disorders. For more information about mutations: The National Cancer Institute offers a discussion of hereditary mutations and information about acquired mutations . The Welcome Trust offers a brief overview of mutations and polymorphisms . The Centre for Genetics Education provides a fact sheet discussing changes to the genetic code Mutations: In the living cell, DNA undergoes frequent chemical change, especially when it is being replicated (in S phase of the eukaryotic cell cycle). Most of these changes are quickly repaired. Those that are not result in a mutation. Thus, mutation is a failure of DNA repair. Single-base substitutions A single base, says an A, becomes replaced by another. Single base substitutions are also called point mutations. (If one purine [A or G] or pyrimidine [C or T] is replaced by the other, the substitution is called a transition. If a purine is replaced by a pyrimidine or vice-versa, the substitution is called a transversion.) 226
Missense mutations With a missense mutation, the new nucleotide alters the codon so as to produce an altered amino acid in the protein product. EXAMPLE: sickle-cell disease The replacement of A by T at the 17th nucleotide of the gene for the beta chain of hemoglobin changes the codon GAG (for glutamic acid) to GTG (which encodes valine). Thus the 6th amino acid in the chain becomes valine instead of glutamic acid. ANOTHER EXAMPLE: Patient A with cystic fibrosis (scroll down). Nonsense mutations With a nonsense mutation, the new nucleotide changes a codon that specified an amino acid to one of the STOP codons (TAA, TAG, or TGA). Therefore, translation of the messenger RNA transcribed from this mutant gene will stop prematurely. The earlier in the gene that this occurs, the more truncated the protein product and the more likely that it will be unable to function. EXAMPLE: Patient B Here is a sampling of the more than 1000 different mutations that have been found in patients with cystic fibrosis. Each of these mutations occurs in a huge gene that encodes a protein (of 1480 amino acids) called the cystic fibrosis transmembrane conductance regulator (CFTR). The protein is responsible for transporting chloride ions through the plasma membrane. The gene encompasses over 6000 nucleotides spread over 27 exons on chromosome 7. The numbers in the mutation column represent the number of the nucleotides affected. Defects in the protein cause the various symptoms of the disease. Unlike sickle-cell disease, then, no single mutation is responsible for all cases of cystic fibrosis. People with cystic fibrosis inherit two mutant genes, but the mutations need not be the same. In one patient with cystic fibrosis (Patient B), the substitution of a T for a C at nucleotide 1609 converted a glutamine codon (CAG) to a STOP codon (TAG). The protein produced by this patient had only the first 493 amino acids of the normal chain of 1480 and could not function. 227
Silent mutations Most amino acids are encoded by several different codons. For example, if the third base in the TCT codon for serine is changed to any one of the other three bases, serine will still be encoded. Such mutations are said to be silent because they cause no change in their product and cannot be detected without sequencing the gene (or its mRNA). Splice-site mutations The removal of intron sequences, as pre-mRNA is being processed to form mRNA, must be done with great precision. Nucleotide signals at the splice sites guide the enzymatic machinery. If a mutation alters one of these signals, then the intron is not removed and remains as part of the final RNA molecule. The translation of its sequence alters the sequence of the protein product. Insertions and Deletions (Indels): Extra base pairs may be added (insertions) or removed (deletions) from the DNA of a gene. The number can range from one to thousands. Collectively, these mutations are called indels. Indels involving one or two base pairs (or multiples thereof) can have devastating consequences to the gene because translation of the gene is "frameshifted". This figure shows how by shifting the reading frame one nucleotide to the right, the same sequence of nucleotides encodes a different sequence of amino acids. The mRNA is translated in new groups of three nucleotides and the protein specified by these new codons will be worthless. Scroll up to see two other examples (Patients C and D). Frameshifts often create new STOP codons and thus generate nonsense mutations. Perhaps that is just as well as the protein would probably be too garbled anyway to be useful to the cell. Indels of three nucleotides or multiples of three may be less serious because they preserve the reading frame (see Patient E above). However, a number of inherited human disorders are caused by the insertion of many copies of the same triplet of nucleotides. Huntington's disease and the fragile X syndrome are examples of such trinucleotide repeat diseases. Fragile X Syndrome Several disorders in humans are caused by the inheritance of genes that have undergone insertions of a string of 3 or 4 nucleotides repeated over and over. A locus on the human X chromosome contains such a stretch of nucleotides in which the triplet CGG is repeated (CGGCGGCGGCGG, etc.). The number of CGGs may be as few as 5 or as many as 50 without causing a harmful phenotype (these repeated nucleotides are in a noncoding region of the gene). Even 100 repeats usually cause no harm. However, these longer repeats have a tendency to grow longer still from one generation to the next (to as many as 4000 repeats). This causes a constriction in the X chromosome, which makes it quite fragile. Males who inherit such a chromosome (only from their mothers, of 228
course) show a number of harmful phenotypic effects including mental retardation. Females who inherit a fragile X (also from their mothers; males with the syndrome seldom become fathers) are only mildly affected. This image shows the pattern of inheritance of the fragile X syndrome in one family. The number of times that the trinucleotide CGG is repeated is given under the symbols. The gene is on the X chromosome, so women (circles) have two copies of it; men (squares) have only one. People with a gene containing 80–90 repeats are normal (light red), but this gene is unstable, and the number of repeats can increase into the hundreds in their offspring. Males who inherit such an enlarged gene suffer from the syndrome (solid red squares). (Data from C. T. Caskey, et al.). Huntington's Disease In this disorder, the repeated trinucleotide is CAG, which adds a string of glutamines (Gln) to the encoded protein (called hunting tin). The abnormal protein increases the level of the p53 protein in brain cells causing their death by apoptosis. Muscular Dystrophy Some forms of muscular dystrophy that appear in adults are caused by tri- or tetranucleotide, e.g. (CTG)n and (CCTG)n, repeats where n may run into the thousands. The huge RNA transcripts that result interfere with the alternative splicing of other transcripts in the nucleus. Duplications Duplications are a doubling of a section of the genome. During meiosis, crossing over between sister chromatics that are out of alignment can produce one chromatic with an duplicated gene and the other (not shown) having two genes with deletions. In the case shown here, unequal crossing over created a second copy of a gene needed for the synthesis of the steroid hormone aldosterone.
However, this new gene carries inappropriate promoters at its 5' end (acquired from the 11-beta hydroxyls gene) that cause it to be expressed more strongly than the normal gene. The mutant gene is dominant: all members of one family (through four generations) who inherited at least one chromosome carrying this duplication suffered from high blood pressure and was prone to early death from stroke. Gene duplication has also been implicated in several human neurological disorders. Gene duplication has occurred repeatedly during the evolution of eukaryotes. Genome analysis reveals many genes with similar sequences in a single organism. Presumably these paralogous genes have arisen by repeated duplication of an ancestral gene. Such gene duplication can be beneficial.
229
o
Over time, the duplicates can acquire different functions. The proteins they encode can take on different functions; for example, if the original gene product carried out two different functions (see "pleiotropy"), each duplicated gene can now specialize at one function and do a better job at it than the parental gene. o But even if they do not, changes in the regulatory sequences of the genes (promoters and enhancers) may cause the same protein to be expressed at different times and/or in different tissues. Either situation can provide the basis for adaptive evolution. But even while two paralogous genes are still similar in sequence and function, their existence provides redundancy ("belt and suspenders"). This may be a major reason why knocking out genes in yeast, "knockout mice", etc. so often has such a mild effect on the phenotype. The function of the knocked out gene can be taken over by a paralog. After gene duplication, random loss — or inactivation — of one of these genes at a later time in o one group of descendants o Different from the loss in another group could provide a barrier (a "post-zygotic isolating mechanism") to the two groups interbreeding. Such a barrier could cause speciation: the evolution of two different species from a single ancestral species. Translocations Translocations are the transfer of a piece of one chromosome to a no homologous chromosome. Translocations are often reciprocal; that is, the two no homologues swap segments. Translocations can alter the phenotype is several ways: the break may occur within a gene destroying its function Translocated genes may come under the influence of different promoters and enhancers so that their expression is altered. The translocations in Burkitt's lymphoma are an example. The breakpoint may occur within a gene creating a hybrid gene. This may be transcribed and translated into a protein with an N-terminal of one normal cell protein coupled to the C-terminal of another. The Philadelphia chromosome found so often in the leukemic cells of patients with chronic myelogenous leukemia (CML) is the result of a translocation which produces a compound gene (bcr-abl).
230
Frequency of Mutations: Mutations are rare events. This is surprising. Humans inherit 3 x 109 base pairs of DNA from each parent. Just considering single-base substitutions, this means that each cell has 6 billion (6 x 109) different base pairs that can be the target of a substitution. Single-base substitutions are most apt to occur when DNA is being copied; for eukaryotes that means during S phase of the cell cycle. No process is 100% accurate. Even the most highly skilled typist will introduce errors when copying a manuscript. So it is with DNA replication. Like a conscientious typist, the cell does proofread the accuracy of its copy. But, even so, errors slip through. It has been estimated that in humans and other mammals, uncorrected errors (= mutations) occur at the rate of about 1 in every 50 million (5 x 107) nucleotides added to the chain. (Not bad — I wish that I could type so accurately.) But with 6 x 109 base pairs in a human cell, that mean that each new cell contains some 120 new mutations. Should we be worried? Probably not. Most (as much as 97%) of our DNA does not encode anything. This includes: repetitive DNA like Alu elements and other so-called "junk" DNA But not all our "junk" DNA is junk. As more vertebrate genomes are sequenced, it turns out that they contain stretches of DNA that do not encode proteins or RNA but have none-the-less been remarkably conserved during vertebrate evolution. Some of these regions have accumulated fewer mutations than protein-encoding genes have. This suggests that these sequences are extremely important to the welfare of the organism, but why is as yet unknown. Noncoding DNA in introns and flanking structural genes. (However, mutations here can have an effect by altering the expression of the gene or interfering with correct splicing of the gene's mRNA.) Even in coding regions, the existence of synonymous codons may result in the altered (mutated) gene still encoding the same amino acid in the protein. How can we measure the frequency at which phenotype-altering mutations occur? In humans, it is not easy. First we must be sure that the mutation is newly-arisen. (Some populations have high frequencies of a particular mutation, not because the gene is especially susceptible, but because it has been passed down through the generations from a early "founder". [Link to an example]). Recessive mutations (most of them are) will not be seen except on the rare occasions that both parents contribute a mutation at the same locus to their child. This leaves us with estimating mutation frequencies for genes that are inherited as o autosomal dominants o X-linked recessives; that is, recessives on the X chromosome which will be expressed in males because they inherit only one X chromosome. Some Examples (expressed as the frequency of mutations occurring at that locus in the gametes)
231
o
Autosomal dominants Retinoblastoma in the RB gene [Link]: about 8 per million (8 x 10-6) o Osteogenesis imperfecta in one or the other of the two genes that encode Type I collagen [Link]: about 1 per 100,000 (10-5) o Inherited tendency to polyps (and later cancer) in the colon. in a tumor suppressor gene (APC) [Link]: ~10-5 X-linked recessives o Hemophilia A [Link] ~3 x 10-5 (the Factor VIII gene) o Duchenne Muscular Dystrophy (DMD) [Link] >8 x 10-5 (the dystrophin gene) Why should the mutation frequency in the dystrophin gene be so much larger than most of the others? It's probably a matter of size. The dystrophin gene stretches over 2.3 x 106 base pairs of DNA. This is almost 0.1% of the entire human genome! Such a huge gene offers many possibilities for damage. Measuring Mutation Rate: The frequency with which a given mutation is seen in a population (e.g., the mutation that causes cystic fibrosis) provides only a rough approximation of mutation rate — the rate at which fresh mutations occur — because of historical factors at work such as natural selection (positive or negative) drift Founder effect In addition, most methods for counting mutations require that the mutation have a visible effect on the phenotype. Thus mutations in noncoding DNA mutations that produce o synonymous codons (encode the same amino acid) o or, sometimes, new codons that encode a chemically-similar amino acid mutations which disrupt a gene whose functions are redundant; that is, can be compensated for by other genes will not be seen. But now these problems have been largely solved. The story is told in a report by D. R. Denver, et al. in the 5 August 2004 issue of Nature. The Procedure Their organism = C. elegans Its advantages o compact genome o Hermaphroditic — it fertilizes its own eggs and any new germline mutation will soon be either lost or appear on both homologous chromosomes. o rapid generation time (4 days) They created 198 different experimental lines of worms.
232
They grew them under optimum conditions to minimize any effects of natural selection. Only one offspring was kept at each new generation. Each line was maintained for several hundred generations. At the end of this time, random stretches of DNA o derived from multiple locations on each of the six C. elegans chromosomes and o Totaling an average of ~21 thousand base pairs for each line were sequenced from each of the 198 lines and the sequences compared with the same loci in natural populations of C. elegans. Results: Examining the DNA sequences from their experimental animals (a total of over 4 million base pairs!), and comparing them with the controls, turned up a total of 30 mutations. 17 of these were insertions or deletions ("indels') o 7 in exons — all but 2 of which produced frameshifts and a premature STOP codon. o 10 in introns or between genes 13 of these were single base substitutions ("point" mutations) o 3 in exons: one "silent" producing a synonymous codon; two that changed the encoded amino acid. o 10 in introns or between genes Calculating Mutation Rate: From these results I have pooled their data to calculate an approximate rate at which spontaneous mutations occur throughout the genome. Mutation Rate = # of mutations observed [30] ÷ (# of experimental lines [198]) x (average # of generations [339]) x (average # of base pairs sequenced [~21,000]) Yielding a rate of 2.1 x 10-8 mutations per base pair per generation. The total C. elegans genome contains some 108 base pairs so this tells us that two new germline mutations occur somewhere in each of C. elegans's two haploid genomes in each generation. More recently (January 2007), Haag-Liautard, et al. have made a similar analysis for Drosophila (whose genome is about the same size as that of C. elegans). And their mutation rate is about the same as well: ~10-8 mutations per base pair per generation. If the elegans rate holds true for humans (with a haploid genome of 3 x 109 base pairs), that would produce some 60 newly-arisen germline mutations in each of the two haploid genomes that go on to make a new baby. But humans have a far higher proportion of "junk" DNA than does C. elegans, and Many of the mutations seen in the C. elegans (as well as the Drosophila) studies appear to be relatively harmless. So I think we can rest easy. Males Contribute More Mutations Than Females: If most mutations occur during S phase of cell division, then males should be more at risk. This is because Only two dozen (24) or so mitotic divisions occur from the fertilized egg that starts a little girl's embryonic development and the setting aside of her future eggs (which is done long before she is even born). 233
The sperm of 30-year old man, in contrast, is the descendant of at least 400 mitotic divisions since the fertilized egg that formed him. So, Fathers are more likely than mothers to transmit newly-formed mutations to their children. (But chromosomal aberrations, like aneuploidy, are more apt to arise in eggs than in sperm.) The children of aged fathers suffer more genetic disorders than those of young fathers. Actual measurements show that this phenomenon of "male bias" is not as bad as the numbers suggest. Possible reasons: Perhaps many mutations (e.g., those caused by chemicals within the cell or by radiation) occur independently of DNA replication and thus would affect males and females equally. Even in an older man, fresh sperm may come from precursor stem cells that have been held in "reserve" and are not the result of years of mitotic divisions. Evolution may have led to mechanisms that enhance the accuracy of DNA repair in the precursors of sperm. Somatic vs. Germline Mutations: The significance of mutations is profoundly influenced by the distinction between germline and soma. Mutations that occur in a somatic cell, in the bone marrow or liver for example, may damage the cell make the cell cancerous kill the cell Whatever the effect, the ultimate fate of that somatic mutation is to disappear when the cell in which it occurred, or its owner, dies. Germline mutations, in contrast, will be found in every cell descended from the zygote to which that mutant gamete contributed. If an adult is successfully produced, every one of its cells will contain the mutation. Included among these will be the next generation of gametes, so if the owner is able to become a parent, that mutation will pass down to yet another generation.
234
About the Human Genome Project Basic Information: What is the Human Genome Project? FAQs Begun formally in 1990, the U.S. Human Genome Project was a Glossary 13-year effort coordinated by the U.S. Department of Energy and Acronyms the National Institutes of Health. The project originally was Links planned to last 15 years, but rapid technological advances Genetics 101 accelerated the completion date to 2003. Project goals were to Publications identify all the approximately 20,000-25,000 genes in Meetings Calendar human DNA, Media Guide determine the sequences of the 3 billion chemical base pairs About the Project: that make up human DNA, What is it? store this information in databases, Goals improve tools for data analysis, Landmark Papers transfer related technologies to the private sector, and Sequence Address the ethical, legal, and social issues (ELSI) that may Databases arise from the project. Timeline To help achieve these goals, researchers also studied the genetic History makeup of several nonhuman organisms. These include the Ethical Issues common human gut bacterium Escherichia coli, the fruit fly, and Benefits the laboratory mouse. Genetics 101 A unique aspect of the U.S. Human Genome Project is that it was FAQs the first large scientific undertaking to address potential ELSI implications arising from project data. Medicine & the New Genetics: Another important feature of the project was the federal Home government's long-standing dedication to the transfer of technology Gene Testing to the private sector. By licensing technologies to private Gene Therapy companies and awarding grants for innovative research, the project Pharmacogenomics catalyzed the multibillion-dollar U.S. biotechnology industry and Disease fostered the development of new medical applications. Information Landmark papers detailing sequence and analysis of the human Genetic genome were published in February 2001 and April 2003 issues of Counseling Nature and Science. See an index of these papers and learn more about the insights gained from them. Ethical, Legal, For more background information on the U.S. Human Genome Social Issues: Home Project, see the following Privacy Legislation HGP Goals Gene Testing HGP History Gene Therapy HGP Timeline Patenting Human Genome News Forensics What's a genome? And why is it important? Genetically A genome is the entire DNA in an organism, including its Modified Food genes. Genes carry information for making all the proteins required Behavioral by all organisms. These proteins determine, among other things, Genetics how the organism looks, how well its body metabolizes food or 235
Minorities, Race, fights infection, and sometimes even how it behaves. Genetics DNA is made up of four similar chemicals (called bases and Human Migration abbreviated A, T, C, and G) that are repeated millions or billions of times throughout a genome. The human genome, for example, has Education: Teachers 3 billion pairs of bases. Students The particular order of As, Ts, Cs, and Gs is extremely Careers important. The order underlies all of life's diversity, even dictating Webcasts whether an organism is human or another species such as yeast, Images rice, or fruit fly, all of which have their own genomes and are Videos themselves the focus of genome projects. Because all organisms are Chromosome related through similarities in DNA sequences, insights gained Poster from nonhuman genomes often lead to new knowledge about Presentations human biology. Genetics 101 To understand more read Genética Websites o The Science Behind the Human Genome Project: en Español Understanding the Basics o Facts About Genome Sequencing Research: Home o Primer: Genomics and Its Impact on Science and Sequence Society Databases What are some practical benefits to learning about DNA? Landmark Papers Knowledge about the effects of DNA variations among individuals Insights can lead to revolutionary new ways to diagnose, treat, and someday prevent the thousands of disorders that affect us. Besides providing Publications: Chromosome clues to understanding human biology, learning about nonhuman Poster organisms' DNA sequences can lead to an understanding of their Primer Molecular natural capabilities that can be applied toward solving challenges in Genetics health care, agriculture, energy production, environmental List of All remediation, and carbon sequestration. Publications For more details, see Anticipated Benefits of Human Genome Research. Search This What are some of the ethical, legal, and social challenges Site presented by genetic information, and what is being done to address these issues? The Department of Energy and the National Institutes of Health search Genome Programs set aside 3% to 5% of their respective annual Contact Us HGP budgets for the study of the project's ethical, legal, and social Privacy Statement issues (ELSI). Nearly $1 million was spent on HGP ELSI research. Site Stats and For an in-depth look at the ELSI surrounding the project, see our Credits suite of ELSI pages. Site Map Where can I learn more about the U.S. Human Genome Project? Explore the links in the left-hand column including Frequently Asked Questions (FAQs) Publications Glossary 236
Human Genome News archives Search this site: search
This web site maintained by the Human Genome Management Information System (HGMIS) at Oak Ridge National Laboratory for the U.S. Department of Energy Human Genome Program. Send the url of this page to a friend
Last modified: Tuesday, August 19, 2008 Home * Contacts * Disclaimer Base URL: www.ornl.gov/hgmis Site sponsored by the U.S. Department of Energy Office of Science, Office of Biological and Environmental Research, Human Genome Program Human Genome Project: From Wikipedia, the free encyclopedia Jump to: navigation, search
DNA Replication. The Human Genome Project (HGP) was an international scientific research project with a primary goal to determine the sequence of chemical base pairs which make up DNA and to identify and map the approximately 20,000-25,000 genes of the human genome from both a physical and functional standpoint.
237
o o o o o o
The project began in 1990 initially headed by James D. Watson at the U.S. National Institutes of Health. A working draft of the genome was released in 2000 and a complete one in 2003, with further analysis still being published. A parallel project was conducted outside of government by the Celera Corporation. Most of the government-sponsored sequencing was performed in universities and research centers from the United States, Canada, New Zealand and Britain. The mapping of human genes is an important step in the development of medicines and other aspects of health care. While the objective of the Human Genome Project is to understand the genetic makeup of the human species, the project also has focused on several other nonhuman organisms such as E. coli, the fruit fly, and the laboratory mouse. It remains one of the largest single investigational projects in modern science. [Citation needed] The HGP originally aimed to map the nucleotides contained in a haploid reference human genome (more than three billion). Several groups have announced efforts to extend this to diploid human genomes including the International HapMap Project, Applied Biosystems, Perlegen, Illumina, JCVI, Personal Genome Project, and Roche-454. The "genome" of any given individual (except for identical twins and cloned organisms) is unique; mapping "the human genome" involves sequencing multiple variations of each gene. The project did not study the entire DNA found in human cells; some heterochromatic areas (about 8% of the total) remain un-sequenced. Contents: [hide] 1 Project 1.1 Background 1.2 State of completion 1.3 Goals 1.4 How it was accomplished 2 Public versus private approaches 2.1 History 2.2 Methods 3 Genome donors 4 Benefits 5 Ethical, legal and social issues 6 See also 7 References 8 External links Project: Background: The project began with the culmination of several years of work supported by the United States Department of Energy, in particular workshops in 1984 [1] and 1986 and a subsequent initiative of the US Department of Energy.[2] This 1987 report stated boldly, "The ultimate goal of this initiative is to understand the human genome" and "knowledge of the human as necessary to the continuing progress of medicine and other health sciences as knowledge of human anatomy has been for the present state of medicine." 238
Candidate technologies were already being considered for the proposed undertaking at least as early as 1985.[3] James D. Watson was head of the National Center for Human Genome Research at the National Institutes of Health (NIH) in the United States starting from 1988. Largely due to his disagreement with his boss, Bernadine Healy, over the issue of patenting genes, Watson was forced to resign in 1992. He was replaced by Francis Collins in April 1993, and the name of the Center was changed to the National Human Genome Research Institute (NHGRI) in 1997. The $3-billion project was formally founded in 1990 by the United States Department of Energy and the U.S. National Institutes of Health, and was expected to take 15 years. In addition to the United States, the international consortium comprised geneticists in China, France, Germany, Japan, and the United Kingdom. Due to widespread international cooperation and advances in the field of genomics (especially in sequence analysis), as well as major advances in computing technology, a 'rough draft' of the genome was finished in 2000 (announced jointly by then US president Bill Clinton and the British Prime Minister Tony Blair on June 26, 2000).[4] Ongoing sequencing led to the announcement of the essentially complete genome in April 2003, 2 years earlier than planned.[5] In May 2006, another milestone was passed on the way to completion of the project, when the sequence of the last chromosome was published in the journal Nature.[6] State of completion: There are multiple definitions of the "complete sequence of the human genome". According to some of these definitions, the genome has already been completely sequenced, and according to other definitions, the genome has yet to be completely sequenced. There have been multiple popular press articles reporting that the genome was "complete." The genome has been completely sequenced using the definition employed by the International Human Genome Project. A graphical history of the human genome project shows that most of the human genome was complete by the end of 2003. However, there are a number of regions of the human genome that can be considered unfinished: First, the central regions of each chromosome, known as centromeres, are highly repetitive DNA sequences that are difficult to sequence using current technology. The centromeres are millions (possibly tens of millions) of base pairs long, and for the most part these are entirely un-sequenced. Second, the ends of the chromosomes, called telomeres, are also highly repetitive, and for most of the 46 chromosome ends these too are incomplete. It is not known precisely how much sequence remains before the telomeres of each chromosome are reached, but as with the centromeres, current technological restraints are prohibitive. Third, there are several loci in each individual's genome that contain members of multigene families that are difficult to disentangle with shotgun sequencing methods these multigene families often encode proteins important for immune functions. Other than these regions, there remain a few dozen gaps scattered around the genome, some of them rather large, but there is hope that all these will be closed in the next couple of years. 239
In summary: the best estimates of total genome size indicate that about 92.3% of the genome has been completed [2] and it is likely that the centromeres and telomeres will remain un-sequenced until new technology is developed that facilitates their sequencing. Most of the remaining DNA is highly repetitive and unlikely to contain genes, but it cannot be truly known until it is entirely sequenced. Understanding the functions of all the genes and their regulation is far from complete. The roles of junk DNA, the evolution of the genome, the differences between individuals, and many other questions are still the subject of intense interest by laboratories all over the world. Goals: The sequence of the human DNA is stored in databases available to anyone on the Internet. The U.S. National Center for Biotechnology Information (and sister organizations in Europe and Japan) house the gene sequence in a database known as GenBank, along with sequences ofknown and hypothetical genes and proteins. Other organizations such as the University of California, Santa Cruz[3], and Ensembl[4] present additional data and annotation and powerful tools for visualizing and searching it. Computer programs have been developed to analyze the data, because the data themselves are difficult to interpret without such programs. The process of identifying the boundaries between genes and other features in raw DNA sequence is called genome annotation and is the domain of bioinformatics. While expert biologists make the best annotators, their work proceeds slowly, and computer programs are increasingly used to meet the high-throughput demands of genome sequencing projects. The best current technologies for annotation make use of statistical models that take advantage of parallels between DNA sequences and human language, using concepts from computer science such as formal grammars. Another, often overlooked, goal of the HGP is the study of its ethical, legal, and social implications. It is important to research these issues and find the most appropriate solutions before they become large dilemmas whose effect will manifest in the form of major political concerns. All humans have unique gene sequences. Therefore the data published by the HGP does not represent the exact sequence of each and every individual's genome. It is the combined genome of a small number of anonymous donors. The HGP genome is a scaffold for future work in identifying differences among individuals. Most of the current effort in identifying differences among individuals involves single nucleotide polymorphisms and the HapMap. Key findings of Genome Project: 1. There are approx. 30,000 genes in human beings, the same range as in mice and twice that of roundworms. Understanding how these genes express themselves will provide clues to how diseases are caused. 2. All human races are 99.99 % alike, so racial differences are genetically insignificant. This could mean all humans are descended from a single original mother. 3. Most genetic mutation occurs in the male of the species and as such are agents of change. They are also more likely to be responsible for genetic disorders. 4. Genomics has led to advances in genetic archaeology and has improved our understanding of how we evolved as humans and diverged from apes 25 million years 240
ago. It also tells how our body works, including the mystery behind how the sense of taste works. How it was accomplished: Funding came from the US government through the National Institutes of Health in the United States, and the UK charity, the Wellcome Trust, who funded the Sanger Institute (then the Sanger Centre) in Great Britain, as well as numerous other groups from around the world. The genome was broken into smaller pieces; approximately 150,000 base pairs in length. These pieces were then spliced into a type of vector known as "bacterial artificial chromosomes", or BACs, which are derived from bacterial chromosomes which have been genetically engineered. The vectors containing the genes can be inserted into bacteria where they are copied by the bacterial DNA replication machinery. Each of these pieces was then sequenced separately as a small "shotgun" project and then assembled. The larger, 150,000 base pairs go together to create chromosomes. This is known as the "hierarchical shotgun" approach, because the genome is first broken into relatively large chunks, which are then mapped to chromosomes before being selected for sequencing. Human Genome Project is called a Mega Project because of the following facts: 1. The human genome has approx. 3.3 x 109 base-pairs; if the cost of sequencing is US $3 per base-pair, then the approx. cost will be US $10 billion. 2. If the sequence obtained were to be stored in a typed form in books and if each page contains 1000 letters and each book contains 1000 pages, then 3300 such books would be needed to store the complete information. 3. The enormous quantity of data expected to be generated also necessitates the use of high speed computer hard-drives for data storage and super-computers for retrieval and analysis. Public versus private approaches: In 1998, a similar, privately funded quest was launched by the American researcher Craig Venter, and his firm Celera Genomics. Venter was a scientist at the NIH during the early 1990s when the project was initiated. The $300,000,000 Celera effort was intended to proceed at a faster pace and at a fraction of the cost of the roughly $3 billion publicly funded project. Celera used a riskier technique called whole genome shotgun sequencing, which had been used to sequence bacterial genomes of up to six million base pairs in length, but not for anything nearly as large as the three billion base pair human genome. Celera initially announced that it would seek patent protection on "only 200–300" genes, but later amended this to seeking "intellectual property protection" on "fullycharacterized important structures" amounting to 100–300 targets. The firm eventually filed preliminary ("place-holder") patent applications on 6,500 whole or partial genes. Celera also promised to publish their findings in accordance with the terms of the 1996 "Bermuda Statement," by releasing new data annually (the HGP released its new data daily), although, unlike the publicly funded project, they would not permit free redistribution or commercial use of the data. In March 2000, President Clinton announced that the genome sequence could not be patented, and should be made freely available to all researchers. The statement sent Celera's stock plummeting and dragged down the biotechnology-heavy Nasdaq. The biotechnology sector lost about $50 billion in market capitalization in two days. Although 241
the working draft was announced in June 2000, it was not until February 2001 that Celera and the HGP scientists published details of their drafts. Special issues of Nature (which published the publicly funded project's scientific paper)[7] and Science (which published Celera's paper[8]) described the methods used to produce the draft sequence and offered analysis of the sequence. These drafts covered about 83% of the genome (90% of the euchromatic regions with 150,000 gaps and the order and orientation of many segments not yet established). In February 2001, at the time of the joint publications, press releases announced that the project had been completed by both groups. Improved drafts were announced in 2003 and 2005, filling in to ≈92% of the sequence currently. The competition proved to be very good for the project, spurring the public groups to modify their strategy in order to accelerate progress. The rivals initially agreed to pool their data, but the agreement fell apart when Celera refused to deposit its data in the unrestricted public database GenBank. Celera had incorporated the public data into their genome, but forbade the public effort to use Celera data. HGP is the most well known of many international genome projects aimed at sequencing the DNA of a specific organism. While the human DNA sequence offers the most tangible benefits, important developments in biology and medicine are predicted as a result of the sequencing of model organisms, including mice, fruit flies, zebrafish, yeast, nematodes, plants, and many microbial organisms and parasites. In 2004, researchers from the International Human Genome Sequencing Consortium (IHGSC) of the HGP announced a new estimate of 20,000 to 25,000 genes in the human genome.[9] Previously 30,000 to 40,000 had been predicted, while estimates at the start of the project reached up to as high as 2,000,000. The number continues to fluctuate and it is now expected that it will take many years to agree on a precise value for the number of genes in the human genome. History: For more details on this topic, see History of genetics. In 1976, the genome of the RNA virus Bacteriophage MS2 was the first complete genome to be determined, by Walter Fiers and his team at the University of Ghent (Ghent, Belgium).[10] The idea for the shotgun technique came from the use of an algorithm that combined sequence information from many small fragments of DNA to reconstruct a genome. This technique was pioneered by Frederick Sanger to sequence the genome of the Phage Φ-X174, a virus (bacteriophage) that primarily infects bacteria that was the first fully sequenced genome (DNA-sequence) in 1977.[11] The technique was called shotgun sequencing because the genome was broken into millions of pieces as if it had been blasted with a shotgun. In order to scale up the method, both the sequencing and genome assembly had to be automated, as they were in the 1980s. Those techniques were shown applicable to sequencing of the first free-living bacterial genome (1.8 million base pairs) of Haemophilus influenzae in 1995 [12] and the first animal genome (~100 Mbp) [13] It involved the use of automated sequencers, longer individual sequences using approximately 500 base pairs at that time. Paired sequences separated by a fixed distance of around 2000 base pairs which were critical elements enabling the development of the first genome assembly programs for reconstruction of large regions of genomes (aka 'contigs'). 242
Three years later, in 1998, the announcement by the newly-formed Celera Genomics that it would scale up the shotgun sequencing method to the human genome was greeted with skepticism in some circles. The shotgun technique breaks the DNA into fragments of various sizes, ranging from 2,000 to 300,000 base pairs in length, forming what is called a DNA "library". Using an automated DNA sequencer the DNA is read in 800bp lengths from both ends of each fragment. Using a complex genome assembly algorithm and a supercomputer, the pieces are combined and the genome can be reconstructed from the millions of short, 800 base pair fragments. The success of both the public and privately funded effort hinged upon a new, more highly automated capillary DNA sequencing machine, called the Applied Biosystems 3700, that ran the DNA sequences through an extremely fine capillary tube rather than a flat gel. Even more critical was the development of a new, larger-scale genome assembly program, which could handle the 30–50 million sequences that would be required to sequence the entire human genome with this method. At the time, such a program did not exist. One of the first major projects at Celera Genomics was the development of this assembler, which was written in parallel with the construction of a large, highly automated genome sequencing factory. Development of the assembler was led by Brian Ramos. The first version of this assembler was demonstrated in 2000, when the Celera team joined forces with Professor Gerald Rubin to sequence the fruit fly Drosophila melanogaster using the whole-genome shotgun method[14]. At 130 million base pairs, it was at least 10 times larger than any genome previously shotgun assembled. One year later, the Celera team published their assembly of the three billion base pair human genome. The Human Genome Project was a 13 year old mega project that was launched in the year 1990 and completed in 2003. This project is closely associated to the branch of biology called Bio-informatics. The human genome project international consortium announced the publication of a draft sequence and analysis of the human genome—the genetic blueprint for the human being. An American company—Celera, led by Craig Venter and the other huge international collaboration of distinguised scientist led by Francis Collins, director, National Human Genome Research Institute, U.S., both publised their findings. This Mega Project is co-ordinated by the U.S. Department of Energy and the National Institute of Health. During the early years of the project, the Wellcome Trust (U.K.) became a major partner, other countries like Japan, Germany, China and France contributed significantly. Already the atlas has revealed some starting facts. The two factors that made this project a success is: 1. Genetic Engineering Techniques, with which it is possible to isolate and clone any segment of DNA. 2. Availability of simple and fast technologies, to determining the DNA sequences. Being the most complex organisms, human beings was expected to have more than 100,000 genes or combination of DNA that provides commands for every characteristics of the body. Instead their studies show that humans have only 30,000 genes – around the same as mice, three times as many as flies, and only five times more than bacteria. Scientist told that not only are the numbers similar, the genes themselves, baring a few, are alike in mice and men. In a companion volume to the Book of Life, scientists have created a catalogue of 1.4 million single-letter differences, or single nucleotide 243
polymorphisms (SNP's) – and specified their exact locations in the human genome. This SNP map, the world's largest publicly available catalogue of SNP's, promises to revolutionize both mapping diseases and tracing human history. The sequence information from the consortium has been immediately and freely released to the world, with no restrictions on its use or redistribution. The information is scanned daily by scientists in academia and industry, as well as commercial database companies, providing key information services to bio-technologists. Already, many genes have been identified from the genome sequence, including more than 30 that play a direct role in human diseases. By dating the three millions repeat elements and examining the pattern of interspersed repeats on the Y-chromosome, scientists estimated the relative mutation rates in the X and the Y chromosomes and in the male and the female germ lines. They found that the ratio of mutations in male Vs female is 2:1. Scientists point to several possible reasons for the higher mutation rate in the male germ line, including the fact that there are a greater number of cell divisions involve in the formation of sperm than in the formation of eggs. Methods: The IHGSC used pair-end sequencing plus whole-genome shotgun mapping of large (≈100 Kbp) plasmid clones and shotgun sequencing of smaller plasmid sub-clones plus a variety of other mapping data to orient and check the assembly of each human chromosome[7]. The Celera group emphasized the importance of the ―whole-genome shotgun‖ sequencing method, relying on sequence information to orient and locate their fragments within the chromosome. However they used the publicly available data from HGP to assist in the assembly and orientation process, raising concerns that the Celera sequence was not independently derived.[8][15][16] Genome donors: In the IHGSC international public-sector Human Genome Project (HGP), researchers collected blood (female) or sperm (male) samples from a large number of donors. Only a few of many collected samples were processed as DNA resources. Thus the donor identities were protected so neither donors nor scientists could know whose DNA was sequenced. DNA clones from many different libraries were used in the overall project, with most of those libraries being created by Dr. Pieter J. de Jong. It has been informally reported, and is well known in the genomics community, that much of the DNA for the public HGP came from a single anonymous male donor from Buffalo, New York (code name RP11).[17] HGP scientists used white blood cells from the blood of two male and two female donors (randomly selected from 20 of each) -- each donor yielding a separate DNA library. One of these libraries (RP11) was used considerably more than others, due to quality considerations. One minor technical issue is that male samples contain just over half as much DNA from the sex chromosomes (one X chromosome and one Y chromosome) compared to female samples (which contain two X chromosomes). The other 22 chromosomes (the autosomes) are the same for both genders. Although the main sequencing phase of the HGP has been completed, studies of DNA variation continue in the International HapMap Project, whose goal is to identify patterns of single nucleotide polymorphism (SNP) groups (called haplotypes, or ―haps‖). 244
The DNA samples for the HapMap came from a total of 270 individuals: Yoruba people in Ibadan, Nigeria; Japanese people in Tokyo; Han Chinese in Beijing; and the French Centre d‘Etude du Polymorphisms Humain (CEf) resource, which consisted of residents of the United States having ancestry from Western and Northern Europe. In the Celera Genomics private-sector project, DNA from five different individuals were used for sequencing. The lead scientist of Celera Genomics at that time, Craig Venter, later acknowledged (in a public letter to the journal Science) that his DNA was one of 21 samples in the pool, five of which were selected for use[18][19]. On September 4, 2007, a team led by Craig Venter published his complete DNA sequence[20], unveiling the six-billion-nucleotide genome of a single individual for the first time. Benefits: The work on interpretation of genome data is still in its initial stages. It is anticipated that detailed knowledge of the human genome will provide new avenues for advances in medicine and biotechnology. Clear practical results of the project emerged even before the work was finished. For example, a number of companies, such as Myriad Genetics started offering easy ways to administer genetic tests that can show predisposition to a variety of illnesses, including breast cancer, disorders of hemostasis, cystic fibrosis, liver diseases and many others. Also, the etiologies for cancers, Alzheimer's disease and other areas of clinical interest are considered likely to benefit from genome information and possibly may lead in the long term to significant advances in their management. There are also many tangible benefits for biological scientists. For example, a researcher investigating a certain form of cancer may have narrowed down his/her search to a particular gene. By visiting the human genome database on the world wide web, this researcher can examine what other scientists have written about this gene, including (potentially) the three-dimensional structure of its product, its function(s), its evolutionary relationships to other human genes, or to genes in mice or yeast or fruit flies, possible detrimental mutations, interactions with other genes, body tissues in which this gene is activated, diseases associated with this gene or other datatypes. Further, deeper understanding of the disease processes at the level of molecular biology may determine new therapeutic procedures. Given the established importance of DNA in molecular biology and its central role in determining the fundamental operation of cellular processes, it is likely that expanded knowledge in this area will facilitate medical advances in numerous areas of clinical interest that may not have been possible without them. The analysis of similarities between DNA sequences from different organisms is also opening new avenues in the study of evolution. In many cases, evolutionary questions can now be framed in terms of molecular biology; indeed, many major evolutionary milestones (the emergence of the ribosome and organelles, the development of embryos with body plans, the vertebrate immune system) can be related to the molecular level. Many questions about the similarities and differences between humans and our closest relatives (the primates, and indeed the other mammals) are expected to be illuminated by the data from this project. The Human Genome Diversity Project (HGDP), spinoff research aimed at mapping the DNA that varies between human ethnic groups, which was rumored to have been halted, 245
actually did continue and to date has yielded new conclusions.[citation needed] In the future, HGDP could possibly expose new data in disease surveillance, human development and anthropology. HGDP could unlock secrets behind and create new strategies for managing the vulnerability of ethnic groups to certain diseases (see race in biomedicine). It could also show how human populations have adapted to these vulnerabilities. Advantages of Human Genome Project: 1. Knowledge of the effects of variation of DNA among individuals can revolutionize the ways to diagnose, treat and even prevent a number of diseases that affects the human beings. 2. It provides clues to the understanding of human biology. Ethical, legal and social issues: The project's goals included not only identifying all of the approximately 24,000 genes in the human genome, but also to address the ethical, legal, and social issues (ELSI) that might arise from the availability of genetic information. Five percent of the annual budget was allocated to address the ELSI arising from the project. Debra Harry, Executive Director of the U.S group Indigenous Peoples Council on Biocolonialism (IPCB), says that despite a decade of ELSI funding, the burden of genetics education has fallen on the tribes themselves to understand the motives of Human genome project and its potential impacts on their lives. Meanwhile, the government has been busily funding projects studying indigenous groups without any meaningful consultation with the groups. (See Biopiracy.)[21] The main criticism of ELSI is the failure to address the conditions raised by populationbased research, especially with regard to unique processes for group decision-making and cultural worldviews. Genetic variation research such as HGP is group population research, but most ethical guidelines, according to Harry, focus on individual rights instead of group rights. She says the research represents a clash of culture: indigenous people's life revolves around collectivity and group decision making whereas the Western culture promotes individuality. Harry suggests that one of the challenges of ethical research is to include respect for collective review and decision making, while also upholding the Western model of individual rights. The distribution of genes in mammalian chromosomes is striking. It turns out that human chromosomes have crowded urban centers with many genes in close proximity to one another and also vast expanses of unpopulated desert where only non coding DNA can be found. This distribution of genes is in marked contrast to the genomes of many other organisms. The full set of proteins encoded by the human genome is more complex than those of the invertebrates because humans have rearranged old protein domains into a rich collection of new architectures. The sequence will serve as a foundation for a broad range of functional genomic tools to help biologists to probe the function of the genes in a more systematic manner. Comparative genomics will also offer scientists insights into important regions in the sequence that performs regulatory functions. The human genome sequence provides a great help to build the tools to conquer most of the illness that cause untold human sufferings and premature death. Already the genome has helped to detect more than 30 diseased genes, including some of the common diseases like breast cancer, color blindness etc. There will be a lot more emphasis now on preventive medicines. The consortium's ultimate goal is to produce a completely 'finished' sequence with no gaps 246
and 99.9 % accuracy. Although the near finished version is adequate for most biomedical research, the Human Genome Project has made a commitment to filling all gaps and resolving all uncertainty in the sequence by the year 2003 C.E. The draft genome sequence has provided an initial look at the human gene content, but many uncertainties remain. One of the Human Genome Project priorities will be to refine the data to accurately reflect every gene and every alternatively spliced form. Several steps are needed to reach this ambitious goal. See also: Chimpanzee Genome Project Craig Venter's Genome EuroPhysiome Gene patent Genome project Human Cytome Project Human genome Human microbiome project Human Variome Project HUGO Gene Nomenclature Committee International HapMap Project National Human Genome Research Institute Neanderthal Genome Project Personal Genome Project Sanger Institute The 1000 Genomes Project Genographic Project References: 1. ^ Cook-Deegan R (1989). "The Alta Summit, December 1984". Genomics 5: 661–3. doi:10.1016/0888-7543(89)90042-6. http://www.ornl.gov/sci/techresources/Human_Genome/project/alta.shtml. 2. ^ Barnhart, Benjamin J. (1989). "DOE Human Genome Program". Human Genome Quarterly 1: 1. http://www.ornl.gov/sci/techresources/Human_Genome/publicat/hgn/v1n1/01doehgp.sht ml. Retrieved 2005-02-03. 3. ^ DeLisi, Charles (2001). "Genomes: 15 Years Later A Perspective by Charles DeLisi, HGP Pioneer". Human Genome News 11: 3–4. http://genome.gsc.riken.go.jp/hgmis/publicat/hgn/v11n3/05delisi.html. Retrieved 200502-03. 4. ^ "White House Press Release". http://www.ornl.gov/sci/techresources/Human_Genome/project/clinton1.shtml. Retrieved on 2006-07-22. 5. ^ "BBC NEWS". http://news.bbc.co.uk/1/hi/sci/tech/2940601.stm. Retrieved on 2006-07-22. 6. ^ "Guardian Unlimited". http://www.guardian.co.uk/uklatest/story/0,,5829253,00.html. Retrieved on 2006-07-22. 247
7. ^ a b International Human Genome Sequencing Consortium (2001). "Initial sequencing and analysis of the human genome." (PDF). Nature 409: 860–921. doi:10.1038/35057062. http://www.nature.com/nature/journal/v409/n6822/pdf/409860a0.pdf. 8. ^ a b Venter, JC, et al. (2001). "The sequence of the human genome." (PDF). Science 291: 1304–1351. doi:10.1126/science.1058040. PMID 11181995. http://www.sciencemag.org/cgi/reprint/291/5507/1304.pdf. 9. ^ IHGSC (2004). "Finishing the euchromatic sequence of the human genome.". Nature 431: 931–945. doi:10.1038/nature03001. http://www.nature.com/nature/journal/v431/n7011/full/nature03001.html. 10. ^ Fiers W, Contreras R, Duerinck F, et al. (April 1976). "Complete nucleotide sequence of bacteriophage MS2 RNA: primary and secondary structure of the replicase gene". Nature 260 (5551): 500–7. doi:10.1038/260500a0. PMID 1264203. 11. ^ Sanger F, Air GM, Barrell BG, et al. (February 1977). "Nucleotide sequence of bacteriophage phi X174 DNA". Nature 265 (5596): 687–95. doi:10.1038/265687a0. PMID 870828. 12. ^ Fleischmann, R. D. et al. (1995). "Whole-genome random sequencing and assembly of Haemophilus influenzae Rd.". Science 269: 496–512. doi:10.1126/science.7542800. PMID 7542800. 13. ^ C. elegans Sequencing Consortium (1998). "Genome sequence of the nematode C. elegans: A platform for investigating biology.". Science 282: 2012–18. doi:10.1126/science.282.5396.2012. PMID 9851916. 14. ^ Adams, MD. et al. (2000). "The genome sequence of Drosophila melanogaster.". Science 287: 2185–2195. doi:10.1126/science.287.5461.2185. PMID 10731132. 15. ^ Waterston RH, Lander ES, Sulston JE (2002). "On the sequencing of the human genome". Proc Natl Acad Sci U S A. 99: 3712–6. doi:10.1073/pnas.042692499. PMID 11880605. 16. ^ Waterston RH, Lander ES, Sulston JE (2003). "More on the sequencing of the human genome". Proc Natl Acad Sci U S A. 100: 3022–4. doi:10.1073/pnas.0634129100. PMID 12631699. 17. ^ Osoegawa, Kazutoyo (2001). "A Bacterial Artificial Chromosome Library for Sequencing the Complete Human Genome". Genome Research 11: 483–96. doi:10.1101/gr.169601. PMID 11230172. http://www.genome.org/cgi/content/full/11/3/483. 18. ^ Kennedy D (2002). "Not wicked, perhaps, but tacky". Science 297: 1237. doi:10.1126/science.297.5585.1237. PMID 12193755. 19. ^ Venter D (2003). "A Part of the Human Genome Sequence". Science 299: 1183–4. doi:10.1126/science.299.5610.1183. PMID 12595674. 20. ^ Levy S, Sutton G, Ng PC, et al. (September 2007). "The diploid genome sequence of an individual human". PLoS Biol. 5 (10): e254. doi:10.1371/journal.pbio.0050254. PMID 17803354.
248
21. ^ Ms. Harry's comments in the International Forum on Globalization Teach-in held in New York City in February 2001 were based on her recent article, Biopiracy and Globalization: Indigenous Peoples Face a New Wave of Colonialism, published in the magazine Splice, January/April 2001 Volume 7 Issues 2 & 3 ([1][dead link]) External links: Human Genome Project official information page Wikinews has related news: Mexico presents first population-wide genome map for a Latin country Wikibooks has a book on the topic of Genes, Technology and Policy
Delaware Valley Personalized Medicine Project Uses data from the Human Genome Project to help make medicine personal National Human Genome Research Institute (NHGRI). NHGRI led the National Institutes of Health's (NIH's) contribution to the International Human Genome Project. This project, which had as its primary goal the sequencing of the three thousand million base pairs that make up human genome, was successfully completed in April 2003. Human Genome News. Published from 1989 to 2002 by the US Department of Energy, this newsletter was a major communications method for coordination of the Human Genome Project. Complete online archives are available. Project Gutenberg hosts e-texts for Human Genome Project, titled Human Genome Project, Chromosome Number # (# denotes 01-22, X and Y). This information is raw sequence, released in November 2002; access to entry pages with download links is available through http://www.gutenberg.org/etext/3501 for Chromosome 1 sequentially to http://www.gutenberg.org/etext/3524 for the Y chromosome. Note that this sequence might not be considered definitive due to ongoing revisions and refinements. In addition to the chromosome files, there is a supplementary information file dated March 2004 which contains additional sequence information. The HGP information pages Department of Energy's portal to the international Human Genome Project, Microbial Genome Program, and Genomics:GTL systems biology for energy and environment yourgenome.org: The Sanger Institute public information pages has general and detailed primers on DNA, genes and genomes, the Human Genome Project and science spotlights. Ensembl project, an automated annotation system and browser for the human genome UCSC genome browser, this site contains the reference sequence and working draft assemblies for a large collection of genomes. It also provides a portal to the ENCODE project. Nature magazine's human genome gateway, including the HGP's paper on the draft genome sequence Wellcome charitable trust description of HGP "You‘re Genes, your health, your future".
249
Learning about the Human Genome. Part 1: Challenge to Science Educators. ERIC Digest. Learning about the Human Genome. Part 2: Resources for Science Educators. ERIC Digest. Patenting Life by Merrill Goozner Prepared Statement of Craig Venter of Celera Venter discusses Celera's progress in deciphering the human genome sequence and its relationship to healthcare and to the federally funded Human Genome Project. Cracking the Code of Life Companion website to 2-hour NOVA program documenting the race to decode the genome, including the entire program hosted in 16 parts in either QuickTime or RealPlayer format. Lone Dog L (1999). "Whose genes are they? The Human Genome Diversity Project". J Health Soc Policy 10 (4): 51–66. PMID 10538186. http://www.haworthpress.com/store/ArticleAbstract.asp?sid=DS104W6XGPL58H9EKU 06C2L1QSSP41VF&ID=5707. [hide] v•d•e Ape-related articles Ape study
Ape language · Ape Trust · Dian Fossey · Birutė Galdikas · Jane Goodall · Chimpanzee genome project · Human genome project
Legal status
Personhood · Research ban · Declaration · Kinshasa Declaration · Great Ape Project · Survival Project
See also
Bushmeat · Ape extinction · List of notable apes · List of fictional apes · Human evolution · Mythic humanoids · Hominid · Planet of the Apes
Retrieved from "http://en.wikipedia.org/wiki/Human_Genome_Project" Categories: Genetics | Genome projects Hidden categories: All articles with dead external links | Articles with dead external links from March 2009 | All articles with unsourced statements | Articles with unsourced statements from November 2007 | Articles with unsourced statements from May 2008 Views: Article Discussion Edit this page History Personal tools: Log in / create account Navigation: Main page
250
Contents • Featured content Current events Random article Interaction: About Wikipedia Community portal Recent changes Contact Wikipedia Donate to Wikipedia Help Toolbox: What links here Related changes Upload file Special pages Printable version Permanent link Cite this page தமிழ் ไ ทย Türkçe Українська Tiếng Việt 中文
This page was last modified on 8 July 2009 at 06:01. Text is available under the Creative Commons Attribution/Share-Alike License; additional terms may apply. See Terms of Use for details. Wikipedia® is a registered trademark of the Wikimedia Foundation, Inc., a non-profit organization. Privacy policy About Wikipedia Disclaimers
251
Introduction - The Human Genome Project: National Center for Human Genome Research, National Institutes of Health. "New Tools for Tomorrow's Health Research." Bethesda, MD: Department of Health and Human Services, 1992. Since the beginning of time, people have yearned to explore the unknown, chart where they have been, and contemplate what they have found. The maps we make of these treks enable the next explorers to push ever farther the boundaries of our knowledge - about the earth, the sea, the sky, and indeed, ourselves. On a new quest to chart the innermost reaches of the human cell, scientists have now set out on biology's most important mapping expedition: the Human Genome Project. Its mission is to identify the full set of genetic instructions contained inside our cells and to read the complete text written in the language of the hereditary chemical DNA (deoxyribonucleic acid). As part of this international project, biologists, chemists, engineers, computer scientists, mathematicians, and other scientists will work together to plot out several types of biological maps that will enable researchers to find their way through the labyrinth of molecules that define the physical traits of a human being. Packed tightly into nearly every one of the several trillion body cells is a complete copy of the human "genome" - all the genes that make up the master blueprint for building a man or woman. One hundred thousand or so genes sequestered inside the nucleus of each cell are parceled among the 46 sausage-shaped genetic structures known as chromosomes. New maps developed through the Human Genome Project will enable researchers to pinpoint specific genes on our chromosomes. The most detailed map will allow scientists to decipher the genetic instructions encoded in the estimated 3 billion base pairs of nucleotide bases that make up human DNA. Analysis of this information, likely to continue throughout much of the 21st century, will revolutionize our understanding of how genes control the functions of the human body. This knowledge will provide new strategies to diagnose, treat, and possibly prevent human diseases. It will help explain the mysteries of embryonic development and give us important insights into our evolutionary past. The development of gene-splicing techniques over the past 20 years has given scientists remarkable opportunities to understand the molecular basis of how a cell functions, not only in disease, but in everyday activities as well. Using these techniques, scientists have mapped out the genetic molecules, or genes, that control many life processes in common microorganisms. Continued improvement of these biotechniques has allowed researchers to begin to develop maps of human chromosomes, which contain many more times the amount of genetic information than those of microorganisms. Though still somewhat crude, these maps have led to the discovery of some important genes. By the mid-1980s, rapid advances in chromosome mapping and other DNA techniques led many scientists to consider mapping all 46 chromosomes in the very large human genome. Detailed, standardized maps of all human chromosomes and knowledge about the nucleotide sequence of human DNA will enable scientists to find and study the genes involved in human diseases much more efficiently and rapidly than has ever been 252
possible. This new effort - the Human Genome Project - is expected to take 15 years to complete and consists of two major components. The first - creating maps of the 23 pairs of chromosomes - should be completed in the first 5 to 10 years. The second component sequencing the DNA contained in all the chromosomes - will probably require the full 15 years. Although DNA sequencing technology has advanced rapidly over the past few years, it is still too slow and costly to use for sequencing even the amount of DNA contained in a single human chromosome. So while some genome project scientists are developing chromosome maps, others will be working to improve the efficiency and lower the cost of sequencing technology. Large-scale sequencing of the human genome will not begin until those new machines have been invented. Why do the Human Genome Project? Most inherited diseases are rare, but taken together; the more than 3,000 disorders known to result from single altered genes rob millions of healthy and productive lives. Today, little can be done to treat, let alone cure, most of these diseases. But having a gene in hand allows scientists to study its structure and characterize the molecular alterations, or mutations that result in disease. Progress in understanding the causes of cancer, for example, has taken a leap forward by the recent discovery of cancer genes. The goal of the Human Genome Project is to provide scientists with powerful new tools to help them clear the research hurdles that now keep them from understanding the molecular essence of other tragic and devastating illnesses, such as schizophrenia, alcoholism, Alzheimer's disease, and manic depression. Gene mutations probably play a role in many of today's most common diseases, such as heart disease, diabetes, immune system disorders, and birth defects. These diseases are believed to result from complex interactions between genes and environmental factors. When genes for diseases have been identified, scientists can study how specific environmental factors, such as food, drugs, or pollutants interact with those genes. Once a gene is located on a chromosome and its DNA sequence worked out, scientists can then determine which protein the gene is responsible for making and find out what it does in the body. This is the first step in understanding the mechanism of a genetic disease and eventually conquering it. One day, it may be possible to treat genetic diseases by correcting errors in the gene itself, replacing its abnormal protein with a normal one, or by switching the faulty gene off. Finally, Human Genome Project research will help solve one of the greatest mysteries of life: How does one fertilized egg "know" to give rise to so many different specialized cells, such as those making up muscles, brain, heart, eyes, skin, blood, and so on? For a human being or any organism to develop normally, a specific gene or sets of genes must be switched on in the right place in the body at exactly the right moment in development. Information generated by the Human Genome Project will shed light on how this intimate dance of gene activity is choreographed into the wide variety of organs and tissues that make up a human being. Go to next story: Ethical issues of the Human Genome Project? See Graphics Gallery: Comparative Scale of Mapping See the Human Genome Program web site at the Department of Energy Return to About Biotech directory 253
Issues Index About Biotech Index Site Feedback Ad Content Feedback About AE Discussions Copyright © Info Privacy Policy Sitemap Email this Link Contact Access Excellence Home Search
Custom Search on the AE Site -Advertisement-
254
THE HUMAN GENOME PROJECT Jim Dodds and Sandra Enger 1992 Woodrow Wilson Biology Institute Suitable for grades 9-12. Goal: To stimulate growth in students' abilities to analyze some of the novel ethical issues which are expected to arise as a result of knowledge developed in the coming decades by the Human Genome Project. Materials: 1. Macintosh computer. 2. "Genome Project", software written by us in Hypercard 2.1. Hard copy could not be included in this description because of length restrictions. For a copy of the software, send a formatted 3.5" "floppy " disk and stamped, self-addressed envelope to Jim Dodds at the St. Louis Priory School, 500 S. Mason Road, St. Louis, MO. 63141 3. A liquid crystal palette for overhead projection is recommended but not required. Procedure: The basic strategy of the module is to pose an ethical dilemma, then counter the student's response with a countervailing consideration. One alternative is to do this as a wholeclass activity, with attention directed to a projection screen. When "Genome Project" is opened, the following text appears on the screen: Pick your topic: 1. Should fetuses with genetic defects be aborted? 2. Should the new technology be used to change the gene pool? 3. Discrimination? - The use of genetic data by insurance companies, prospective employers, others. 4. Should anyone own the information produced by the genome project? 5. The genetic component of behavior The need for professional counseling when reporting genetic profiles. The teacher clicks on a button at the bottom of the screen to select the topic. A fact situation is then presented on the screen, with a choice to be made. The teacher invites the class to discuss the fact situation and make a consensus choice. Clicking on the button for that choice then brings up a screen which gives a contrary view. This can then be the basis for further discussion and possible refinement of the class' view of the ethical question presented. If a palette is not available, all the screens can be printed using the ―print stack" command under the file menu. This "hard copy" can then be used as transparency masters. The disadvantage of this approach is that, throughout the lesson, the teacher must find the appropriate transparency for each choice made. A third option is to let students work in pairs or groups of 3 or 4 at computers. To employ this option, the teacher needs only to copy Hypercard 2.1 and Genome Project onto the hard drive of each computer in the lab. The text on any of the screens can easily be edited by the teacher, just as with a word processor. More elaborate changes (adding cards or buttons) can also be made by a
255
teacher with an elementary knowledge of Hypercard programming. We invite your suggestions for improving and updating the software. The Human Genome Project: Background Information: The Human Genome Project (HGP) is a project which has as its ultimate goal the identification and location of the positions of all genes of the human species. The actual sequence of the nucleotides making up the genes will also be another part of the project. Nobel laureate Walter Gilbert described the human genome as the Holy Grail of biology. The concept of developing this project began to take shape during the late 1960's and throughout the 1970's. When the first maps of genes were conceived, these maps were based on direct observation of chromosomes. Patterns of familial inheritance of genetic based disorders such as Huntington's disease were studied to deduce the possible mode of inheritance. As biochemical analysis of DNA became possible, segments of DNA associated with a pattern of inheritance were identified. These segments of DNA, called markers, allowed scientists to begin to identify regions of chromosomes that coded for genetic disorders. As biotechnological techniques developed, DNA sequencing became possible, and the nucleotides in a chromosomal region or a gene could be determined. Renato Dulbecco was the first researcher to suggest publicly the idea of a human genome project. The U.S. Department of Energy (DOE) was also considering such a project because legal issues related to radiation or chemical exposure was surfacing. Military personnel and civilian populations had been subjected to radiation exposure during atomic testing. Vietnam veterans had been exposed to Agent Orange. Nuclear power facilities posed possible radiation exposure to employees and to the general public in the event of an accident. The resiliency of the human genome was of interest, and a genetic knowledge base was needed to assess this resiliency. The debate to organize the HGP dates back to 1985. Italy began a genome project in 1987. The United Kingdom and the former U.S.S.R. began projects in 1988. Japan has also begun a project, and the U.S. project officially began in October 1990. The U.S. project was projected to cost 3 billion dollars over 15 years. The major sources of funding in the U.S. are the National Institutes of Health (NIH), the United States Department of Energy (DOE), the National Science Foundation (NSF), and the Howard Hughes Medical Institute (HHMI). NIH, DOE, and NSF receive funds appropriated by Congress which means the project is being supported in part by federal tax dollars. Funding from the private sector also contributes to the HGP. The HGP is not only collecting information about the human genome; some researchers are also working on the genomes of other organisms. Some of the organisms being used in the HGP include Escherichia coli, a bacterium, Saccharomyces cerevisiae, a yeast, Drosophila melanogaster, the fruit fly, Caenorhabditis elegans, a nematode, and Mus musculus, the mouse. More sophisticated techniques related to gene identification and DNA sequencing is being developed by many research laboratories as the project progresses.
256
The question might be posed: what is the value of working with organisms other than humans? The genetic information of the other organisms can be manipulated in various ways in the research laboratory to elucidate information related to the genome. Understanding variation, developmental biology and gene regulation are also anticipated outcomes of this aspect of the HGP. The enormity of the HGP may be placed in some perspective if the task of sequencing the base pairs in some selected organisms is considered. The number of base pairs in the haploid DNA of E. coli is 4.7 million pairs, and S. cerevisiae has 15 million pairs. D. melanogaster has 155 million while C. elegans has 80 million. M. musculus has 3,000 million. Haploid human DNA is projected to have 2,800 million base pairs which represent at least 50,000 to 100,000 genes. With the monumental task of trying to decode the human genome comes the necessity to improve and refine techniques for identifying genes and base sequences. In sequencing DNA, DNA must first be cloned or isolated in some way. DNA requires laboratory preparation for sequencing analysis, and the sequencing reactions which are done involve either chemical or enzymatic protocols. Sequencing gels are run and further processed before DNA sequences can be deciphered. To speed the sequencing process, automated and computerized technologies are being developed. Even with automated sequencers the process is slow. In 1991, 2,000 bases could be sequenced per day. At this rate, it would take 1.5 million person days to sequence the entire genome. With all of the information generated from this project, new databases are being established. Some of these databases have information about specific research techniques while others include lists of researchers. Computer technology has also entered the DNA sequencing process. In 1991, Oak Ridge National Laboratory was testing an artificial intelligence program which was called GRAIL. A "DNA chip" is also a computerized sequencing application. The DNA library will continue to expand, and with this increased information, new problems of a different type are surfacing. As the information regarding the human genome expands, we will be able to access information about our own genetic makeup. Genetic based diseases can be detected or predicted. The genetic constituency of an embryo could be surveyed for potential problems. Genetic disorders for which there are no existing corrections will be detected. Also, questions as to who should have access to your genetic profile will surface. What will employers and insurance companies do with such information? What kinds of psychological implications does this present an individual who will develop an untreatable disorder at age 40? Whose genome will be selected as the information base for the HGP? Actually, the DNA library that is developed will represent a profile compiled from many individuals. The information will be similar to having a catalog of many different genetic variations. Some Techniques Used in the Genome Project: Restriction Fragment Length Polymorphisms (RFLPs): Each restriction enzyme is specific to a certain base sequence (" restriction site") and will cut DNA at all such sites to produce a number of "restriction fragments". No two individuals will have exactly the same base sequence unless they are identical twins. Because of this DNA variability, restriction fragments from a given region of an 257
individual's genome can be separated using gel electrophoresis to reveal a unique pattern ("fingerprint"). Inheritance of RFLPs can be followed through families. By using RFLPs scientists are able to construct linkage maps. A type of RFLP called a variable number of tandem repeats (VNTR) has application in forensics. DNA has repeated numbers of regions which are noncoding regions. A VNTR is a small section of repeating, noncoding DNA. VNTRs are scattered throughout a person's DNA, and the number of repeats can vary from a few to a few hundred. This variability gives individual unique VNTR regions. Even the homologous chromosomes of a person tend to differ. Because of these differences, the VNTRs in an individual's DNA can be used to identify with near certainty the confirmation or rejection of an accused person in crimes such as murder or rape where a small sample of blood or semen is collected. Automated DNA Sequencing: Lloyd Smith and Leroy Hood of Caltech developed an automated sequencing process that is used to speed up the task of DNA sequencing. The technique makes use of at least four different fluorescent dyes that attach specifically to adenine, thymine, guanine or cytosine. Restriction fragments are tagged with dye. The dyed fragments are passed through a glass tube that is filled with a special transport gel. Small DNA fragments move through the gel more rapidly than larger fragments. When the fragments reach the end of the gel, they are excited by a beam from an argonion laser. Each dye will fluoresce with a different color. Light emitted by the fluorescing dye is sent to a photomultiplier and then converted to a digital signal. A computer program is able to differentiate among the signals and, in turn, order the sequences of bases on the DNA fragments. Polymerase Chain Reaction (PCR): Using the polymerase chain reaction (PCR), millions of copies of a specific DNA segment can be made in a test tube. PCR is also an automated process. Many physical mapping strategies depend on creating an array of linear DNA overlaps. Multiple copies of DNA fragments are needed to complete the mapping process. PCR can be applied for forensic purposes as well. From a very tiny amount of DNA, the polymerase chain reaction can be used to produce more copies of the DNA for analysis. References: Books BSCS, Mapping and Sequencing the Human Genome: Science, Ethics and Public Policy, Colorado Springs, CO, Colorado College, 1991. Davis, Joel, Mapping the Code, New York: John Wiley & Sons, 1990. Friedman, Tracy L., The Science and Politics of the Human Genome Project , undergraduate thesis, Princeton University, 1990. Hanna, K., Biomedical Politics. Washington, D.C., National Academy Press, 1991. Lee, Thomas, the Human Genome Project: Cracking the Code of Life, New York: Plenum Press, 1991. Nossel, G. and Coppel, R., Reshaping Life. New York: Press Syndicate , 1989. Shapiro, Robert, the Human Blueprint, New York: St. Martin's Press, 1991.
258
U.S. Congress, Office of Technology Assessment, Mapping our Genes-The Genome Projects: How Big, How Fast?, Washington, D. C.: U.S. Government Printing Office, April, 1988. Wills, C., Exons, Introns, and Talking Genes. U.S.A. Basic Books, 1991. Professional Journals: Adams, M. et al. (1991). "Complementary DNA Sequencing: Expressed Sequence Tags and Human Genome Project." Science 252, 1651-1656. Barinaga, M., "Will 'DNA Chip' Speed Genome Initiative?", Science , 9/27/91, 1489. Cook-Deegan, R.M. (1991). "Origins of the Human Genome Project." The FASEB Journal 5, 9-11. Cook-Deegan, Robert M., "Public Policy Implications of the Human Genome Project" Murray, T. (1991). "Ethical Issues in Human Genome Research." The FASEB Journal 5, 55-60. Placa, J. (1992). "The Genome Project: Life After Watson. " Science 256, 956-958. Roberts, L., "GRAIL Seeks Out Genes Buried in DNA Sequence", Science, 11/8/91, 805. Watson, J.D. and Cook-Deegan, Robert M., "Origins of the Human Genome Project ", FASEB Journal, January, 1991, 8-11. Popular Press: Shapiro, J., "Among Twin Men", U.S. News, 12/30/91 and 1/6/92
The Woodrow Wilson National Fellowship Foundation CN 5281, Princeton NJ 08543-5281
Tel :( 609)452-7007
259
[email protected] Fax :( 609)452-0066
CHROMOSOME From Wikipedia, the free encyclopedia Jump to: navigation, search For a non-technical introduction to the topic, see Introduction to genetics.
Diagram of a duplicated and condensed (metaphase) eukaryotic chromosome. (1) Chromatid – one of the two identical parts of the chromosome after S phase. (2) Centromere – the point where the two chromatids touch, and where the microtubules attach. (3) Short arm. (4) Long arm. A chromosome is an organized structure of DNA and protein that is found in cells. It is a single piece of coiled DNA containing many genes, regulatory elements and other nucleotide sequences. Chromosomes also contain DNA-bound proteins, which serve to package the DNA and control its functions. The word chromosome comes from the Greek χρῶμα (chroma, color) and σῶμα (soma, body) due to their property of being very strongly stained by particular dyes. Chromosomes vary widely between different organisms. The DNA molecule may be circular or linear, and can be composed of 10,000 to 1,000,000,000[1] nucleotides in a long chain. Typically eukaryotic cells (cells with nuclei) have large linear chromosomes and prokaryotic cells (cells without defined nuclei) have smaller circular chromosomes, although there are many exceptions to this rule. Furthermore, cells may contain more than one type of chromosome; for example, mitochondria in most eukaryotes and chloroplasts in plants have their own small chromosomes. In eukaryotes, nuclear chromosomes are packaged by proteins into a condensed structure called chromatin. This allows the very long DNA molecules to fit into the cell nucleus. The structure of chromosomes and chromatin varies through the cell cycle. Chromosomes are the essential unit for cellular division and must be replicated, divided, and passed 260
successfully to their daughter cells so as to ensure the genetic diversity and survival of their progeny. Chromosomes may exist either duplicated or unduplicated—unduplicated chromosomes are single linear strands, whereas duplicated chromosomes (copied during synthesis phase) contain two copies joined by a centromere. Compaction of the duplicated chromosomes during mitosis and meiosis results in the classic four-arm structure (pictured to the right). Chromosomal recombination plays a vital role in genetic diversity. If these structures are manipulated incorrectly, through processes known as chromosomal instability and translocation, the cell may undergo mitotic catastrophe and die, or it may aberrantly evade apoptosis leading to the progression of cancer. However, in practice "chromosome" is a rather loosely defined term. In prokaryotes, a small circular DNA molecule may be called either a plasmid or a small chromosome. These small circular genomes are also found in mitochondria and chloroplasts, reflecting their bacterial origins. The simplest chromosomes are found in viruses: these DNA or RNA molecules are short linear or circular chromosomes that often lack any structural proteins. Contents: [hide] 1 History o 1.1 Nucleus as the seat of heredity o 1.2 Chromosomes as vectors of heredity 2 Chromosomes in eukaryotes o 2.1 Chromatin 2.1.1 Interphase chromatin 2.1.2 Metaphase chromatin and division 3 Chromosomes in prokaryotes o 3.1 Structure in sequences o 3.2 DNA packaging 4 Number of chromosomes in various organisms o 4.1 Eukaryotes o 4.2 Prokaryotes 5 Karyotype o 5.1 Historical note 6 Chromosomal aberrations 7 Human chromosomes 8 See also 9 External links 10 References History: Nucleus as the seat of heredity The origin of this groundbreaking idea lies in a few sentences tucked away in Ernst Haeckel's Generelle Morphologie of 1866.[2] The evidence for this insight gradually accumulated until, after twenty or so years, two of the greatest in a line of great German scientists [citation needed] spelled out the concept. August Weismann proposed that the germ line is separate from the soma, and that the cell nucleus is the repository of the hereditary material, which, he proposed, is arranged along 261
the chromosomes in a linear manner. Further, he proposed that at fertilisation a new combination of chromosomes (and their hereditary material) would be formed. This was the explanation for the reduction division of meiosis (first described by van Beneden). Chromosomes as vectors of heredity: In a series of experiments, Theodor Boveri gave the definitive demonstration that chromosomes are the vectors of heredity. His two principles were based upon the continuity of chromosomes and the individuality of chromosomes [citation needed]. It is the second of these principles that was so original [citation needed]. Boveri was able to test the proposal put forward by Wilhelm Roux, that each chromosome carries a different genetic load, and showed that Roux was right. Upon the rediscovery of Mendel, Boveri was able to point out the connection between the rules of inheritance and the behaviour of the chromosomes. It is interesting to see that Boveri influenced two generations of American cytologists: Edmund Beecher Wilson, Walter Sutton and Theophilus Painter were all influenced by Boveri (Wilson and Painter actually worked with him). In his famous textbook The Cell, Wilson linked Boveri and Sutton together by the Boveri-Sutton theory. Mayr remarks that the theory was hotly contested by some famous geneticists: William Bateson, Wilhelm Johannsen, Richard Goldschmidt and T.H. Morgan, all of a rather dogmatic turn-of-mind. Eventually complete proof came from chromosome maps in Morgan's own lab.[3] Chromosomes in eukaryotes: It has been suggested that Eukaryotic chromosome fine structure be merged into this article or section. (Discuss) Eukaryotes (cells with nuclei such as plants, yeast, and animals) possess multiple large linear chromosomes contained in the cell's nucleus. Each chromosome has one centromere, with one or two arms projecting from the centromere, although, under most circumstances, these arms are not visible as such. In addition, most eukaryotes have a small circular mitochondrial genome, and some eukaryotes may have additional small circular or linear cytoplasmic chromosomes. In the nuclear chromosomes of eukaryotes, the uncondensed DNA exists in a semiordered structure, where it is wrapped around histones (structural proteins), forming a composite material called chromatin. Chromatin: Main article: Chromatin
Fig. 2: The major structures in DNA compaction; DNA, the nucleosome, the 10nm "beads-on-a-string" fibre, the 30nm fibre and the metaphase chromosome. Chromatin is the complex of DNA and protein found in the eukaryotic nucleus which packages chromosomes. The structure of chromatin varies significantly between different stages of the cell cycle, according to the requirements of the DNA. 262
Interphase chromatin: During interphase (the period of the cell cycle where the cell is not dividing), two types of chromatin can be distinguished: Euchromatin, which consists of DNA that is active, e.g., being expressed as protein. Heterochromatin, which consists of mostly inactive DNA. It seems to serve structural purposes during the chromosomal stages. Heterochromatin can be further distinguished into two types: o Constitutive heterochromatin, which is never expressed. It is located around the centromere and usually contains repetitive sequences. o Facultative heterochromatin, which is sometimes expressed. Individual chromosomes cannot be distinguished at this stage – they appear in the nucleus as a homogeneous tangled mix of DNA and protein. [edit] Metaphase chromatin and division: See also: mitosis and meiosis
Human chromosomes during metaphase. In the early stages of mitosis or meiosis (cell division), the chromatin strands become more and more condensed. They cease to function as accessible genetic material (transcription stops) and become a compact transportable form. This compact form makes the individual chromosomes visible, and they form the classic four arm structure, a pair of sister chromatids attached to each other at the centromere. The shorter arms are called p arms (from the French petit, small) and the longer arms are called q arms (q follows p in the Latin alphabet). This is the only natural context in which individual chromosomes are visible with an optical microscope. During divisions, long microtubules attach to the centromere and the two opposite ends of the cell. The microtubules then pull the chromatids apart, so that each daughter cell inherits one set of chromatids. Once the cells have divided, the chromatids are uncoiled and can function again as chromatin. In spite of their appearance, chromosomes are structurally highly condensed, which enables these giant DNA structures to be contained within a cell nucleus (Fig. 2). The self-assembled microtubules form the spindle, which attaches to chromosomes at specialized structures called kinetochores, one of which is present on each sister chromatid. A special DNA base sequence in the region of the kinetochores provides, along with special proteins, longer-lasting attachment in this region. 263
Chromosomes in prokaryotes: The prokaryotes – bacteria and archaea – typically have a single circular chromosome, but many variations do exist.[4] Most bacteria have a single circular chromosome that can range in size from only 160,000 base pairs in the endosymbiotic bacteria Candidatus Carsonella ruddii,[5] to 12,200,000 base pairs in the soil-dwelling bacteria Sorangium cellulosum.[6] Spirochaetes of the genus Borrelia are a notable exception to this arrangement, with bacteria such as Borrelia burgdorferi, the cause of Lyme disease, containing a single linear chromosome.[7] Structure in sequences: Prokaryotic chromosomes have less sequence-based structure than eukaryotes. Bacteria typically have a single point (the origin of replication) from which replication starts, whereas some archaea contain multiple replication origins.[8] The genes in prokaryotes are often organized in operons, and do not usually contain introns, unlike eukaryotes. DNA packaging: Prokaryotes do not possess nuclei. Instead, their DNA is organized into a structure called the nucleoid.[9] The nucleoid is a distinct structure and occupies a defined region of the bacterial cell. This structure is, however, dynamic and is maintained and remodeled by the actions of a range of histone-like proteins, which associate with the bacterial chromosome.[10] In archaea, the DNA in chromosomes is even more organized, with the DNA packaged within structures similar to eukaryotic nucleosomes.[11][12] Bacterial chromosomes tend to be tethered to the plasma membrane of the bacteria. In molecular biology application, this allows for its isolation from plasmid DNA by centrifugation of lysed bacteria and pelleting of the membranes (and the attached DNA). Prokaryotic chromosomes and plasmids are, like eukaryotic DNA, generally supercoiled. The DNA must first be released into its relaxed state for access for transcription, regulation, and replication. Number of chromosomes in various organisms: Main article: List of number of chromosomes of various organisms Eukaryotes: These tables give the total number of chromosomes (including sex chromosomes) in a cell nucleus. For example, human cells are diploid and have 22 different types of autosome, each present as two copies, and two sex chromosomes. This gives 46 chromosomes in total. Other organisms have more than two copies of their chromosomes, such as bread wheat, which is hexaploid and has six copies of seven different chromosomes – 42 chromosomes in total. Chromosome numbers in some plants
Chromosome numbers (2n) in some animals Species
#
Species
Plant Species
#
Common fruit fly
8
Guinea Pig[20] 64
Arabidopsis thaliana (diploid)[13]
10
Dove[citation needed]
78
Garden snail[21]
54
Rye (diploid)[14]
14
Earthworm Octodrilus 36 [22] complanatus
Tibetan fox
36
264
#
Maize (diploid)[15] 20
Domestic cat[23]
38
Domestic pig 38
Einkorn wheat 14 [16] (diploid)
Laboratory mouse
40
Laboratory rat 42
Rabbit[citation needed]
44
Syrian hamster
44
Hare[citation needed]
46
Human[24]
46
Bread wheat 42 (hexaploid)[16]
Gorillas, Chimpanzees[24]
48
Domestic sheep
54
Potato (tetraploid)[17]
Elephants[25]
56
Cow
60
Donkey
62
Horse
64
Dog[26]
78
Kingfisher[27] 132
Goldfish[28]
100104
Silkworm[29]
Durum wheat 28 (tetraploid)[16]
Cultivated tobacco (diploid)[18]
48 48
Adder's Tongue approx Fern (diploid)[19] 1,400
56
Chromosome numbers in other organisms Species Trypanosoma brucei
Large Chromosomes 11
Intermediate Chromosomes 6
Small Chromosomes ~100
Chicken[30] 8 2 sex chromosomes 60 Normal members of a particular eukaryotic species all have the same number of nuclear chromosomes (see the table). Other eukaryotic chromosomes, i.e., mitochondrial and plasmid-like small chromosomes, are much more variable in number, and there may be thousands of copies per cell.
265
The 24 human chromosome territories during prometaphase in fibroblast cells. Asexually reproducing species have one set of chromosomes, which is the same in all body cells. Sexually reproducing species have somatic cells (body cells), which are diploid [2n] having two sets of chromosomes, one from the mother and one from the father. Gametes, reproductive cells, are haploid [n]: They have one set of chromosomes. Gametes are produced by meiosis of a diploid germ line cell. During meiosis, the matching chromosomes of father and mother can exchange small parts of themselves (crossover), and thus create new chromosomes that are not inherited solely from either parent. When a male and a female gamete merge (fertilization), a new diploid organism is formed. Some animal and plant species are polyploid [Xn]: They have more than two sets of homologous chromosomes. Plants important in agriculture such as tobacco or wheat are often polyploid, compared to their ancestral species. Wheat has a haploid number of seven chromosomes, still seen in some cultivars as well as the wild progenitors. The more-common pasta and bread wheats are polyploid, having 28 (tetraploid) and 42 (hexaploid) chromosomes, compared to the 14 (diploid) chromosomes in the wild wheat.[31] Prokaryotes: Prokaryote species generally have one copy of each major chromosome, but most cells can easily survive with multiple copies.[32] For example, Buchnera, a symbiont of aphids has multiple copies of its chromosome, ranging from 10–400 copies per cell.[33] However, in some large bacteria, such as Epulopiscium fishelsoni up to 100,000 copies of the chromosome can be present.[34] Plasmids and plasmid-like small chromosomes are, as in eukaryotes, very variable in copy number. The number of plasmids in the cell is almost entirely determined by the rate of division of the plasmid – fast division causes high copy number, and vice versa. Karyotype: Main article: Karyotype
Figure 3: Karyogram of a human male In general, the karyotype is the characteristic chromosome complement of a eukaryote species.[35] The preparation and study of karyotypes is part of cytogenetics. Although the replication and transcription of DNA is highly standardized in eukaryotes, the same cannot be said for their karyotypes, which are often highly variable. There may be variation between species in chromosome number and in detailed organization. In some cases, there is significant variation within species. Often there is 1. variation between the two sexes; 2. Variation between the germ-line and soma (between gametes 266
and the rest of the body); 3. variation between members of a population, due to balanced genetic polymorphism; 4. geographical variation between races; 5. mosaics or otherwise abnormal individuals. Also, variation in karyotype may occur during development from the fertilised egg. The technique of determining the karyotype is usually called karyotyping. Cells can be locked part-way through division (in metaphase) in vitro (in a reaction vial) with colchicine. These cells are then stained, photographed, and arranged into a karyogram, with the set of chromosomes arranged, autosomes in order of length, and sex chromosomes (here X/Y) at the end: Fig. 3. Like many sexually reproducing species, humans have special gonosomes (sex chromosomes, in contrast to autosomes). These are XX in females and XY in males. Historical note: Investigation into the human karyotype took many years to settle the most basic question. How many chromosomes does a normal diploid human cell contain? In 1912, Hans von Winiwarter reported 47 chromosomes in spermatogonia and 48 in oogonia, concluding an XX/XO sex determination mechanism.[36] Painter in 1922 was not certain whether the diploid number of man is 46 or 48, at first favouring 46.[37] He revised his opinion later from 46 to 48, and he correctly insisted on man's having an XX/XY system.[38] New techniques were needed to definitively solve the problem: 1. Using cells in culture 2. Pretreating cells in a hypotonic solution, which swells them and spreads the chromosomes 3. Arresting mitosis in metaphase by a solution of colchicine 4. Squashing the preparation on the slide forcing the chromosomes into a single plane 5. Cutting up a photomicrograph and arranging the result into an indisputable karyogram. It took until the mid-1950s until it became generally accepted that the human karyotype include only 46 chromosomes. Considering the techniques of Winiwarter and Painter, their results were quite remarkable.[39][40] Chimpanzees (the closest living relatives to modern humans) have 48 chromosomes. Chromosomal aberrations: Main articles: Chromosome abnormalities and aneuploidy
The three major single chromosome mutations; deletion (1), duplication (2) and inversion (3).
267
The two major two-chromosome mutations; insertion (1) and translocation (2).
In Down syndrome, there are three copies of chromosome 21 Chromosomal aberrations are disruptions in the normal chromosomal content of a cell, and are a major cause of genetic conditions in humans, such as Down syndrome. Some chromosome abnormalities do not cause disease in carriers, such as translocations, or chromosomal inversions, although they may lead to a higher chance of birthing a child with a chromosome disorder. Abnormal numbers of chromosomes or chromosome sets, aneuploidy, may be lethal or give rise to genetic disorders. Genetic counseling is offered for families that may carry a chromosome rearrangement. The gain or loss of DNA from chromosomes can lead to a variety of genetic disorders. Human examples include: Cri du chat, which is caused by the deletion of part of the short arm of chromosome 5. "Cri du chat" means "cry of the cat" in French, and the condition was so-named because affected babies make high-pitched cries that sound like those of a cat. Affected individuals have wide-set eyes, a small head and jaw, and are moderately to severely mentally retarded and very short. Wolf-Hirschhorn syndrome, which is caused by partial deletion of the short arm of chromosome 4. It is characterized by severe growth retardation and severe to profound mental retardation. 268
Down's syndrome, usually is caused by an extra copy of chromosome 21 (trisomy 21). Characteristics include decreased muscle tone, stockier build, asymmetrical skull, slanting eyes and mild to moderate mental retardation.[41] Edwards syndrome, which is the second-most-common trisomy; Down syndrome is the most common. It is a trisomy of chromosome 18. Symptoms include mental and motor retardation and numerous congenital anomalies causing serious health problems. Ninety percent die in infancy; however, those that live past their first birthday usually are quite healthy thereafter. They have a characteristic clenched hands and overlapping fingers. Patau Syndrome, also called D-Syndrome or trisomy-13. Symptoms are somewhat similar to those of trisomy-18, but they do not have the characteristic hand shape. Idic15, abbreviation for Isodicentric 15 on chromosome 15; also called the following names due to various researches, but they all mean the same; IDIC(15), Inverted dupliction 15, extra Marker, Inv dup 15, partial tetrasomy 15 [42] Jacobsen syndrome, also called the terminal 11q deletion disorder. This is a very rare disorder. Those affected have normal intelligence or mild mental retardation, with poor expressive language skills. Most have a bleeding disorder called Paris-Trousseau syndrome. Klinefelter's syndrome (XXY). Men with Klinefelter syndrome are usually sterile, and tend to have longer arms and legs and to be taller than their peers. Boys with the syndrome are often shy and quiet, and have a higher incidence of speech delay and dyslexia. During puberty, without testosterone treatment, some of them may develop gynecomastia. Turner syndrome (X instead of XX or XY). In Turner syndrome, female sexual characteristics are present but underdeveloped. People with Turner syndrome often have a short stature, low hairline, abnormal eye features and bone development and a "cavedin" appearance to the chest. XYY syndrome. XYY boys are usually taller than their siblings. Like XXY boys and XXX girls, they are somewhat more likely to have learning difficulties. Triple-X syndrome (XXX). XXX girls tend to be tall and thin. They have a higher incidence of dyslexia. Small supernumerary marker chromosome. This means there is an extra, abnormal chromosome. Features depend on the origin of the extra genetic material. Cat-eye syndrome and isodicentric chromosome 15 syndromes (or Idic15) are both caused by a supernumerary marker chromosome, as is Pallister-Killian syndrome. Chromosomal mutations produce changes in whole chromosomes (more than one gene) or in the number of chromosomes present. Deletion – loss of part of a chromosome Duplication – extra copies of a part of a chromosome Inversion – reverse the direction of a part of a chromosome Translocation – part of a chromosome breaks off and attaches to another chromosome Most mutations are neutral – have little or no effect A detailed graphical display of all human chromosomes and the diseases annotated at the correct spot may be found at [43]. 269
Human chromosomes: Human cells have 23 pairs of large linear nuclear chromosomes, giving a total of 46 per cell. In addition to these, human cells have many hundreds of copies of the mitochondrial genome. Sequencing of the human genome has provided a great deal of information about each of the chromosomes. Below is a table compiling statistics for the chromosomes, based on the Sanger Institute's human genome information in the Vertebrate Genome Annotation (VEGA) database.[44] Number of genes is an estimate as it is in part based on gene predictions. Total chromosome length is an estimate as well, based on the estimated size of unsequenced heterochromatin regions.
Chromosome
Genes 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21
4,220 1,491 1,550 446 609 2,281 2,135 1,106 1,920 1,793 379 1,430 924 1,347 921 909 1,672 519 1,555 1,008 578
Total bases 247,199,719 242,751,149 199,446,827 191,263,063 180,837,866 170,896,993 158,821,424 146,274,826 140,442,298 135,374,737 134,452,384 132,289,534 114,127,980 106,360,585 100,338,915 88,822,254 78,654,742 76,117,153 63,806,651 62,435,965 46,944,323 270
Sequenced bases[45] 224,999,719 237,712,649 194,704,827 187,297,063 177,702,766 167,273,993 154,952,424 142,612,826 120,312,298 131,624,737 131,130,853 130,303,534 95,559,980 88,290,585 81,341,915 78,884,754 77,800,220 74,656,155 55,785,651 59,505,254 34,171,998
22 1,092 49,528,953 34,893,953 X (sex chromosome) 1,846 154,913,754 151,058,754 Y (sex chromosome) 454 57,741,652 25,121,652 Total 32,185 3,079,843,747 2,857,698,560 See also: Locus (explains gene location nomenclature) Sex-determination system o XY sex-determination system X chromosome X-inactivation Y chromosome Y-chromosomal Adam Y-chromosomal Aaron Genetic genealogy o Genealogical DNA test Genetic deletion List of number of chromosomes of various organisms For information about chromosomes in genetic algorithms, see chromosome (genetic algorithm) External links: Wikimedia Commons has media related to: Chromosomes
An Introduction to DNA and Chromosomes from HOPES: Huntington's Outreach Project for Education at Stanford Chromosome Abnormalities at AtlasGeneticsOncology What Can Our Chromosomes Tell Us?, from the University of Utah's Genetic Science Learning Center Try making a karyotype yourself, from the University of Utah's Genetic Science Learning Center Kimballs Chromosome pages Chromosome News from Genome News Network Eurochromnet, European network for Rare Chromosome Disorders on the Internet http://www.ensembl.org Ensembl project, presenting chromosomes, their genes and syntenic loci graphically via the web Genographic Project Home reference on Chromosomes from the U.S. National Library of Medicine References: 1. ^ Paux E, Sourdille P, Salse J, et al. (2008). "A Physical Map of the 1-Gigabase Bread Wheat Chromosome 3B". Science 322 (5898): 101–104. Doi: 10.1126/science.1161847. PMID 18832645. 2. ^ Haeckel E. 1866. Generelle Morphologie der Organismen: Allgemeine Gründzuge der organischen Formen-Wissenschaft. 2 vols, Reimer, Berlin. 3. ^ Mayr E. 1982. The growth of biological thought. Harvard. p749 271
4. ^ Thanbichler M, Shapiro L (2006). "Chromosome organization and segregation in bacteria". J. Struct. Biol. 156 (2): 292–303. Doi: 10.1016/j.jsb.2006.05.007. PMID 16860572. 5. ^ Nakabachi A, Yamashita A, Toh H, Ishikawa H, Dunbar H, Moran N, Hattori M (2006). "The 160-kilobase genome of the bacterial endosymbiont Carsonella". Science 314 (5797): 267. Doi:10.1126/science.1134196. PMID 17038615. 6. ^ Pradella S, Hans A, Spröer C, Reichenbach H, Gerth K, Beyer S (2002). "Characterisation, genome size and genetic manipulation of the myxobacterium Sorangium cellulosum so ce56". Arch Microbiol 178 (6): 484–92. Doi: 10.1007/s00203002-0479-2. PMID 12420170. 7. ^ Hinnebusch J, Tilly K (1993). "Linear plasmids and chromosomes in bacteria". Mol Microbiol 10 (5): 917–22. Doi: 10.1111/j.1365-2958.1993.tb00963.x. PMID 7934868. 8. ^ Kelman LM, Kelman Z (2004). "Multiple origins of replication in archaea". Trends Microbiol. 12 (9): 399–401. Doi: 10.1016/j.tim.2004.07.001. PMID 15337158. 9. ^ Thanbichler M, Wang SC, Shapiro L (2005). "The bacterial nucleoid: a highly organized and dynamic structure". J. Cell. Biochem. 96 (3): 506–21. Doi: 10.1002/jcb.20519. PMID 15988757. 10. ^ Sandman K, Pereira SL, Reeve JN (1998). "Diversity of prokaryotic chromosomal proteins and the origin of the nucleosome". Cell. Mol. Life Sci. 54 (12): 1350–64. Doi: 10.1007/s000180050259. PMID 9893710. 11. ^ Sandman K, Reeve JN (2000). "Structure and functional relationships of archaeal and eukaryal histones and nucleosomes". Arch. Microbiol. 173 (3): 165–9. Doi: 10.1007/s002039900122. PMID 10763747. 12. ^ Pereira SL, Grayling RA, Lurz R, Reeve JN (1997). "Archaeal nucleosomes". Proc. Natl. Acad. Sci. U.S.A. 94 (23): 12633–7. doi:10.1073/pnas.94.23.12633. PMID 9356501. http://www.pnas.org/cgi/pmidlookup?view=long&pmid=9356501. 13. ^ Armstrong SJ, Jones GH (January 2003). "Meiotic cytology and chromosome behaviour in wild-type Arabidopsis thaliana". J. Exp. Bot. 54 (380): 1–10. doi: 10.1093/jxb/54.380.1. PMID 12456750. http://jexbot.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=12456750. 14. ^ Gill BS, Kimber G (April 1974). "The Giemsa C-banded karyotype of rye". Proc. Natl. Acad. Sci. U.S.A. 71 (4): 1247–9. doi:10.1073/pnas.71.4.1247. PMID 4133848. 15. ^ Kato A, Lamb JC, Birchler JA (September 2004). "Chromosome painting using repetitive DNA sequences as probes for somatic chromosome identification in maize". Proc. Natl. Acad. Sci. U.S.A. 101 (37): 13554–9. doi: 10.1073/pnas.0403659101. PMID 15342909. PMC: 518793. http://www.pnas.org/cgi/pmidlookup?view=long&pmid=15342909. 16. ^ A b c Dubcovsky J, Luo MC, Zhong GY, et al. (1996). "Genetic map of diploid wheat, Triticum monococcum L., and its comparison with maps of Hordeum vulgare L". Genetics 143 (2): 983–99. PMID 8725244.
272
17. ^ Ellison, W. (1935). "A study of the chromosome numbers and morphology in certain British varieties of the common cultivated potato (solanum buberosum L.)" (PDF). Genetica 17 (1): 1–26. doi: 10.1007/BF01984179. http://www.springerlink.com/index/V8437QN6316363UX.pdf. Retrieved on 2008-05-11. 18. ^ Kenton A, Parokonny AS, Gleba YY, Bennett MD (August 1993). "Characterization of the Nicotiana tabacum L. genome by molecular cytogenetics". Mol. Gen. Genet. 240 (2): 159–69. Doi: 10.1007/BF00277053. PMID 8355650. 19. ^ Leitch IJ, Soltis DE, Soltis PS, Bennett MD (2005). "Evolution of DNA amounts across land plants (embryophyta)". Ann. Bot. 95 (1): 207–17. doi:10.1093/aob/mci014. PMID 15596468. http://aob.oxfordjournals.org/cgi/content/full/95/1/207. 20. ^ Umeko Semba, Yasuko Umeda, Yoko Shibuya, Hiroaki Okabe, Sumio Tanase and Tetsuro Yamamoto (2004). "Primary structures of guinea pig high- and low-molecularweight kininogens". International Immunopharmacology 4 (10-11): 1391–1400. doi:10.1016/j.intimp.2004.06.003. http://www.sciencedirect.com/science/article/B6W7N4CX6PRC-1/2/97487fdf611a04e3c88690da9e6d853b. 21. ^ Vitturi R, Libertini A, Sineo L, et al. (2005). "Cytogenetics of the land snails Cantareus aspersus and C. mazzullii (Mollusca: Gastropoda: Pulmonata)". Micron 36 (4): 351–7. Doi: 10.1016/j.micron.2004.12.010. PMID 15857774. 22. ^ Vitturi R, Colomba MS, Pirrone AM, Mandrioli M (2002). "rDNA (18S-28S and 5S) colocalization and linkage between ribosomal genes and (TTAGGG)(n) telomeric sequence in the earthworm, Octodrilus complanatus (Annelida: Oligochaeta: Lumbricidae), revealed by single- and double-color FISH". J. Hered. 93 (4): 279–82. doi:10.1093/jhered/93.4.279. PMID 12407215. http://jhered.oxfordjournals.org/cgi/content/full/93/4/279. 23. ^ Nie W, Wang J, O'Brien PC, et al. (2002). "The genome phylogeny of domestic cat, red panda and five mustelid species revealed by comparative chromosome painting and G-banding". Chromosome Res. 10 (3): 209–22. Doi: 10.1023/A:1015292005631. PMID 12067210. 24. ^ A b De Grouchy J (1987). "Chromosome phylogenies of man, great apes, and Old World monkeys". Genetica 73 (1-2): 37–52. PMID 3333352. 25. ^ Houck ML, Kumamoto AT, Gallagher DS, Benirschke K (2001). "Comparative cytogenetics of the African elephant (Loxodonta africana) and Asiatic elephant (Elephas maximus)". Cytogenet. Cell Genet. 93 (3-4): 249–52. Doi:10.1159/000056992. PMID 11528120. 26. ^ Wayne RK, Ostrander EA (1999). "Origin, genetic diversity, and genome structure of the domestic dog". Bioessays 21 (3): 247–57. Doi: 10.1002/(SICI)15211878(199903)21:3 (inactive 2009-03-11). PMID 10333734. 27. ^ Burt DW (2002). "Origin and evolution of avian microchromosomes". Cytogenet. Genome Res. 96 (1-4): 97–112. Doi: 10.1159/000063018. PMID 12438785. 28. ^ Ciudad J, Cid E, Velasco A, Lara JM, Aijón J, Orfao A (2002). "Flow cytometry measurement of the DNA contents of G0/G1 diploid cells from three different teleost fish species". Cytometry 48 (1): 20–5. Doi: 10.1002/cyto.10100. PMID 12116377.
273
29. ^ Yasukochi Y, Ashakumary LA, Baba K, Yoshido A, Sahara K (2006). "A secondgeneration integrated map of the silkworm reveals synteny and conserved gene order between lepidopteran insects". Genetics 173 (3): 1319–28. Doi: 10.1534/genetics.106.055541. PMID 16547103. 30. ^ Smith J, Burt DW (1998). "Parameters of the chicken genome (Gallus gallus)". Anim. Genet. 29 (4): 290–4. Doi: 10.1046/j.1365-2052.1998.00334.x. PMID 9745667. 31. ^ Sakamura, T. (1918), Kurze Mitteilung uber die Chromosomenzahlen und die Verwandtschaftsverhaltnisse der Triticum-Arten. Bot. Mag., 32: 151-154. 32. ^ Charlebois R.L. (Ed) 1999. Organization of the prokaryote genome. ASM Press, Washington DC. 33. ^ Komaki K, Ishikawa H (March 2000). "Genomic copy number of intracellular bacterial symbionts of aphids varies in response to developmental stage and morph of their host". Insect Biochem. Mol. Biol. 30 (3): 253–8. Doi:10.1016/S09651748(99)00125-3. PMID 10732993. 34. ^ Mendell JE, Clements KD, Choat JH, Angert ER (May 2008). "Extreme polyploidy in a large bacterium". Proc. Natl. Acad. Sci. U.S.A. 105 (18): 6730–4. doi:10.1073/pnas.0707522105. PMID 18445653. http://www.pnas.org/cgi/pmidlookup?view=long&pmid=18445653. 35. ^ White, M. J. D. (1973). The chromosomes (6th Ed.). London: Chapman and Hall, distributed by Halsted Press, New York. pp. 28. ISBN 0-412-11930-7. 36. ^ Von Winiwarter H (1912). "Études sur la spermatogenese humaine". Arch. Biologie 27 (93): 147–9. 37. ^ Painter TS (1922). "The spermatogenesis of man". Anat. Res. 23: 129. 38. ^ Painter TS (1923). "Studies in mammalian spermatogenesis II. The spermatogenesis of man". J. Exp. Zoology 37: 291–336. Doi: 10.1002/jez.1400370303. 39. ^ Tjio JH, Levan A (1956). "The chromosome number of man". Hereditas 42: 1–6. 40. ^ Hsu T.C. Human and mammalian cytogenetics: a historical perspective. SpringerVerlag, N.Y. p10: "It's amazing that he [Painter] even came close!" 41. ^ Miller, Kenneth R. (2000). "9-3". Biology (5th Ed.). Upper Saddle River, New Jersey: Prentice Hall. pp. 194–5. ISBN 0-13-436265-9. 42. ^ European Chromosome 11 Network 43. ^ Exploring Genes & Genetic Disorders 44. ^ http://vega.sanger.ac.uk/Homo_sapiens/index.html all data in this table was derived from this database, Nov 11, 2008. 45. ^ Sequenced percentages are based on fraction of euchromatin portion, as the Human Genome Project goals called for determination of only the euchromatic portion of the genome. Telomeres, centromeres, and other heterochromatic regions have been left undetermined, as have a small number of unclonable gaps. See http://www.ncbi.nlm.nih.gov/genome/seq/ for more information on the Human Genome Project.
274
Chromosomes Composition: Index to this page In eukaryotes, chromosomes consist of a single molecule of Structure DNA [Link to visual proof] associated with: Chromosome Many copies of 5 kinds of histones. Histones are proteins Numbers rich in lysine and arginine residues and thus positively Karyotypes charged. For this reason they bind tightly to the negatively Translocations charged phosphates in DNA. FISH a small number of copies of many different kinds of non DNA Content histone proteins. Most of these are transcription factors that regulate which parts of the DNA will be transcribed into RNA. Structure For most of the life of the cell, chromosomes are too elongated and tenuous to be seen under a microscope. Before a cell gets ready to divide by mitosis, each chromosome is duplicated (during S phase of the cell cycle). As mitosis begins, the duplicated chromosomes condense into short (~ 5 µm) structures which can be stained and easily observed under the light microscope. These duplicated chromosomes are called dyads. When first seen, the duplicates are held together at their centromeres. In humans, the centromere contains ~1 million base pairs of DNA. Most of this is repetitive DNA: short sequences (e.g., 171 bp) repeated over and over in tandem arrays. While they are still attached, it is common to call the duplicated chromosomes sister chromatids, but this should not obscure the fact that each is a bona fide chromosome with a full complement of genes. The kinetochore is a complex of proteins that forms at each centromere and serves as the attachment point for the spindle fibers that will separate the sister chromatids as mitosis proceeds into anaphase. The shorter of the two arms extending from the centromere is called the p arm; the longer is the q arm. Staining with the trypsin-giemsa method reveals a series of alternating light and dark bands called G bands. G bands are numbered and provide "addresses" for the assignment of gene loci. Diagram of p and q arms, G bands, and gene loci
275
Chromosome Numbers: All animals have a characteristic number of chromosomes in their body cells called the diploid (or 2n) number. These occur as homologous pairs, one member of each pair having been acquired from the gamete of one of the two parents of the individual whose cells are being examined. The gametes contain the haploid number (n) of chromosomes. (In plants, the haploid stage takes up a larger part of its life cycle - Link) Diploid numbers of some commonly studied organisms (as well as a few extreme examples) Homo sapiens (human) 46 Mus musculus (house mouse)
40
Drosophila melanogaster (fruit fly)
8
Caenorhabditis elegans (microscopic roundworm)
12
Saccharomyces cerevisiae (budding yeast)
32
Arabidopsis thaliana (plant in the mustard family)
10
Xenopus laevis (South African clawed frog)
36
Canis familiaris (domestic dog)
78
Gallus gallus (chicken)
78
Zea mays (corn or maize)
20
Muntiacus reevesi (the Chinese muntjac, a deer)
23
Muntiacus muntjac (its Indian cousin)
6
Myrmecia pilosula (an ant)
2
Parascaris equorum var. univalens (parasitic roundworm) 2 Cambarus clarkii (a crayfish)
200
Equisetum arvense (field horsetail, a plant) 216 Karyotypes: The complete set of chromosomes in the cells of an organism is its karyotype. It is most often studied when the cell is at metaphase of mitosis and all the chromosomes are present as dyads. The karyotype of the human female contains 23 pairs of homologous chromosomes: 22 pairs of autosomes 1 pair of X chromosomes The karyotype of the human male contains: the same 22 pairs of autosomes one X chromosome one Y chromosome (A gene on the Y chromosome designated SRY is the master switch for making a male.)
276
Link to a karyotype of a normal human male stained by the trypsin-giemsa method (the image is 84K) The X and Y chromosomes are called the sex chromosomes.) Discussion of sex chromosomes
Above is a human karyotype (of which sex?). It differs from a normal human karyotype in having an extra #21 dyad. As a result, this individual suffered from a developmental disorder called Down syndrome. The inheritance of an extra chromosome is called trisomy, in this case trisomy 21. It is an example of aneuploidy Translocations Karyotype analysis can also reveal translocations between chromosomes. A number of these cause cancer, for example 1 the Philadelphia chromosome (Ph ) formed by a translocation between chromosomes 9 and 22 and a cause of Chronic Myelogenous Leukemia (CML) [Link] a translocation between chromosomes 8 and 14 that causes Burkitt's lymphoma [Link] a translocation between chromosomes 18 and 14 that causes B-cell leukemia [Link] FISH: Location of the gene for muscle glycogen phosphorylase on human chromosome 11 This image (courtesy of David C. Ward) provides dramatic evidence of the truth of the story of chromosomes. A piece of single-stranded DNA was prepared that was complementary to the DNA of the human gene encoding the enzyme muscle glycogen phosphorylase. A fluorescent molecule was attached to this DNA. The dyads in a human cell were treated to denature their DNA; that is, to make the DNA single277
stranded. When this preparation was treated with the fluorescent DNA, the complementary sequences found and bound each other. This produced a fluorescent spot close to the centromere of each sister chromatid of two homologous dyads (of chromosome 11, upper right). This analytical procedure, which here revealed the gene locus for the muscle glycogen phosphorylase gene, is called fluorescence in situ hybridization or FISH. DNA Content: The molecule of DNA in a single human chromosome ranges in size from 50 x 106 nucleotide pairs in the smallest chromosome (stretched full-length this molecule would extend 1.7 cm) up to 250 x 106nucleotide pairs in the largest (which would extend 8.5 cm). Stretched end-to-end, the DNA in a single human diploid cell would extend over 2 meters. See some of the DNA molecule released from a single human chromosome. In the intact chromosome, however, this molecule is packed into a much more compact structure. [Link]. The packing reaches its extreme during mitosis when a typical chromosome is condensed into a structure about 5 µm long (a 10,000-fold reduction in length). Welcome&Next Search
278
DEFINITION OF CHROMOSOME Chromosome: A visible carrier of the genetic information. The 3 billion bp (base pairs) in the human genome are organized into 24 distinct, physically separate microscopic units called chromosomes. All genes are arranged linearly along the chromosomes. The nucleus of most human cells contains two sets of chromosomes, one set given by each parent. Each set has 23 single chromosomes--22 autosomes and an X or Y sex chromosome. (A normal female will have a pair of X chromosomes; a male will have an X and Y pair.) Chromosomes contain roughly equal parts of protein and DNA; chromosomal DNA contains an average of 150 million bases. DNA molecules are among the largest molecules now known. Chromosomes can be seen under a light microscope and, when stained with certain dyes, reveal a pattern of light and dark bands reflecting regional variations in the amounts of A and T vs G and C. Differences in size and banding pattern allow the 24 chromosomes to be distinguished from each other, an analysis called a karyotype. A few types of major chromosomal abnormalities, including missing or extra copies or gross breaks and rejoinings (translocations), can be detected by microscopic examination; Down's syndrome, in which an individual's cells contain a third copy of chromosome 21, is diagnosed by karyotype analysis. Most changes in DNA, however, are too subtle to be detected by this technique and require molecular analysis. These subtle DNA abnormalities (mutations) are responsible for many inherited diseases such as cystic fibrosis and sickle cell anemia or may predispose an individual to cancer, major psychiatric illnesses, and other complex diseases. The foregoing definition and discussion pertain to the chromosomes in the nucleus of the cell. The chromosome of the mitochondrion, which is in the cytoplasm of the cell, is a somewhat different story. Last Editorial Review: 7/9/2000 1:38:00 PM Search All of MedicineNet For
279
GENETIC MUTATION A gene mutation is a permanent change in the DNA sequence that makes up a gene. Mutations range in size from a single DNA building block (DNA base) to a large segment of a chromosome. Gene mutations occur in two ways: they can be inherited from a parent or acquired during a person‘s lifetime. Mutations that are passed from parent to child are called hereditary mutations or germline mutations (because they are present in the egg and sperm cells, which are also called germ cells). This type of mutation is present throughout a person‘s life in virtually every cell in the body. Mutations that occur only in an egg or sperm cell, or those that occur just after fertilization, are called new (de novo) mutations. De novo mutations may explain genetic disorders in which an affected child has a mutation in every cell, but has no family history of the disorder. Acquired (or somatic) mutations occur in the DNA of individual cells at some time during a person‘s life. These changes can be caused by environmental factors such as ultraviolet radiation from the sun, or can occur if a mistake is made as DNA copies itself during cell division. Acquired mutations in somatic cells (cells other than sperm and egg cells) cannot be passed on to the next generation. Mutations may also occur in a single cell within an early embryo. As all the cells divide during growth and development, the individual will have some cells with the mutation and some cells without the genetic change. This situation is called mosaicism. Some genetic changes are very rare; others are common in the population. Genetic changes that occur in more than 1 percent of the population are called polymorphisms. They are common enough to be considered a normal variation in the DNA. Polymorphisms are responsible for many of the normal differences between people such as eye color, hair color, and blood type. Although many polymorphisms have no negative effects on a person‘s health, some of these
variations may influence the risk of developing certain disorders. When a gene contains a mutation, the protein encoded by that gene is likely to be abnormal. Sometimes the protein will be able to function, but imperfectly. In other cases, it will be totally disabled. The outcome depends not only on how it alters a protein's function but also on how vital that particular protein is to survival. 280
Hereditary Mutations: • Gene mutations can be either inherited from a parent or acquired. • Hereditary mutations are carried in the DNA of the reproductive cells. When reproductive cells containing mutations combine to produce offspring, the mutation will be in all of the offspring's body cells. The fact that every cell contains the gene change makes it possible to use cheek cells or a blood sample for gene testing.
Prenatal Diagnosis: • Prenatal diagnosis employs a variety of techniques to determine the health and condition of an unborn fetus. Without knowledge gained by prenatal diagnosis, there could be an untoward outcome for the fetus or the mother or both. Congenital anomalies account for 20 to 25% of perinatal deaths. Specifically, prenatal diagnosis is helpful for: • Managing the remaining weeks of the pregnancy • Determining the outcome of the pregnancy • Planning for possible complications with the birth process • Planning for problems that may occur in the newborn infant • Deciding whether to continue the pregnancy • Finding conditions that may affect future pregnancies. 281
Common Diagnostic Tests: • Ultrasonography • Amniocentesis • Chorionic villus sampling • Fetal blood cells in maternal blood • Maternal serum alpha-fetoprotein • Maternal serum beta-HCG • Maternal serum estriol Ultrasonography: • This is a non-invasive procedure that is harmless to both the fetus and the mother. High frequency sound waves are utilized to produce visible images from the pattern of the echos made by different tissues and organs, including the baby in the amniotic cavity. The developing embryo can first be visualized at about 6 weeks gestation. Recognition of the major internal organs and extremities to determine if any are abnormal can best be accomplished between 16 to 20 weeks gestation. • Although an ultrasound examination can be quite useful to determine the size and position of the fetus, the size and position of the placenta, the amount of amniotic fluid, and the appearance of fetal anatomy, there are limitations to this procedure. Subtle abnormalities may not be detected until later in pregnancy, or may not be detected at all. A good example of this is Down syndrome (trisomy 21) where the morphologic abnormalities are often not marked, but only subtle, such as nuchal thickening.
Amniocentesis: • This is an invasive procedure in which a needle is passed through the mother's lower abdomen into the amniotic cavity inside the uterus. Enough amniotic fluid is present for this to be accomplished starting about 14 week‘s gestation. • For prenatal diagnosis, most amniocenteses are performed between 14 and 20 weeks gestation. However, an ultrasound examination always precedes amniocentesis in order to determine gestational age, the position of the fetus and placenta, and determine if enough amniotic fluid is present. Within the amniotic fluid are fetal cells (mostly derived from fetal skin) which can be grown in culture for chromosome analysis, biochemical analysis, and molecular biologic analysis. • In the third trimester of pregnancy, the amniotic fluid can be analyzed for determination of fetal lung maturity. This is important when the fetus is below 35 to 36 weeks gestation, because the lungs may not be mature enough to sustain life. This is because the lungs are not producing enough surfactant. After birth, the infant will develop respiratory distress syndrome from hyaline membrane disease. The amniotic fluid can be analyzed by fluorescence polarization (fpol), for lecithin: sphingomyelin (LS) ratio, and/or for phosphatidyl glycerol (PG). 282
• Risks with amniocentesis are uncommon, but include fetal loss and maternal Rh sensitization. The increased risk for fetal mortality following amniocentesis is about 0.5% above what would normally be expected. Contamination of fluid from amniocentesis by maternal cells is highly unlikely. If oligohydramnios is present, then amniotic fluid cannot be obtained. It is sometimes possible to instill saline into the amniotic cavity and then remove fluid for analysis. Chorionic Villi Sampling: • In this procedure, a catheter is passed via the vagina through the cervix and into the uterus to the developing placenta under ultrasound guidance. Alternative approaches are transvaginal and transabdominal. The introduction of the catheter allows sampling of cells from the placental chorionic villi. These cells can then be analyzed by a variety of techniques. The most common test employed on cells obtained by CVS is chromosome analysis to determine the karyotype of the fetus. The cells can also be grown in culture for biochemical or molecular biologic analysis. CVS can be safely performed between 9.5 and 12.5 weeks gestation. • CVS has the disadvantage of being an invasive procedure, and it has a small but significant rate of morbidity for the fetus; this loss rate is about 0.5 to 1% higher than for women undergoing amniocentesis. Rarely, CVS can be associated with limb defects in the fetus. The possibility of maternal Rh sensitization is present. There is also the possibility that maternal bloods cells in the developing placenta will be sampled instead of fetal cells and confound chromosome analysis. Maternal Blood Sampling For Fetal Cells: • This is a new technique that makes use of the phenomenon of fetal blood cells gaining access to maternal circulation through the placental villi. Ordinarily, only a very small number of fetal cells enter the maternal circulation in this fashion. The fetal cells can be sorted out and analyzed by a variety of techniques to look for particular DNA sequences, but without the risks that these latter two invasive procedures inherently have. Fluorescence in-situ hybridization (FISH) is one technique that can be applied to identify particular chromosomes of the fetal cells recovered from maternal blood and diagnose aneuploid conditions such as the trisomies and monosomy X. • The problem with this technique is that it is difficult to get many fetal blood cells. There may not be enough to reliably determine anomalies of the fetal karyotype or assay for other abnormalities. Maternal Serum Alpha Feto Protein: • The developing fetus has two major blood proteins--albumin and alpha-fetoprotein (AFP). Since adults typically have only albumin in their blood, the MSAFP test can be utilized to determine the levels of AFP from the fetus. Ordinarily, only a small amount of AFP gains access to the amniotic fluid and crosses the placenta to mother's blood. However, when there is a neural tube defect in the fetus, from failure of part of the embryologic neural tube to close, then there is a means for escape of more AFP into the amniotic fluid. Neural tube defects include anencephaly (failure of closure at the cranial end of the neural tube) and spina bifida (failure of closure at the caudal end of the neural tube). Also, if there is an omphalocele or gastroschisis (both are defects in the fetal abdominal wall), the AFP from the fetus will end up in maternal blood in higher amounts. 283
• In order for the MSAFP test to have the greatesT utility, the gestational age must be known with certainty. This is because the amount of MSAFP increases with gestational age (as the fetus and the amount of AFP produced increase in size). Also, the race of the mother and presence of gestational diabetes are important to know, because the MSAFP can be affected by these factors. The MSAFP is typically reported as multiples of the mean (MoM). The greater the MoM, the more likely a defect is present. The MSAFP has the greatest sensitivity between 16 and 18 weeks gestation, but can still be useful between 15 and 22 weeks gestation. • However, the MSAFP can be elevated for a variety of reasons which are not related to fetal neural tube or abdominal wall defects, so this test is not 100% specific. The most common cause for an elevated MSAFP is a wrong estimation of the gestational age of the fetus, multiple pregnancies. • Using a combination of MSAFP screening and ultrasonography, almost all cases of anencephaly can be found and most cases of spina bifida. Neural tube defects can be distinguished from other fetal defects (such as abdominal wall defects) by use of the acetylcholinesterase test performed on amniotic fluid obtained by amniocentesis--if the acetylcholinesterase is elevated along with MSAFP then a neural tube defect is likely. If the acetylcholinesterase is not detectable, then some other fetal defect is suggested. • The genetic polymorphisms due to mutations in the methylene tetrahydrofolate reductase gene may increase the risk for NTDs. Folate is a cofactor for this enzyme, which is part of the pathway of homocysteine metabolism in cells. The C677T and the A1298C mutations are associated with elevated maternal homocysteine concentrations and an increased risk for NTDs in fetuses. Prevention of many neural tube defects can be accomplished by supplementation of the maternal diet with only 4 mg of folic acid per day, but this vitamin supplement must be taken a month before conception and through the first trimester. • The MSAFP can also be useful in screening for Down syndrome and other trisomies. The MSAFP tends to be lower when Down syndrome or other chromosomal abnormalities is present. Maternal serum beta-HCG: • This test is most commonly used as a test for pregnancy. Beginning at about a week following conception and implantation of the developing embryo into the uterus, the trophoblast will produce enough detectable beta-HCG (the beta subunit of human chorionic gonadotropin) to diagnose pregnancy. Thus, by the time the first menstrual period is missed, the beta-HCG will virtually always be elevated enough to provide a positive pregnancy test. The beta-HCG can also be quantified in serum from maternal blood, and this can be useful early in pregnancy when threatened abortion or ectopic pregnancy is suspected, because the amount of beta-HCG will be lower than expected. • Later in pregnancy, in the middle to late second trimester, the beta-HCG can be used in conjunction with the MSAFP to screen for chromosomal abnormalities, and Down syndrome in particular. An elevated beta-HCG coupled with a decreased MSAFP suggests Down syndrome. • Very high levels of HCG suggest trophoblastic disease (molar pregnancy). The absence of a fetus on ultrasonography along with an elevated HCG suggests a 284
hydatidiform mole. The HCG level can be used to follow up treatment for molar pregnancy to make sure that no trophoblastic disease, such as a choriocarcinoma, persists. Maternal serum estriol: • The amount of estriol in maternal serum is dependent upon a viable fetus, a properly functioning placenta, and maternal well-being. The substrate for estriol begins as dehydroepiandrosterone (DHEA) made by the fetal adrenal glands. This is further metabolized in the placenta to estriol. The estriol crosses to the maternal circulation and is excreted by the maternal kidney in urine or by the maternal liver in the bile. The measurement of serial estriol levels in the third trimester will give an indication of general well-being of the fetus. If the estriol level drops, then the fetus is threatened and delivery may be necessary emergently. Estriol tends to be lower when Down syndrome is present and when there is adrenal hypoplasia with anencephaly. • Inhibin-A Inhibin is secreted by the placenta and the corpus luteum. Inhibin-A can be measured in maternal serum. An increased level of inhibin-A is associated with an increased risk for trisomy 21. A high inhibin-A may be associated with a risk for preterm delivery. • Pregnancy-associated plasma protein A (PAPP-A) Low levels of PAPP-A as measured in maternal serum during the first trimester may be associated with fetal chromosomal anomalies including trisomies 13, 18, and 21. In addition, low PAPP-A levels in the first trimester may predict an adverse pregnancy outcome, including a small for gestational age (SGA) baby or stillbirth. A high PAPP-A level may predict a large for gestational age (LGA) baby. • "Triple" or "Quadruple" screen Combining the maternal serum assays may aid in increasing the sensitivity and specificity of detection for fetal abnormalities. The classic test is the Òtriple screenÓ for alphafetoprotein (MSAFP), beta-HCG, and estriol (uE3). The "quadruple screen" adds inhibinA. Techniques for Pathologic Examination: A variety of methods can be employed for analysis of fetal and placental tissues: • Gross Examination: – The most important procedure to perform is simply to look at the fetus or fetal parts. Obviously, examination of an intact fetus is most useful, though information can still be gained from examination of fetal parts. – The pattern of gross abnormalities can often suggest a possible chromosomal abnormality or a syndrome. Abnormalities can often be quite subtle, particularly the earlier the gestational age. – Consultations are obtained with clinical geneticists to review the findings. A description of the findings is put into a report (surgical pathology or autopsy). – Examination of the placenta is very important, because the reason for the fetal loss may be a placental problem • Microscopic Examination: – Microscopic findings are generally less useful than gross examination for the fetus, but microscopic examination of the placenta is important. Microscopy can aid in determination of gestational age (lung, kidney maturity), presence of infection, presence of neoplasia, or presence of "dysplasia" (abnormal organogenesis). 285
• Radiography: – Standard anterior-posterior and lateral radiographic views are essential for analysis of the fetal skeleton. Radiographs are useful for comparison with prenatal ultrasound, and help define anomalies when autopsy consent is limited, or can help to determine sites to be examined microscopically. Conditions diagnosed by postmortem radiography may include: • Skeletal anomalies (dwarfism, dysplasia, etc.) • Neural tube defects (anencephaly, spina bifida, etc.) • Osteogenesis imperfecta • Soft tissue changes (hydrops, hygroma, etc.) • Teratomas or other neoplasms • Growth retardation • Orientation and audit of fetal parts • Assessment of catheter or therapeutic device placement • Microbiologic Culture: – Culture can aid in diagnosis or confirmation of congenital infections. Examples of congenital infection include: • T - toxoplasmosis • O - other, such as Listeria monocytogenes, group B streptococcus, syphilis • R - rubella • C - cytomegalovirus • H - herpes simplex or human immunodeficiency virus (HIV) – Cultures have to be appropriately obtained with the proper media and sent with the proper requisitions ("routine" includes aerobic and anaerobic bacteria; fungal and viral cultures must be separately ordered). – Viral cultures are difficult and expensive. Separate media and collection procedures may be necessary depending upon what virus is being sought. – Bacterial contamination can be a problem. • Karyotyping: – Tissues must be obtained as fresh as possible for culture and without contamination. – A useful procedure is to wash the tissue samples in sterile saline prior to placing them into cell culture media. – Tissues with the best chance for growth are those with the least maceration: placenta, lung, and diaphragm. – Obtaining tissue from more than one site can increase the yield by avoiding contamination or by detection of mosaicism. • FISH (performed on fresh tissue or paraffin blocks): – In addition to karyotyping, fluorescence in situ hybridization (FISH) can be useful. A wide variety of probes are available. It is useful for detecting aneuploid conditions (trisomies, monosomies). – Fresh cells are desirable, but the method can be applied even to fixed tissues stored in paraffin blocks, though working with paraffin blocks is much more time consuming and interpretation can be difficult. The ability to use FISH on paraffin blocks means that archival tissues can be examined in cases where karyotyping was not performed, or cells didn't grow in culture. 286
• DNA Probes: – Fetal cells obtained via amniocentesis or CVS can be analyzed by probes specific for DNA sequences. One method employs restriction fragment length polymorphism (RFLP) analysis. This method is useful for detection of mutations involving genes that are closely linked to the DNA restriction fragments generated by the action of an endonuclease. The DNA of family members is analyzed to determine differences by RFLP analysis. – In some cases, if the DNA sequence of a gene is known, a probe to a DNA sequence specific for a genetic marker is available, and the polymerase chain reaction (PCR) technique can be applied for diagnosis. – There are many genetic diseases, but only in a minority have particular genes been identified, and tests to detect them have been developed in some of these. Thus, it is not possible to detect all genetic diseases. Moreover, testing is confounded by the presence of different mutations in the same gene, making testing more complex. • Biochemical Analysis: – Tissues can be obtained for cell culture or for extraction of compounds that can aid in identification of inborn errors of metabolism. Examples include: • long-chain fatty acids (adrenoleukodystrophy) • amino acids (aminoacidurias) • Flow Cytometry: – Flow cytometry is useful only for determination of the amount of DNA and can yield no information about individual chromosomes with aneuploidy. Thus, the condition that flow cytometry can routinely detect is triploidy. – Very little sample (0.1 gm) is required. The technique can also be applied to fixed tissues in paraffin blocks. • Electron Microscopy: – Rarely used and requires prompt fixation with no maceration. Examples of conditions to be diagnosed with EM include: • mitochondrial myopathies • viral infections
287
• GENETIC COUNSELING • Genetic counseling is the process of: • evaluating family history and medical records • ordering genetic tests • evaluating the results of this investigation • helping parents understand and reach decisions about what to do next • Most couples planning a pregnancy or who are expecting don't need genetic counseling. About 3% of babies are born with birth defects each year, according to the Centers for Disease Control and Prevention (CDC) — and of the malformations that do occur, the most common are also among the most treatable. Cleft palate and clubfoot, two of the more common birth defects, can be surgically repaired, as can many heart malformations. • The best time to seek genetic counseling is before becoming pregnant, when a counselor can help assess your risk factors. But even after you become pregnant, a meeting with a genetic counselor can still be helpful. For example, sometimes babies have been diagnosed with spina bifida before birth. Recent research suggests that delivering a baby with spina bifida via cesarean section (avoiding the trauma of travel through the birth canal) can minimize damage to the spine — and perhaps reduce the likelihood that the child will need a wheelchair. • Experts recommend that all pregnant women, regardless of age or circumstance, be offered genetic counseling and testing to screen for Down syndrome. Risk factors that require genetic counseling: • a standard prenatal screening test (such as the alpha fetoprotein test) yields an abnormal result • an amniocentesis yields an unexpected result (such as a chromosomal defect in the unborn baby) • either parent or a close relative has an inherited disease or birth defect • either parent already has children with birth defects or genetic disorders • the mother-to-be has had two or more miscarriages or babies that died in infancy • the mother-to-be will be 35 or older when the baby is born. Chances of having a child with Down syndrome increase with the mother's age: a woman has a 1 in 350 chance of conceiving a child with Down syndrome at age 35, a 1 in 110 chance at age 40, and a 1 in 30 chance at age 45. Genetic Counseling Process: • Gathering family history • Look over medical records, medications, ultrasound before pregnancy • Interactions with parents about inheritance patterns, risk patterns • Puts forth various options available • If the parents learned prior to conception that they are at high risk for having a child with a severe or fatal defect, options might include: • pre-implantation diagnosis — when eggs that have been fertilized in vitro (in a laboratory, outside of the womb) are tested for defects at the 8-cell (blastocyst) stage, and only nonaffected blastocysts are implanted in the uterus to establish a pregnancy • using donor sperm or donor eggs 288
• adoption • If the parents have received a diagnosis of a severe or fatal defect after conception, the options might include: • preparing yourself for the challenges they'll face when the baby is born • fetal surgery to repair the defect before birth (surgery can only be used to treat some defects, such as spina bifida or congenital diaphragmatic hernia, a hole in the diaphragm that can cause severely underdeveloped lungs. Most defects cannot be surgically repaired.) • ending the pregnancy Gene Therapy: • Gene therapy is a technique for correcting defective genes responsible for disease development. Researchers may use one of several approaches for correcting faulty genes: • A normal gene may be inserted into a nonspecific location within the genome to replace a nonfunctional gene. This approach is most common. • An abnormal gene could be swapped for a normal gene through homologous recombination. • The abnormal gene could be repaired through selective reverse mutation, which returns the gene to its normal function. • The regulation (the degree to which a gene is turned on or off) of a particular gene could be altered. • In most gene therapy studies, a "normal" gene is inserted into the genome to replace an "abnormal," disease-causing gene. A carrier molecule called a vector must be used to deliver the therapeutic gene to the patient's target cells. Currently, the most common vector is a virus that has been genetically altered to carry normal human DNA. Viruses have evolved a way of encapsulating and delivering their genes to human cells in a pathogenic manner. Scientists have tried to take advantage of this capability and manipulate the virus genome to remove disease-causing genes and insert therapeutic genes. • Target cells such as the patient's liver or lung cells are infected with the viral vector. The vector then unloads its genetic material containing the therapeutic human gene into the target cell. The generation of a functional protein product from the therapeutic gene restores the target cell to a normal state. • To reverse disease caused by genetic damage, researchers isolate normal DNA and package it into a vector, a molecular delivery truck usually made from a disabled virus. They then infect a target cell —usually from a tissue affected by the illness, such as liver or lung cells—with the vector. The vector unloads its DNA cargo, which then begins producing the missing protein and restores the cell to normal.
289
• Recently, French researchers reported dramatic results in treating a disease called severe combined immune deficiency (SCID), the disorder suffered by David, The Boy in the Bubble. A broken gene eliminates the production of an enzyme essential for the development of a normal immune system. Scientists isolated the normal copy of the gene and packaged it into a vector. In the laboratory, they then used the vector to transport the gene into the patient's own bone marrow cells. Bone marrow cells create the immune system. The treated bone marrow cells are then given back to the patient in a germ-free isolation room, where they reconstitute a normal, functioning immune system, freeing the patient from the need to remain in isolation.
Some of the different types of viruses used as gene therapy vectors: • Retroviruses - A class of viruses that can create double-stranded DNA copies of their RNA genomes. These copies of its genome can be integrated into the chromosomes of host cells. Human immunodeficiency virus (HIV) is a retrovirus. • Adenoviruses - A class of viruses with double-stranded DNA genomes that cause respiratory, intestinal, and eye infections in humans. The virus that causes the common cold is an adenovirus. • Adeno-associated viruses - A class of small, single-stranded DNA viruses that can insert their genetic material at a specific site on chromosome 19. • Herpes simplex viruses - A class of double-stranded DNA viruses that infect a particular cell type, neurons. Herpes simplex virus type 1 is a common human pathogen that causes cold sores. Other Modes Of Gene Therapy: • Besides virus-mediated gene-delivery systems, there are several nonviral options for gene delivery. The simplest method is the direct introduction of therapeutic DNA into target cells. This approach is limited in its application because it can be used only with certain tissues and requires large amounts of DNA. • Another nonviral approach involves the creation of an artificial lipid sphere with an aqueous core. This liposome, which carries the therapeutic DNA, is capable of passing the DNA through the target cell's membrane. • Therapeutic DNA also can get inside target cells by chemically linking the DNA to a molecule that will bind to special cell receptors. Once bound to these receptors, the therapeutic DNA constructs are engulfed by the cell membrane and passed into the 290
interior of the target cell. This delivery system tends to be less effective than other options. • Researchers also are experimenting with introducing a 47th (artificial human) chromosome into target cells. This chromosome would exist autonomously alongside the standard 46 --not affecting their workings or causing any mutations. It would be a large vector capable of carrying substantial amounts of genetic code, and scientists anticipate that, because of its construction and autonomy, the body's immune systems would not attack it. A problem with this potential method is the difficulty in delivering such a large molecule to the nucleus of a target cell. Factors That Hinder Its Effectiveness: • Short-lived nature of gene therapy - Before gene therapy can become a permanent cure for any condition, the therapeutic DNA introduced into target cells must remain functional and the cells containing the therapeutic DNA must be long-lived and stable. Problems with integrating therapeutic DNA into the genome and the rapidly dividing nature of many cells prevent gene therapy from achieving any long-term benefits. Patients will have to undergo multiple rounds of gene therapy. • Immune response - Anytime a foreign object is introduced into human tissues, the immune system is designed to attack the invader. The risk of stimulating the immune system in a way that reduces gene therapy effectiveness is always a potential risk. Furthermore, the immune system's enhanced response to invaders it has seen before makes it difficult for gene therapy to be repeated in patients. • Problems with viral vectors - Viruses, while the carrier of choice in most gene therapy studies, present a variety of potential problems to the patient --toxicity, immune and inflammatory responses, and gene control and targeting issues. In addition, there is always the fear that the viral vector, once inside the patient, may recover its ability to cause disease. • Multigene disorders - Conditions or disorders that arise from mutations in a single gene are the best candidates for gene therapy. Unfortunately, some the most commonly occurring disorders, such as heart disease, high blood pressure, Alzheimer's disease, arthritis, and diabetes, are caused by the combined effects of variations in many genes. Multigene or multifactorial disorders such as these would be especially difficult to treat effectively using gene therapy. Ethical Issues: What is normal and what is a disability or disorder, and who decides? Are disabilities diseases? Do they need to be cured or prevented? Does searching for a cure demean the lives of individuals presently affected by disabilities? Is somatic gene therapy (which is done in the adult cells of persons known to have the disease) more or less ethical than germline gene therapy (which is done in egg and sperm cells and prevents the trait from being passed on to further generations)? In cases of somatic gene therapy, the procedure may have to be repeated in future generations. Preliminary attempts at gene therapy are exorbitantly expensive. Who will have access to these therapies? Who will pay for their use?
291
GENETIC COUNSELING
Definition: ―It is defined as a process in which patients or their relatives at the risk of a genetic disorder are made aware of the consequences of the disorder, its transmission and the ways by which this can be prevented or mitigated‖. Or ―Genetic Counseling is a communication process by which personal genetic risk information is translated into practical information for families‖. The Genetic Counselor: The Genetic Counselors are health care professionals with specialized training and experience in the areas of medical genetics and counseling. Role of Genetic Counselor: 1. Helping people to understand information about birth defects or genetic disorders. This includes explaining patterns of inheritance, recurrence risks, natural, history of disease and genetic testing options. 2. Providing non-directive supporting counseling regarding issues related to a diagnosis or testing options. 3. Helping individuals and families makes decisions with which they are comfortable, based on their personal ethical and religious standards. 4. Connecting individuals and families with appropriate resources, such as support groups or specific types of medical clinics locally and nationally. Purpose of Genetic Counseling: There are several purposes or aspects to be addressed within the scope of genetic counseling. These include obtaining a pedigree, tracing, and ethnicity, exploring issues of consanguinity and documenting exposures to toxins, disease, or environmental agents during pregnancy. Pedigree: In all types of genetic counseling and important aspect of the counseling process is information gathering about family and medical history. Information gathering is performed by drawing a chart called a pedigree. A pedigree is made of symbols and lines that represent a family history. To accurately assess the risk of inherited diseases, information about three generations of family, including health status and cause of death, is usually needed. If a family history is complicated, information from more distant relatives may be helpful, and medical records may be requested, for any family members who have had genetic disorders. Thorough examination of a family history may enable a counselor to calculate the probability of occurrence of genetic disorders in the future. Ethnicity: In obtaining a family history, a genetic counselor asks about a person‘s ethnicity or ancestral origin. There are some ethnic groups that have a higher chance of being carriers of some genetic disease or abnormalities. For instance, the chance that an African American is a carrier of a gene for sickle cell disease is one in ten. People of Jewish or central Europeon ancestory are likely to be carriers of several conditions including Tay-Sachs disease, canavan‘s disease, and cystic fibrosis. People of Mediterranean ancestory are likely to be carriers of a type of anemia called thalassemia. 292
Genetic Counselors discuss inheritance patterns of these diseases, carrier risks and genetic screening or testing options. Consanguinity: Another question of genetic counselor will asks about in obtaining a family history is whether the couple related to one another by blood. The practice of marrying or having children with relatives is infrequent in the United States, but is more common in some countries. When two are related by blood, there is an increased chance for their children to be effected with conditions that are inherited in a recessive pattern. In recessive inheritance, each parent of a child affected with a disease carries a single gene for a disease. The child gets two copies, one from each parent, and is affected. People who have a common ancestor are more likely than unrelated people to be carriers of genes for the same recessively inherited disorders. Depending on family history and ethnic background, blood tests can be offered to couples to get more information about the chance of these conditions occurring. Exposure during Pregnancy: During prenatal genetic counseling, the counselor will ask about pregnancy history. If a woman has taken medications or has had exposure to a potentially harmful substance from the environment such a chemical, toxin, or radiation, the genetic counselor can discuss the possibility of adverse effects. Ultrasound is often a useful tool to look for some effects of exposure. Precautions: There are no physical precautions that are needed before genetic counseling. However, persons who will receive the result of genetic test should be prepared mentally and emotionally for the possibility of unpleasant information. This include discussing if they want to know the result of genetic testing and what choice they may have to make based on the information supplied. Steps Of Genetic Counseling: 1. An accurate diagnosis of disorder. To complete an accurate diagnosis the following procedure should be followed: A: History: A proper record of the history of the patient is necessary: This includes both present and relevant past history. Family history includes siblings and other relatives also. Kindly note if there is any other person in the family with a similar problem. Obstetric history of includes exposure to teratogens (drugs, X-rays) in pregnancy. History of abortion or still birth if any should be recorded. Enquiry should be made about consanguinity as it increases the risk especially in autosomal recessive disorders. B. Peidgree Charting: At a glance this offers in a concise manner the state of disorder in a family. Constructing a pedigree with proper interrogation though time consuming, is ultimately rewarding. If forms an indispensable step towards counseling. Symbols for pedigree charting: 293
C. Estimation of risk: It forms one of the most important aspects of genetic counseling. It is often called recurrence risk. To estimate it one requires taking into account following points: Mode of inheritance. Analysis of Pedigree/ Family tree. Results of various tests such as linkage studies. In order to arrive at a risk one has to work out the probability. The probability of an outcome is defined as the no. or more precisely the proportion of times it occurs in a large series of events. Routinely the probability is indicated as a proportion fraction of one. Probability: 25/ 1/4 indicate that on average the events will be observed on 1 in 4 or 25% of occasions. D. Transmitting Information: After completing the diagnosis, pedigree charging and estimation of risk the next most important step is of communicating this information to the consultants. This important functioning involves various factors. These are often not taken seriously, but are of crucial importance in genetic counseling. These are as follows: Psychology of the patient. The Emotional stress under prevailing circumstances. Attitude of family members towards the patients. Educational, social and financial background of the family. Gaining confidence of consultants in subsequence meetings during follow up. Ethical, moral and legal implications involved in the process. Above all, communication skills to transmit facts in an effective manner i.e. making them more acceptable and palatable. Now the role of genetic counselor is to render help to consultants enabling them to take decisions. Should this be directive? It is difficult to say on this issue. In strict sense ―Counseling‖ can not/should not does lead to directive advise? Also difficulty is encountered in making the relatives aware of the probabilities which are often complicated in certain situations. These are not well understood by the people counseled. E. Management: In genetics, ―Treatment‖ implies a very limited scope. It naturally aims for prevention rather than cure. In fact for most of the genetic disorders cure is unknown. Treatment is therefore directed towards minimizing the damage by early detection and preventing further irreversible damage. For example n PKU, i.e. phenylketonuria. This disorder is characterized by a deficiency of phenylalanine hydroxylase enzyme, which is necessary for the conversion of phenylalanine to tyrosine. PKU if not detected early, may lead to mental retardation owing to the involvement of the nervous system at a later stage. The ideal situation would be an early detection of the disease followed by preventive measures, like living the patient a diet free from phenylalanine and thus preventing damage to the nervous system. In some other situations the defective gene proves to be so in certain environment. This implies that the change in the environment shall mitigate gene expression. Here also, an 294
ideal way would be to replace the defective gene by a normal one, but this is left for the future and may be in years to come such replacements may become a reality. Preventing Aspects: In the present situation the aim of a geneticist is chiefly to prevent genetic defect. This means that a prenatal diagnosis of the disorder should be made and the pregnancy (with abnormal fetus) be terminated. Termination of pregnancy should however be acceptable to the couple seeking advice .With the background let us try to work out various possibilities in some of the genetic problems. 1. A problems of infertility or inability to get a child. The couple has two alternative either they can think of adoption, in which case pre-adoption counseling is important. In such children a careful clinical examination of the child is done to rule out the possibility of a genetic disorder, since the parental/family background of these children is unknown. 2. Another alternative for such couple would be to go in for an AID (Artificial insemination donor). This is appropriate if the father has or is at risk of an autosomal dominant trait. It is also advisable when both partners are carriers of an autosomal recessive disorder. However AID is not indicated, if mother has an autosomal dominant or X-linked disorder. 3. Analysis of a given case may be achieved through genetic test such as chromosome analysis or with the help of various biochemical carrier detection tests. The test results if negative, shall reassure the consultant that they are not at risk of disorder. However, in a given situation, after making prenatal diagnosis or by working out the probabilities one can offer the information to the parents. Ultimately the decision regarding termination of pregnancy has to be made by the couple. Follow-up in Genetic Clinics: Follow up is essential in all the branches under the faculty of medicine. It is more important for the patients, attending genetic clinics. So it is desirable to arrange more follow-up interviews. This will make sure that they (consultants) understand and remember the information based on to them. In some families with genetic disorders repeated follow-up visits to the genetic clinic become essential. These visits are aimed at preventing the disease in any other family member by a reproductive planning. Prenatal diagnosis followed by termination of pregnancy, if necessary. For the family members with genetic disorders, acceptance of the disease, treatment, if possible and counseling towards a more palatable way to lead life may be suggested. For Example: Take a family with Down‘s syndrome (21trisomy). The couple should first accept this defect in their child. They should then be made aware of and referred to a school for mentally retarded children, where the child can be trained properly. Simultaneously the couple can be informed about the possibilities of prenatal detection of this disorder as well as carrier detection (translocation-carrier) in parents. This will prevent another down baby in the family. Genetic Screening: Genetic Screening forms a part of the public health programmed. The aim of such screening programmers was to identify newborns with genetic disorders so that early detection and treatment of the disease could be undertaken. 295
Genetic screening, in contrast to genetic testing, is a broader concept and applies to testing of populations or groups independent of a positive family history or symptom manifestation. Purposes of these screening are: To detect the presence of apparent and non-apparent diseases. To provide reproductive information. To gain information concerning the incidence of a disorder in the population. Screening Programmers: The criteria for these programmers will be as follow: The disorder should be clearly defined. It should have a reasonable frequency in the population concerned warranting screening. Disorder should be preferably treatable. The screening test should be less time consuming. The test should be relatively inexpensive so that it can be applied on a large scale. The test should be reliable i.e. ideally it should have minimal false positive and no false negative results.With these prerequisites, screening programmes can be organized for newborns or for pregnant women. In the latter, maternal serum can be screened for neural tube defects estimating alfa-feto- proteins. HIGHER value of alfa-feto- protein signify a neural tube defect while Unusually LOW value of alfa-feto protein indicates fetus with Down‘s syndrome. Type Of Genetic Counseling: Genetic Counseling can prospective or Retrospective :1. Prospective: 1. This approach may find wider application to cover a no. of recessive defects. 2. This approach identifies the individuals for any particular defect by screening eg. Sickle cell anemia. Thalasemia, which can be prevented. 2. Retrospective: This can be done after contraception, pregnancy termination and sterilization. a) When blood relatives marry each other there is an increased risk in the offspring of traits controlled by recessive genes e.g. Albinism. Alkaptonuria Phenylketonuria So, lowering of consanguineous marriages would be advantageous to the health of the community. b) Late Marriages: Genetic defect through trisomy 21, mongolism can be prevented by early marriages than late marriage. i) Protection of individuals and whole community against chemical mutagens. ii) Protecting people from unnecessary exposure to X-ray by protective aprons. iii) Detection of genetic carriers, in numerous disorders e.g. Haemophilia, PKU, galactosaemia, actalasia, will help in prevention. iv) Prenatal diagnosis through amniocentesis (as early as 14 week of pregnancy) for mothers aged 35 and above (advanced maternal age), for Down‘s syndrome, muscular dystrophies will help in early prevention. 296
v) Screening of newborn infants, large list of screening test for early diagnosis of genetic abnormalities are available viz, Sex chromosome abnormalities. Congenital dislocation of hip, PKU, Congenital Hypothyroidism, Sickle cell disease, Cystic Fibrosis, Duchenne muscular dystrophy Congenital adrenal hyperplasia G6 PD deficiency vi) Neonatal examination for dislocation of hip so that it can be corrected early screening for other defects Viz PKU, congenital hypothyroidism, sickle cell anemia, cystic fibrosis etc. can be carried out. vii) Recognizing Pre-clinical cases viz. Diabetes, Gout, Sickle cell anemia Thalasemia viii) Some of the genetic conditions can be corrected if recognized early eg. Heamophilia Spina bifida ix) The genetic conditions can cause physical or mental disability; much can be done for the patients and family through rehabilitation. Descricption of types of genetic counseling: Or applications of genetic counseling: Genetic counselors work with people concerned about the risk of an inherited disease or condition. These people represent several different populations. Prenatal genetic counseling is provided to couples that have an increased risk of birth defects or inherited conditions, and are expecting a child or planning a pregnancy. Pediatric genetic counseling is provided to families with children suspected of having a genetic disorder or with children previously diagnosed with a genetic disorder. Adult genetic counseling is provided to adults with clinical features of an inherited disease or a family history of an inherited disease. Cancer genetic counseling is provided to those with a strong family history of certain types of cancers. Prenatal Genetic Counseling: There are several different reasons a person or couple may seek prenatal genetic counseling. If a woman is of age 35 or older and pregnant, then there is an increased chance that her fetus may have a change in the number of chromosomes present. Changes in chromosome number may lead to mental retardation and birth defects. Down syndrome is the most common change in chromosome number that occurs proportionally more often in the fetuses of older women. Couples may seek prenatal genetic counseling because of abnormal results of screening tests performed during pregnancy. 297
A blood test called the alpha fetal protein (AFP) test is offered to all pregnant women. This blood test screens for Down syndrome, open spine defects (Spina bifida), and another type of mental retardation caused by a change in chromosome number called trisomy 18. When this test is abnormal, further tests are offered to get more information about the chances of these conditions actually occurring in the fetus. Another reason that people seek prenatal genetic counseling is a family history of birth or inherited diseases. In some cases, blood tests of the parents may be available to indicate if their children would be at risk of being affected. Genetic counselors assess risk in each case, help persons to understand their risks, and explore how they feel about or will cope with these risks. Prenatal tests that are offered during genetic counseling include: Level II ultrasounds. Maternal serum AFP screening Chorionic villus sampling (CVS) Amniocentesis. Level II Ultrasound is a detailed ultrasound surveying fetal anatomy for birth defects. Ultrasound is limited to detection of structural changes in anatomy and cannot detect changes in chromosome number. The maternal serum AFP screening is used to indicate if a pregnant woman has a higher or lower chance of having a child with certain birth defects. This test can only provide information concerning the probability of a birth defect. The screening cannot diagnose an actual birth defect. Chorionic Villous sampling (CVS) : CVS is a way of learning how many chromosomes are present in a fetus. A small piece of a placental tissue is obtained for these studies during the tenth or twelfth week of pregnancy. Amniocentesis is also a way of learning how many chromosomes are present in a fetus. Amniotic fluid is obtained for these studies, usually between 15 and 20 week of pregnancy. There is a small risk of miscarriage associated with both of these tests. Genetic Counseling regarding these procedures involves the careful explanation of benefits and limitations of each testing option. A genetic counselor also tries to explore how person feels about prenatal testing and the impact of such testing on the pregnancy. Genetic counselors are supportive of any decision a person makes about whether or not to have prenatal tests performed. Pediatric Genetic Counseling: Families or pediatricians seek genetic counseling when a child has features of an inherited condition. Any child who is born with more than one defect, mental retardation or dimorphic features has an increased chance of having a genetic syndrome. A common type of mental retardation in males for which genetic testing is available is fragile Xsyndrome. Genetic testing is also available for many other childhood illnesses such as hemophilia and muscular dystrophy. Genetic counselors work with medical geneticists to determine if a genetic syndrome is present. This process includes a careful:-
298
Examination of family history. Medical history of the child. Review of patient medical records in the family. A physical examination of the child. Sometimes blood work or other diagnostic test. If a diagnosis is made, then a medical geneticist and genetic counselor review what is known about the inheritance of the condition, the natural history of the condition ,treatment options, further examinations that may be needed for health problems common in diagnosed syndrome and resources for helping the family. The genetic counselor also helps the family adjust to the diagnosis by providing emotional support and counseling. Many families are devastated by receiving a diagnosis, learning of the likely outcome for the child and by the loss of the hoped for healthy child. There would also be a discussion about recurrence risks in the family and who else in the family may be at risk. Adult Genetic Counseling: Adults may seek genetic counseling when a person in the family decided to be tested for the presence of a known genetic condition, when an adult begins exhibiting symptoms of an inherited condition, or when there is a new diagnosis of someone with an adult-onset disorder in the family. In addition, the birth of a child with obvious features of a genetic disease leads to diagnosis of a parent who is more mildly affected. Genetic counseling for adults may lead to the consideration of pre symptomatic genetic testing. Testing a person to determine the likelihood for a condition existing before any symptoms occur in an area of controversy. Huntington‘s disease is an example of a genetic disease for which presymptomatic testing is available. This is a neurological disease resulting in dementia. Onset of the condition is between 30 and 50 years of age. Huntingson‘s disease is an inherited in an autosomal dominant pattern. If a person has a parent with the disease, the risk of being affected is 50% would pre symptomatic testing relieve or create anxiety? Would a person benefit from removal of doubt about being affected? Would knowing about the conditions help a person with life planning? Genetic counselors help people sort through their feelings about such testing and whether or not the results would be helpful to them. Cancer Genetic Counseling: A family history of early onset breast, ovarian or colon cancer in multiple generations of family is a common reason a person would seek a genetic counselor who works with people who have cancer. While most cancer is not inherited, there are some families in which a dominant gene is present and causing the disease. A genetic counselor is able to discuss the chances that the cancer in the family is related to a dominantly inherited gene. The counselor can also discuss the option of testing for the breast and ovarian cancer genes, BRCA 1 and BRCA 2. In some cases the person 299
seeking testing have already had cancer but others have not. Therefore, presymptomatic testing is also an issue in cancer genetics. Emotional support is important for these people, as they have often lost close relatives from cancer and are fearful of their own risks. For families in which a dominant form of cancer is detected through genetic testing, a plan can be made for increased surveillance of disease symptoms. Ethical Issues In Genetic Counseling: Prenatal diagnosis of anomalies or chromosomal abnormalities may lead to a decision about whether or not a couple wished to continue a pregnancy. Some couples choose to continue a pregnancy. Prenatal diagnosis gives them additional time to emotionally prepare for the birth of the child and to gather resources. Others choose not to continue a pregnancy in which problems have been diagnosed. These couples have unique emotional needs. Often the child is a very much desired addition to the family, and parents are devastated that the child is not healthy. Presymptomatic testing for adult-onset disorders and cancer raises difficult issues regarding the need to know and the reality of dealing with abnormal results before symptoms occur. The National Society of Genetic Counselors has created a code of Ethics to guide genetic counselors in caring for people. The Code of Ethics consist of four ethical principles: Beneficences are the promotion of personal well-being in others. The genetic counselor is an advocate for the person being counseled. Non-maleficience is the concept of doing no harm to a person. Autonomy is recognizing the value of an individual, the person‘s abilities and point of view. Important aspects of autonomy are truthfulness with persons, respecting confidentiality and practicing informed consent. Justice is providing equal care for all, freedom of choice, and providing a high quality of care. The main ethical principle of genetic counseling is the attempt to provide nondirective counseling. This principle again points to an individual-centered approach to care by focusing on the thoughts and feelings of each person. Five percent of the Human Genome project budget is designated for research involving the best way to deal with ethical issues that arise as new genetic tests become available. Genetic counselors can help people navigate through the unfamiliar territory of genetic testing. Preparation: Person should be apprised of possible outcomes and given the opportunity to discuss their feelings prior to undergoing genetic tests. There is a burden associated with knowing the probability of a future outcome. Difficult decisions may be required as a result of learning genetic information through testing. The process of adequately preparing an individual for genetic counseling is called informed consent. Ethical genetic counselors always obtain informed consent prior to undertaking any genetic tests. Aftercare: Persons must be provided access to competent counselors and therapists. Such professionals can assist in processing the feelings and reactions that may emerge as a result of receiving the findings of genetic tests. 300
Complications: The complications that arise from the process of genetic counseling are most commonly mental and emotional. Individuals and couples who have received genetic counseling of experience mental changes such as depression and anguish when they receive unfavorable results about tests. Complication include the need to make difficult decisions regarding themselves, their families, or their unborn children. This is also referred but unwanted outcomes may become known before they occur. Depending on the condition personal preferences and situation, persons may elect to continue with a pregnancy that is likely to result in a child with one or more abnormalities terminate a pregnancy, select a different partner, or decided not to have children. These are all difficult situations that may require the assistance and interventions of a trained mental health counselor or therapist. Results: The results given to a person during genetic counseling are highly individualized and depend on the nature of tests being performed and the issues of importance to the person being counseled. The results of the process of genetic counseling vary. Genetic Counseling offers information to people, thereby allowing them to make informed choices. Some of the options may not be easy or pleasant to contemplate. However, they are based on hard data rather then on wishes, hopes, and some other non-scientific basis. Genetic Counselors have an ethical duty to obtain informed consent from individuals prior to beginning genetic counseling, provide unbiased information and the ability to interact in a non judgmental or coercive manner. Health Care Team Roles: Genetic Counselors are specially trained members of health care team who have a master‘s degree in genetic counseling. They receive referrals from obstetricians, pediatricians, family physicians, and other doctors. They interpret the results of tests from laboratory personnel, medical geneticists, pathologists. They refer people to therapists and counselors for assistance in resolving issues that arise from the process of genetic counseling. Role of Nurse In Genetic Counseling: 1. Recognize or suspect genetic disorders by their physical characteristics and clinical manifestations. 2. Create a genetic pedigree (diagram of the family history), including cause of death and any genetically linked ailment. Explain those aspects of diagnosis, prognosis and treatment that affect the patient and his family. Relate information that parents affected or at risk individuals and caregivers need to know to plan for the care of the patient and his family. 3. Clear-up misconceptions and allay feelings of guilt. 4. Assist with the diagnostic process by exploring medical and family history information, by using physical assessment skills, by obtaining blood sample, or by assisting with other means of sample collection, as indicated. 5. Enhance and reinforce self-image and self-worth of parents, child or the individual at risk for the presenting with a genetic condition. 301
6. Encourage interaction with family and friends, offer referrals, phone numbers of support group. 7. Refer and prepare family for genetic counseling: a. Inform that the prenatal testing does not mean termination of pregnancy e.g. It may confirm that the fetus is not affected, thus eliminating worry throughout pregnancy, although the determination of an abnormality is also a possibility. b. Encourage parents and patients to allow adequate time to deliberate on a course of action. E.g. they should not rush into a test without full knowledge of what the result can and cannot tell, nor should they rush to make future reproductive decisions such as tubal ligation because in a few years they may want more children. c. Remain non-judgmental. 8. Check with the Govt. Policy for information and resources regarding neonate testing required, state regulations on genetic testing and research. 9. Recognize that there are many ethical, legal, Psychosocial and professional issues associated with obtaining, using and sorting genetic information. 10. Be aware of associated professional responsibilities, including informed consent, documentation in medical records, medical releases and individual privacy of information. Applications of Genetics In Nursing: Genetics is affecting all of health care, including nursing. The way in which nurse‘s think about planning health care must be seen how now through a ―genetic eye‖ or lens, and nurses must learn to ―think genetically‖. While efforts to integrate genetics into nursing began in earnest in the early 1980s, this effort did not accelerate until the mid-1990s. Before nursing can fully incorporate genetic knowledge into education and practice in a meaningful way, the way in which genetics will influence health care must be understood. Today genetic approaches are used to diagnose disease, provide information about the course of disease and confirm the existence of disease in asymptomatic individuals. It is now evident that inherited predisposition is important in a number of common disease of later life, such as; coronary heart disease, hypertension, diabetes mellitus, and some rheumatic, cancer and mental illnesses. This has led to increased use of genetic testing. Genetic tests are used to assess risk in pre symptomatic individuals with a family history of the disorder, and to provide information that assists in effective disease management. Regular colonoscopy and cervical screening, for instance, could prevent thousands of deaths each year. Genetic Knowledge offers new opportunities to detect, prevent and treat disease, but there is a potential for harm and complex ethical, legal and social implications surround the use of genetic approaches in health care. ‗ Nursing practice in genetics-related health care blends the principles of human genetics with nursing care in collaboration with other professional, including genetics specialists, to foster health improvement, maintenance, and restoration. In any practice setting, nurses will carry out five main activities in genetics-related nursing practice.
302
1. Help collect and interpret relevant family and medical histories. 2. Identify patients and families who need further genetic evaluation and counseling and refer them to appropriate genetics services. 3. Offer genetics information and resources to patients and families. 4. Collaborate with genetics specialists and 5. Participate in the management and coordination of care of patients with genetic conditions. Genetics-related nursing practice includes the care of clients who have genetics conditions, persons who may be predisposed to develop or pass on genetic conditions, and persons who are seeking genetics information and referral for additional genetics services.
303
UNIT-IV
304
SYLLABUS Unit
Hours
IV
10
Content Epidemiology: �Scope, epidemiological approach and methods, �Morbidity, mortality, �Concepts of causation of diseases and their screening, �Application of epidemiology in health care delivery, Health surveillance and health informatics �Role of nurse.
305
Concept of disease causation: Introduction: Like health, disease is a dynamic process and it is just the opposite of health. Health denotes perfect harmony and normal functioning of all the body systems i.e. state of complete wellbeing. Whereas disease denotes disharmony and deviations from normal functioning of various body systems i.e. a state of illness. Perfect health and severe disease/wellness and illness and the two endpoints of health and disease continuum. The disharmony and deviations range from bio-chemical disturbance to severe disability culminating to death. There are various causative factors which cause the occurrence of a disease. These factors are related to human beings and their environment. Webster defines as ―a condition in which body health is impaired, a departure from a state of health, an alteration of the human body interrupting the performance of vital functions‖. The Oxford English Dictionary defines diseases as ―a condition of the body or some part or organ of the body in which its functions are disrupted or deranged‖. From an ecological point of view, disease is defined as maladjustment of the human organism to the environment.‖ from a sociological point of view, disease is considered a social phenomenon, occurring in all societies and defined and fought in terms of the particular cultural forces prevalent in the society. The simplest definition is of course, that disease is just the opposite of health –i.e., any deviation from normal functioning or state of complete physical or mental well-being-since health and disease are mutually exclusive. The WHO has defined health but not disease this is because disease has many shades ranging from in apparent cases to severe to manifest illness. Some diseases commence acutely (e.g., food poisoning), and some insidiously (e.g., mental illness, rheumatoid arthritis). In some diseases a ―carrier‖ state occurs in which the individual remains outwardly health, and is able to infect others (e.g., typhoid fever). In some instances, the same organism can cause more than one clinical manifestation (e.g., streptococcus). In some cases the disease can be caused by more than one organism (e.g. diarrhea). Some disease have a short course, and some a prolonged course. The endpoint of disease is variable – recovery, disability or death of the host. Distinction is also made between the words disease, illness and sickness which are not wholly synonymous. The ―disease‖ literally means ―without ease‖ (uneasiness)-when something is wrong with bodily function. Susser has suggested the following the following usage: Disease is a physiological\psychological dysfunction. Illness is a subjective state of the person who feels aware of not being well Sickness is a state of social dysfunction, i.e., a role that the individual assumes when ill. The concept of disease causation differed from time to time with the progress of civilization. It changed from supernatural causes during primitive period to multifactorial causes during modern time. Some of the old concepts still prevail in the world, both in developed and developing countries due to invariable reasons. It is very important to understand the concept of disease causations and disease progress because it can help in identifying public health measures to prevent and control diseases. The aims of epidemiological studies are to acquire knowledge about the nature of diseases/ health 306
problems, their etiological factors and then utilize that knowledge in planning community health services to prevent and control health\problems. Theories and Models Of Disease Causation: Before, the discovery of micro-organisms (bacteria by Louis Pasteur) the French Scientist in 1860 several theories were put forward from time to time. The earliest attempt to attribute a cause to illness occurred during the religious Era (2000 BC to 600 BC). During this period the disease was thought to be Caused by the divine power as punishment for sins as bad deeds or considered as fate. This theory is referred as supernatural theory. Subsequent to supernatural theory, the disease was often attributed to a various physical forces, such as miasma or mists – referred as Miasmatic theory. About 400 BC a rudimentary environmental theory was put forward by Hippocrates. It was believed that the disease was caused by harmful substances in the environment. Some other theories of disease causation during the same period were, theory of contagion, theory of humors by Greek amend Tridosha by ayurveda. With the discovery of micro-organisms by Louis Pasteur mentioned above and Robert Koch, the bacteriologic era commenced in the late 1870, which was the turning point in the disease causation. 1) The Germ Theory: The germ theory became popular during 19th century and in earlier 20th century. This theory attributes micro-organisms as the only cause of diseases. Acc. to this theory there is one single specific micro-organism (causative agent) to every disease. This refers to one to one relationship between the causative agent and the disease. This is also called as Single Cause Theory. For example: - diphtheria due to coryne bacterium diphtheria, cholera due to vibrio chlorae. The Single Cause Theory was further supported by the identification of other specific agents as causative agents for certain health problems e.g. lack of vitamin C causes scurvy. It is now recognized that a disease is rarely caused by a single agent alone, but rather depends on a number of factors which contribute to its occurrence. Therefore modern medicine has moved away from the strict adherence to the germ theory of disease. Single Cause Theory:
2) THEORY OF EPIDEMIOLOGICAL TRIAD: The germ theory or single cause theory has many limitations. It was experienced that everyone exposed to the disease agent did not contract the disease. For exampleTuberculosis, all those who were exposed to he tuberculosis organisms, did not suffer from tuberculosis. Only those who were undernourished lived in dark and dingy places and who did not have immunity against tuberculosis get the disease. This means it was not only the causative agent that was responsible for causing disease but there were other 307
factors related to man and environment which contributed to the occurrence of disease. This leads to the theory of epidemiological triad.
This model is also called as ecological model and is involved through the study of infectious diseases. According to this there are three elements or major factors which are responsible for particular disease causation. These are agent, host and environment. The agent is considered to be the primary factor (e.g. amoeba. Bacteria, fungi, virus) without which a particular disease cannot occur. The host refers to human beings who came in contact with the agent. The host related factors which play an important role are genetic makeup, age, sex, race, immunity, health behavior etc. the environment includes all that is external to the host and agent but that may influence interaction between them. These three factors as long as they remain in equilibrium or balance disease will not occur and is referred as state of health equilibrium.
3) Multifactorial Causation Theory: The epidemiological triad model is applicable to infectious diseases only. It is not applicable to non infectious and chronic diseases like mental illness, coronary heart disease; rheumatoid arthritis etc because they are not linked with specific causation agent and these cannot be prevented and controlled by immunization, isolation and quarantine techniques. These diseases are caused by multiple factors. E.g.: coronary heart disease is caused with certain life style activities such as: smoking, ingestion of food containing high level of 308
cholesterol, lack of exercise, increased mental and emotional stress and environmental pollution etc. control of diet and regular exercise and use of effective stress management techniques have shown to reduce the risk of experiencing myocardial infarction. This leads to the theory of multi factorial causation. This theory thus stresses the multiplicity of interactions between host and environment. This model is equally applicable to infectious diseases except that specific agents causing infectious and non infectious diseases. The multi factorial causation model helps epidemiologist to understand the various associated causative actors, prioritize these and plan preventive and control measures for a particular disease. Multi Cause\Single Effect Model:
It is also found that several causative factors produce many observed effects e.g. air pollution; smoking, specific form of radiation (causes) may produce lung cancer, emphysema and bronchitis (effects). It can be depicted as following:-
4) Web of Causation: This epidemiological concept of disease etiology is given by Mac Mohan and Pugh. According to this concept, disease (effect) never depends upon single isolated cause. Rather it develops as a result of chains of causation in which each link itself is the result of complex interaction of preceding events. These chains which may be a fraction of the whole complex is known as web of causation. This model is particularly applicable to chronic diseases where the causative agent is unknown and which are due to interaction of multiple factors e.g. cardiovascular diseases, cancer. Web Of Causation-Cardiovascular Diseases:
309
5) Dever’s Epidemiologic Model: This model provides another approach to conceptualize interaction of various factors involved in the development of a particular condition. This model is composed of four major categories of factors such as human biology, life style, environment and health care system. Human biological factors are host related factors of epidemiological triad and include genetic inheritance, complex physiologic systems, factors related to maturation and ageing. Life style factors include daily living activities, customs, traditions, health habits and behavior etc. environmental factors include physical, biological, social and spiritual components and are similar to environment aspects of epidemiological triad. Health care system factors include availability, accessibility, adequacy and use of health care services at all levels. All these factors influence health status either positively or negatively. Natural History Of Disease: A disease is the outcome of complex interaction of causative agent, host and environment i.e. epidemiological triad. In the absence of any intervention i.e. preventive or treatment, all diseases follow a natural course of events which refers to ―Natural History of Disease”. The concept of natural history of disease was conceived by epidemiologists as early as 1860 in the United States as an argument for the clinical course of disease. But the concept was defined and associated with preventive and control strategies in 1953 by Leavell and Clark with the help of Schema of natural history of disease. The model was primarily used to explain infectious diseases but it can be effectively used for chronic and non infectious diseases and other health problems. Leavell and Clark have defined the natural history of disease model as ―A narrative and schematic representation which portrays a chronological sequencing of departure from health. The sequence begins with the factors that promote health, but the model also addresses the very first choice that inaugurates pathological departures. An innate function of this model is to describe various approaches to prevent and control pathological processes and this function is collectively known as the level of prevention.” The figure on the next page depicts its confrontation\interaction of the essential elements i.e. agent, host and environment to influence the onset of any disease, the continuum of pathogenesis. Natural History of Disease:
310
The above figure is the necessary framework to understand the pathogenetic chain of events for a particular disease, and for the application of preventive measures. It is customary to describe the natural history of disease as consisting of two phases; prepathogenesis (i.e. the process in the environment) and pathogenesis (i.e. the process in the man) 1. Prepathogenesis phase: this is the period preliminary to the onset of disease in man. The disease agent has not yet entered man, but the factors which favor its interaction with the human host already exist in the environment. This situation is frequently referred to as ―man in the midst of disease‖ or ―man exposed to the risk of disease‖. The causative factors of disease may be classified as AGENT, HOST and ENVIORNMENT. These three factors are reffered to as epidemiological triad. The mere presence of agent, host and favorable environmental factors in the prepathogenesis period is not sufficient to start the disease in man. What is required is the interaction of these three factors to initiate the disease process in man. 2. Pathogenesis phase: The pathogenesis phase begins with the entry of disease ―agent‖ in the susceptible human host. The disease agent multiplies and induces tissue and physiological changes, the disease progresses through a period of incubation and later through early and late pathogenesis. The final outcome of the disease may be recovery, disability or death. The pathogenesis phase may be modified by intervention measures such as immunization and chemotherapy. Determinants Of Disease—Causative/Risk Factors: There are three elements/factors classified as agent, host and environment which are determinants or responsible for causation of disease. All three elements must interact to produce any disease. 1. Definition of Risk factors: The risk factor is defined as ―a factor or an attribute that is significantly associated with the development of a disease and when modified reduce the possibility of occurrence of disease or other specified outcomes.‖ 2. Agent, Host and Environmental Risk Factors: a) Agent Factors: The disease agent is defined as ― an element, a substance – living or non living, or a force- tangible or intangible, the presence or absence of which may following the effective contact with the susceptible human host under proper environmental conditions serve as a stimulus to initiate or perpetuate a disease process‖. The disease agents are usually classified as under: I. Biological agents: these are living agents of disease, e.g. viruses, rickettsiae, fungi, bacteria, protozoa and metazoan. These agents exhibit certain ―host-related‖ biological properties such as: infectivity that is the ability of an infectious agent to invade and multiply in a host; pathogen city that is the ability to induce clinically apparent illness, and virulence that is defined as the proportion of clinical cases resulting in severe clinical manifestations. II. Nutrient agents: these can be proteins, fats, carbohydrates, vitamins, minerals and water. Any excess or deficiency of the intake of nutritive elements may result may result in nutritional disorders like protein energy malnutrition, anemia, goiter, obesity and vitamin deficiencies. 311
III. Physical agents: exposure to excessive heat, cold, humidity, pressure, radiation, electricity, sound, etc may result in illness. IV. Chemical agents: Endogenous: some of the chemicals may be produced in the body as a result of derangement of function, e.g., urea (ureamia), serum bilirubin (jaundice), ketones (ketosis), uric acid (gout), calcium carbonate(kidney stones) Exogenous: agents arising outside of human host, e.g., allergens, metals, fumes, dust, gases, insecticides, etc. these can be acquired by inhalation, ingestion or inoculation. V.Mechanical agents: exposure to chronic friction and other mechanical forces may result in crushing, tearing, sprains, dislocations and even death. VI. Absence or insufficiency: these may be: Chemical factors: hormones (insulin, estrogens, enzymes). Nutrient factors. Lack of structure: thymus. Lack of part of structure: cardiac defects. Chromosomal factors: mongolism, Turner‟s syndrome. Immunological factors: a gamma globulinaemia. VII. Social agents: these are poverty, smoking, drug abuse and alcoholism, unhealthy lifestyles, social isolation, maternal deprivation. b) Host Risk Factors: Host related attributes include i. Demographic characteristics: these include age, sex, race, ethnicity, marital status etc. ii. Biological factors: these include genetic factors, blood chemistry, blood groups, physiological functioning of body system, immune system. iii. Psychosocial and economic characteristics: these include personality traits, education, occupation, social class and status, mental status and emotional make-up, health knowledge and attitude etc. iv. Lifestyle: these include daily living and cultural practices including customs and traditions; health habits and health seeking behaviors such as physical exercise, nutrition practices, sexual practices, use of alcohol, drugs and smoking etc. v. Past history of exposure: exposure can range from infectious disease to smoke in the environment, exposure to various occupational hazards. c) Enviornmental Risk Factors: the various environmental factors influence the life and development of agents and host and their interaction to cause various diseases. By definition the environment is the aggregate of all the external conditions and influences effecting the life and development of an organism. The environment has three components. These are: i. Biological environment: it includes living things comprising of animal kingdom, plants and micro-organisms. Some of these are infectious agents, reservoirs of infection, intermediate host and vectors that transmit diseases. ii. Physical environment: it includes all those things that are non-living, chemical agents and physical factors. These are air, water, soil, environmental sanitation, housing, radiation, gravity, atmospheric pressure, noise, electricity, electronic and electrical machines, radio broadcasting and television transmitter and radar etc. 312
Increasing population, urbanization, industrialization, migration, electronic and electrical devices and media technology etc. have been the causes of environmental pollution and resultant health problems. Lack of environmental sanitation is the cause of various infectious diseases among people. iii. Psycho-social environment: it include over all socio-economic and political organization that effects health care and its delivery system; health legislation; sociocultural customs; traditional values, beliefs and attitudes; education, religion and morals; life style and family and community life. The psycho-social factors which can effect health are: poverty, migration, increasing population, urbanization, stressful situations such as loss of loved ones, loss of job, accidental disabilities, menopause, birth of retarded child, defective lifestyle, harmful health attitude, behavior and practices etc. Screening For Diseases: Historically the annual health examinations were meant for the early detection of ―hidden‖ disease. They are based on conserving the physician-time for diagnosis and treatment and having technicians to administer simple, inexpensive laboratory tests and operate other measuring devices. This is the genesis of screening programmers. Today screening is considered a preventive care function, and an extension of health care. Screening is defined as ―the search for unrecognized disease or defect by means of rapidly applied tests, examinations or other procedures in apparently healthy individuals.‖ Screening differs from periodic health examinations I the following aspects: Capable of wide application. Relatively inexpensive. Requires little physician time. Physician is not required to administer the test, but only to interpret it. Screening is testing for infection or disease in population or in individuals who are not seeking health care; for example, serological testing for AIDS virus in blood donors, neonatal screening, premarital screening for syphilis Case-finding is the use of clinical and laboratory tests to detect disease in individuals seeking health care for other reasons; for example use of VDRL test to detect syphilis in pregnant women. Diagnostic test is defined as the use of clinical or laboratory procedures to confirm the existence of disease in patients with sign and symptoms presumed to be caused by the disease. For example, VDRL testing of patients with lesions suggestive of secondary syphilis. Difference between Screenibg and Diagnostic Test: Screening test Diagnostic test 1) Done on apparently healthy Done on those with sickness 2) Applied to groups Applied to single patients, all diseases are considered 3) Test results are arbitrary and final Diagnosis is not final but modified in light of new evidence. 4) Based on one criterion or cut-off Based on evaluation of a Point. number of symptoms, signs and laboratory findings. 313
5) Less accurate More accurate. 6) Less expensive More expensive. 7) Not a basis for treatment Used as a basis for treatment 8) The initiative comes from the The initiative comes from the agency providing care patient with a complaint. Aims and objectives of screening: To sort out from a large group apparently healthy persons likely to have the disease To bring those who are ―apparently abnormal‖ under medical supervision and treatment. Uses of Screening: i. Case detection: it is also called prescriptive screening. It is defined as presumptive identification of unrecognized disease, which does not arise from a patient‘s request, e.g. neonatal screening. Diseases sought by this method are bacteriuria in pregnancy, breast cancer, cervical cancer, deafness in children, diabetes mellitus, iron deficiency anemia, PKU, pulmonary tuberculosis etc. In this it is made sure that the treatment is started early. ii. Control of disease: it is also called prospective screening. The people are examined for the benefit of others, e.g., screening of immigrants from infectious diseases such as tuberculosis and syphilis to protect home population. It leads to early diagnosis, permit more effective treatment and reduce the spread of infectious disease. iii. Research purposes: screening is also done for research purposes. For example, there are many chronic diseases whose natural history is not fully known e.g. cancer so screening may be done in obtaining basic knowledge about the natural history of such disease. The participants should be informed that no follow-up therapy will be provided. iv. Educational opportunities: there is acquisition of information of public health relevance. Screening programmers provide public awareness and education to other health professionals. Types of Screening: a. Mass screening: in this screening of the whole population or a subgroup whether or not exposed to the risk of having the disease under study. It is not advisable under limited sources. b. High risk or selective screening: in this screening only those who are at high risk to have a particular problem or disease e.g. women 35+ and lower socioeconomic group have more chances of cancer cervix and if they are screened for that, then more chances of detecting the cases. Similarly people having family history of diabetes, breast cancer should be screened for such problems. c. Multiphase screening: it is the application of two more screening tests in combination to large number of people at one time than to carry out separate screening tests for single disease. For e.g. test for lung diseases, cardiovascular diseases, dianaemia, kidney diseases, cancer of breast and uterus, visual and audio defects are grouped tougher. But it is an expensive venture and its benefits are under question. Criteria for Screening: Before the screening programmed is initiated, a decision must be made whether it is worthwhile, which requires ethical, scientific and financial justification. The criteria for screening are based on two considerations: the DISEASE to be screened and the TEST to be applied. 314
Disease: The disease should fulfill the following criteria before it is considered suitable for screening: The condition sought should be an important health problem. There should be a recognizable later or early asymptomatic stage. Natural history of the condition, including development from latent to declared disease, should be adequately understood. There is a test that can detect the disease prior to the onset of signs and symptoms. Facilities should be available for the confirmation of the diagnosis. There is an effective treatment. Here should be an agreed on policy concerning whom to treat as patients (e.g., lower ranges of blood pressure, border-line diabetes. There is good evidence that early detection and treatment reduces morbidity and mortality. The expected benefits (e.g. the number of lives saved) of early detection exceed the risks and costs. When the above criteria are satisfied then only it would be appropriate to consider a suitable screening test Screening test: the test must satisfy the criteria of acceptability, repeatability and validity, besides others such as yield, simplicity, safety, rapidity, ease of administration and cost. Tests most likely to fulfill one cognition may least likely to fill another. The choice of test is often based on compromise. 1. Acceptability: the test should be acceptable to the people at whom it is aimed. 2. Repeatability: the test must give consistent results when repeated more than once on the same individual, under same conditions. The repeatability of the tests depends on three major factors observer variation, biological variation and errors relating to technical methods. 3. Validity (accuracy): it refers to what extent accurately measures which it purports to measure. It must have the ability to separate those who have a disease from those who do not have. Evaluation Of Screening Programmes: The screening programmers must be put into practice after proper evaluation by the following ways: Randomized controlled trials: in this one group receives screening test and a control group which does not receive the test. Uncontrolled trials: it is used to see if people with disease detected through screening appear to live longer after diagnosis and treatment than patients who were not screened. Other methods: case control studies and comparison in trends between areas with different degrees of screening coverage.
315
APPLICATION OF EPIDEMIOLOGY IN HEALTH CARE DELIVERY The ultimate goals of health care services are: to promote and protect health, to alleviate and minimize sufferings and disabilities and to regain health so as to lead socially useful and economically productive life. Preventive approach is the best approach to achieve these goals because preventive measures can be implemented with the joint efforts of health personnel and the people at large at the family and the community level. Epidemiologically the concept of preventive approach is broad based. There are three major levels of prevention i.e. primary, secondary, tertiary prevention. Each of these levels of prevention serves distinct purposes and involves specific interventions which are applied to entire population considering its physical, mental, social and spiritual domains. 1. Primordial Prevention: this includes prevention of the emergence or development of risk factors in countries or population groups in which they have not yet appeared. For e.g. many adult health problems (e.g. obesity, hypertension) have their origins in the childhood, because this is the time when lifestyles are formed (for e.g. smoking, eating patterns, physical exercise). In primordial prevention, efforts are directed towards discouraging children from adopting harmful lifestyles. The main interventi9n is through individual and mass education. 2. Primary Prevention: primary prevention can be defined as ―action taken prior to the onset of disease, which removes the possibility that the disease will ever occur.‖ Primary prevention is the first level prevention and is associated with the prepathogenesis phase or stage of susceptibility of the disease process when the epidemiological factors like: Agent-Host-Environment have not yet interacted to cause a disease. Primary prevention strategies during pre-pathogenesis phase of a disease are aimed to prevent the interaction of these epidemiological factors. If preventive measures are successful then the disease will not occur. There are two types of primary prevention: a. General health promotion: health promotive factors include health education, wholesome nutritious diet, clean and safe environment to live, healthful life style, healthful behaviors and adequate resources. All these aspects are directly related to socioeconomic and cultural aspects of the family and community which must be improved. Health promotive measures encompass activities related to health education, environmental modification, nutritional interventions, life style and behavior changes, effective utilization of resources. These must be planned and executed effectively and efficiently. b. Specific protection: specific protection includes those measures which are directed to intercept causative agents of a particular disease or group of diseases before these agents‘ effect people. These measures include immunization, use of specific nutrients, protection against accidents and environmental and occupational hazards , use of prophylactic and suppressive drugs, avoidance of allergens, protection from carcinogens, stimulation of proper personal hygiene, control of quality safety of foods, cosmetics and drugs and genetic therapy and counseling. The basis of primary prevention measures is to alter the host, agent and environment in such a way that the disease process does not initiate and does not occur. Much of the morbidity, mortality due to infectious diseases, 316
Non-infectious and chronic diseases have been averted and reduced due to primary preventive measures. 3. Secondary Prevention: secondary prevention can be defined as ―action which halts the process of a disease at its incipient stage and prevents complications.‖ Secondary prevention is second level prevention and is associated with pathogenesis i.e. presymptomatic stage and symptomatic i.e. clinical stage of the pathogenesis phase of the disease process. The objectives of secondary preventive measures are: Diagnose the disease at early stage. Control the process of disease in man. Prevent complication. Restore health. Prevent the spread of infections to others in the community. Secondary prevention is more important and emphasized in some chronic and noninfectious diseases such as diabetes; caner, blood pressure etc. because there is limited knowledge of causes and primary preventive strategies. Secondary preventive measures include two types of strategies: a. Early diagnosis and treatment: early diagnosis and treatment are the measures which control the disease process, prevent the spread of infection to others in case of communicable diseases, prevent complications and long term disabilities and restore health. Early diagnosis and treatment has been found the more effective mode of intervention in communicable diseases like tuberculosis, leprosy and STD. It helps in reducing the morbidity and mortality due to these infectious and non-infectious diseases. In case of acute communicable diseases, early diagnosis and treatment helps to shorten the period of communicability, thus limits the spread of infection and reduces mortality. b. Disability limitations: disability interventions are applicable during the late pathogenesis period or clinical stage of the disease process. The objective of these interventions is to prevent or delay the consequences of clinically advanced disease i.e. prevent impairment leading to disability and handicap. The sequence of events leading to disability and handicap is as follows:
Impairment: any loss or abnormality of psychological, physiological, or anatomical structure or function‖, e.g. loss of foot, defective vision or mental retardation. Impairment can be visible or invisible; temporary or permanent; progressive or regressive. Further one impairment can lead to second impairment like leprosy damage of nerves lead to plantar ulcers. Disability: because of impairment the affected person may be unable to carry out certain activities considered normal for his age, sex, etc. this inability to carry out certain activities is termed as ―disability‖. A disability can be defined as ―any restriction or lack
317
of ability to perform an activity in the manner or within the range considered normal for a human being‖ Handicap: it is a disadvantage for a given individual resulting from impairment or a disability that limits or prevents the fulfillment of a role that is normal (depending on age, sex and social and cultural factors) for that individual. Example: - Accident is disease. Loss of foot impairment Cannot walk is disability. Unemployed is handicap (socialized). Some of the nursing measures which may limit the impairment and are advisable in immobile patients are back-care, passive exercise; for diabetic patient include health teaching, exercise, skin care, psychological boosting. 4. Tertiary Prevention: tertiary prevention can be defined as ―all measures available to reduce or limit impairments and disabilities, minimize sufferings caused by the existing departures from good health and to promote the patient‘s adjustment to irremediable conditions‖ Tertiary prevention is the third level of prevention. It occurs late in the pathogenesis stage of disease process when irreversible changes either in anatomy or physiology or both have occurred. At this point the disease process has advanced its clinical stage and entered the disability stage. It is either because the primary and secondary preventive measures have not been effective or not known. Tertiary prevention helps to prevent disability through rehabilitative strategies. Rehabilitative stratigies are used to attain the highest possible level of functional ability. It involves coordinated efforts of medical personnel, sociologists, clinical psychologists, nurses etc. for training and retraining of and helping the person to function, lead a useful life as far as possible and restore a feeling of wellbeing. Rehabilitation is with regard to restoration of: Bodily functions (medical rehabilitation). Personal dignity and confidence (psychological rehabilitation). Family and social relationship (social rehabilitation). The capacity to earn livelihood (vocational rehabilitation). To conclude the three levels of preventions are relative to various stages of natural history of disease. Mutually exclusive relationship exists among all the three levels of prevention.
HEALTH SURVEILLANCE The surveillance means supervision or close watch especially on suspected person. Epidemiologically surveillance means close vigilance on occurrence and distribution of diseases and health related problems, population dynamics, community behavior and environmental processes resulting in increased risk of ill health in the community. It involves identification of missed and suspected cases and contacts, their confirmation by laboratory investigations; identifying source of infection and channel of transmission. This information‘s will help in planning and implementation of prevention and control programmers for various diseases in the community. Thus monitoring of the disease prevalence, its related risk factors and intervention of control programmers for the same are the important activities of surveillance. The epidemiological surveillance can be done at the following levels: 318
I. Individual /family Surveillance: It includes surveillance of an infected person in a family as long as the individual is source of infection to others e.g. typhoid case and carriers. II. Community /Local population Surveillance: It include surveillance of the whole community for early detection and prevention and control of a disease e.g. Malaria. III. National Surveillance: It includes surveillance at the National level e.g. surveillance of small pox after its eradication. IV. International Surveillance: It includes surveillance of some of the diseases which are listed by WHO e.g. Malaria, Influenza, Filarial, Polio etc. and are to be reported to WHO which then provides information to the countries in the world to take timely actions. Survelliance Process: Surveillance is a systematic process. The main steps involved are:1. Collection of relevant information about the diseases under surveillance: effectiveness of surveillance system depends upon identification of cases, collection of relevant information about disease, their recording and reporting. There are number of methods for collection of relevant information about the diseases under surveillance. It may be easier to find some diseases and may be difficult to identify some others. Because of this difficulty no single method can be adopted for surveillance of all diseases. The various methods of surveillance are as under: a) Routine reporting of cases and deaths recorded at health centers, dispensaries and hospitals: All these institutions are required to maintain record of cases reported in their outpatient departments and clinics. Daily recording of cases in OPD of Health Centers includes month, name, age, sex, address, diagnosis, date of onset and remarks. From this record daily, weekly, monthly and yearly reports of diseases occurred and reported at the centre are prepared. This kind of routine reporting can help in making assessment of frequency and distribution of diseases by age, sex, area and time. Such reports are sent to the district and state health authorities. The practice of recording of cases under the routine reporting system is called as passive surveillance. b) Active surveillance: It means actively looking for those particular types of cases who have not been recorded under the routine system. Active surveillance is done by health workers and community people e.g. surveillance of Malaria or Tuberculosis cases. c) Epidemiological investigations: Epidemiological investigations are usually done when there is occurrence of more than usual number of cases in a particular place during particular time period: when there is sudden outbreak of any disease and when a communicable disease which has never occurred before but it has occurred now. This will help in picking up cases and the associated causative factors. Thus epidemiological investigations provide important supplementary information which is not obtained by other surveillance methods. d) Sentinel centers: sentinel centers are those hospitals, health centers, laboratories, special disease hospital etc. which are identified for collecting information for selected diseases. The information are collected, compiled and forwarded to higher authority for immediate action and for making future plans and policies. Sentinel survey can provide reliable information about selected diseases indicating the trend of disease prevalence in a 319
particular area. Such information can call for immediate actions to control the disease and also timely remedial actions in future to prevent the occurrence of disease. e) Special sample survey: Special sample survey of disease is an active and efficient method of surveillance. There are different methods of sample surveys but the survey by cluster sampling technique is recommended by the WHO. The target population, the sample size vary from disease to disease e.g. the target population for poliomyelitis is 5-9 years, for diarrhea 0-4 years, preceding the date of survey. 2. Compilation and analysis of data: Once the surveillance data is collected for a reporting period by whatever method, it needs to be compiled and analyzed to assess the frequency and distribution by person, place and time. The reporting period can be a week, a month and a year. This information can be presented in tables, spot maps, charts and graphs. This kind of presentation helps in determining the pattern of occurrence of disease and whether there is decrease or increase in the number of cases. 3. Reporting of data and providing feedback: Once the data is analyzed a report a report is to be prepared in the format prescribed by the authority. The report is sent regularly for each reporting period. The report should be complete. If there is nil information, it should be reported. If some information is missed or received late, it should be included in the next reporting period. If further investigations are done during the period and if any section is taken or going to be taken, it needs to be reported. Feedback should be given to all the members of health team as to how the data are used which are collected by them and reported through regular meetings and as and when desired by anyone.
HEALTH INFORMATION Health information system is an integral part of the national health system. The health information system can be defined as: ―a mechanism for the collection, processing, analysis and transmission of information required for organizing and operating health services and also for research and training‖ Objectives Of Health Information System: To provide reliable, relevant, up-to-date, adequate, timely and reasonably complete information for health managers at all levels(i.e. centre, intermediate and local) To share technical and scientific information by all health personnel participating in the health services of the country. To provide at periodic intervals the data that will show the general performance of the health services. To assist planners in studying their current functioning and trends in demand and workload. Difference Between Data And Information: Data consist of discrete observations of events that carry little meaning when considered alone. Data as collected from operating health care systems are inadequate for planning. Data need to be transformed into information by reducing, summarizing, adjusting them for variations, such as age, sex composition of population so that comparisons over time and place are possible. Requirements To Be Satisfied By Health Information System: A W.H.O. Expert Committee identified the following requirements to be satisfied by the health information systems: 320
1. The system should be population based. 2. The system should avoid the unnecessary agglomeration of data. 3. The system should be problem-oriented. 4. The system should employ functional and operational terms(e.g. episodes of illness, treatment regimens, laboratory tests) 5. The system should express information briefly and imaginatively(e.g. tables, charts, percentages) 6. The system should make provision for the feed-back of data. Components of A Health Information System: A comprehensive health information system requires information and indicators on the following subjects: 1. Demography and vital events. 2. Environmental health statistics. 3. Health status: mortality, morbidity, disability and quality of life. 4. Health resources: facilities, beds, manpower. 5. Utilization and non-utilization of health services: attendance, admissions waiting lists. 6. Indices of outcome of medical care. 7. Financial statistics (cost, expenditure) related to the particular objective. Uses of Health Information: The important uses to which health information may be applied are:1) To measure the health status of the people and to quantify their health problems and medical and health care needs. 2) For local, national and international comparisons of health status. 3) For planning administration and effective management of health services and programmers. 4) For assessing the attitudes and degree of satisfaction of the beneficiaries with the health system. 5) For research into particular problems of health and disease. Sources of Health Information: 1. Census: the census is an important source of health information. It is take in most of the countries of the world at regular intervals, usually of 10 years. A census is defined by the United Nations as ―the total process of collecting, compiling and publishing demographic, economic and social data pertaining at a specified time or times to all persons in the country or delimited territory‖. Census is a massive undertaking to contact every member of the population in a given time and collect a variety of information. The first regular census in India was taken in 1881, and others took place at 10 year intervals. The supreme officer who directs guides and operates the census is the Census Commissioner for India. 2. Registration of Vital Events: registration of vital events (e.g. births and deaths) keeps a continuous check on demographic changes. If registration of vital events is complete and accurate, it can serve as a reliable source of health information. Much importance is therefore given to registration in certain countries. The United Nations defines a vital events registration system as including ―legal registration, statistical recording and reporting of the occurrence of, and the collection, compilation, 321
presentation, analysis and distribution of statistics pertaining to vital events, i.e., live births, deaths, fetal deaths, marriages, divorces, adoptions, leg imitations, recognitions, annulments and legal separations‖. India has a long tradition of registration of births and deaths. In 1873, the Govt. of India had passed the Births, Deaths and Marriages Registration Act, but the act provided only for voluntary registration. However, the Registration system in India tended to be very unreliable, the data being grossly deficient in regard to accuracy, timeliness, completeness and coverage. This is because of illiteracy, ignorance, lack of concern and motivation. There are also other reasons such as lack of uniformity in the collection, compilation and transmission of data which is different for rural and urban areas, and multiple registration agencies (e.g. health agency, panchayat agency, police agency and revenue agency). The Central Births and Deaths Registration Act, 1969:The Govt. of India promulgated the Central Births and Deaths Registration Act in 1969 in an effort to improve the civil registration system. The Act came to force on 1 April 1970. The Act provides for compulsory registration of births and deaths throughout the country and compilation of vital statistics in the states so as to ensure uniformity and comparability of data. The Act also fixes the responsibility for reporting births and deaths. While the public (e.g. parents, relatives) are to report events occurring in households, the heads of the hospitals, nursing homes, hotels, jails or dharamshalas are to report events occurring in such institutions to the concerning Registrar. The time event for registering the event of births is 14 days and that for the deaths is 7 days. In case of default a fine up to a fine up to Rs.50 can be imposed. Lay Reporting: Lay reporting is defined as the collection of information, its use, and its transmission to other levels of the health system by non-professional health workers like village health guides to record births and deaths in the community. 3. Sample Registration System (SRS): SRS was initiated in mid-1960‘s to provide reliable estimates of births and death rates at the national and state levels. The SRS is a dual record system, consisting of continuous enumeration of births and deaths by an enumerator and an independent survey every 6 months by an investigator-supervisor. This system is more reliable for information on birth and death rates, age specific fertility and mortality rates, infant and adult mortality etc. 4. Notification of Diseases: the primary purpose of notification is to effect prevention and control of the disease. Notification is also a valuable source of morbidity data i.e. the incidence and distribution of certain specified diseases which are modifiable. Lists of modifiable diseases vary from country to country and also within the same country between the states and between urban and rural areas. At the international level the diseases like cholera, plague, yellow fever, relapsing fever, polio, influenza, malaria, and rabies are modifiable to W.H.O. The limitations of notification are: (a) it covers only a small part of the total sickness in the community (b) it suffers from under-reporting (c) many cases esp. atypical and sub clinical cases escape notification due to non recognition e.g. rubella, non-paralytic polio etc. In spite of the above limitations, notification provides valuable information about fluctuations in disease frequency and provides early warning about new occurrences or outbreaks of disease. 322
5. Hospital Records: in India where registration of vital events is defective and notification of infectious diseases is extremely inadequate, hospital data constitute a basic and primary source of information about diseases prevalent in the community. The main drawbacks of hospital data are: They provide information on only those patients who seek medical care. Mild cases may not attend hospital; sub clinical cases are always missed. The admission policy may differ from hospital to hospital; therefore hospital statistics may be highly selective. Population served by a hospital cannot be defined. There are no precise boundaries to the catchment area of the hospital. In spite of above limitations, a lot of useful information about health care activities can be derived from hospital records. A study of hospital data provides information on the following aspects: Geographic sources of patients Age and sex distribution of different diseases and duration of hospital stay Distribution of diagnosis Association between different diseases The period between disease and hospital admission The distribution of patients acc. to different social and biological characteristics The cost of hospital care Such information is of great value in planning of health care services. 6. Disease Registers: a register requires that a permanent record be established, that the cases be followed up, and the basic statistical tabulations be prepared both on frequency and on survival. Morbidity registers exist only for certain diseases such as stroke, myocardial infarction, cancer, blindness, and congenital defects. Tuberculosis and leprosy are also registered in many countries where they are common. These registers are of valuable information as to the duration of illness, case fatality and survival. These registers provide follow-up of patients and provide a continuous account at the frequency of disease in the community. The useful information can be obtained from registers on the natural course of disease, esp. chronic diseases. If the reporting system is effective the register can provide useful data on morbidity from the particular diseases, treatment given and disease-specific mortality. 7. Record Linkage: the term record linkage is used to describe the process of bringing together records relating to one individual (or to one family), the records originating in different times or places. The term medical record linkage implies the assembly and maintenance for each individual in a population, of a file of the more important records relating to his health. The events commonly recorded are birth, marriage, death, hospital admission and discharge. Other useful data might also be included such as sickness absence from work, prophylactic procedures, use of social services etc. the main problem with the record linkage is the volume of data that can accumulate. Therefore in practice record linkage has been applied only on a limited scale e.g. twin studies, measurement of morbidity, chronic disease epidemiology and family and genetic studies.
323
8. Epidemiological Survelliance: in many countries where particular diseases are endemic special control eradication programmers have been instituted for example National Disease Control Programmers against malaria, tuberculosis, leprosy etc. the surveillance programmers are set up to report on the occurrence of new cases and on efforts to control the diseases e.g. immunization is performed. These programmers have yielded considerable morbidity and mortality data for the specific diseases. 9. Other Health Service Records: these are hospital OPD‘s, primary health centers and sub centers, polyclinics, private practitioners, mother and child health centers, school health records, diabetic and hypertensive clinics etc. For e.g. records in MCH centers provide information about birth weight, height, arm circumference, immunization, disease specific mortality and morbidity. The drawback is that it relates only to a certain segment of the general population and the data generated by these records is mostly kept for administrative purposes rather than for monitoring. 10. Enviornmental Health Data: health statistics provide data on various aspects of air, water and noise pollution; harmful food additives; industrial toxicants; inadequate waste disposal and other aspects of combination of population explosion with increased production and consumption of material goods. Environmental data is helpful in the identification and quantification of factors causative of disease. 11. Health and Manpower Statistics: this information relates to the number of physicians (by age, sex, specialty and place of work), dentists, nurses, medical technicians etc. there records are maintained by The State Medical/Dental/Nursing Councils and the Directorates of Medical Education. The census also provides information about occupation. The Institute Of Applied Manpower Research attempts estimates of manpower, taking into account different sources of data, mortality and out turn of qualified persons from different institutions. The Planning Commission also gives estimates of active doctors for different states. 12. Population Surveys: the term health surveys is used for surveys relating to any aspect of health- morbidity, mortality, nutritional status etc. when the mean variable to be studied is disease suffered by the people, the survey is referred as ―morbidity survey‖. The following types of surveys are included under health surveys: Surveys for evaluating the health status of a population that is community diagnosis of problems of health and disease. Surveys for investigations of factors affecting health and disease e.g. environment, occupation, income, circumstances associated with the onset of illness etc. Surveys relating to administration of health services e.g. use of health services, expenditure on health. Evaluation of population health needs and unmet needs, evaluation of medical care. Population surveys can be conducted in almost any setting. These may be cross-sectional or longitudinal; descriptive and analytical or both. Classification of Health Surveys: a) Health examination surveys: provide more valid information. This survey is carried out by teams consisting of doctors, technicians and interviewers. The main disadvantage of this type is it is expensive and cannot be carried out on the extensive scale. It also considers the provision of treatment to people found suffering from certain diseases. 324
b) The health interview: it measures subjective phenomena such as morbidity, disability, impairment, economic loss due to illness, expenditure on disease, beliefs and attitudes. c) Health records survey: involves collection of data from health service records. It is the cheapest method of collecting data. The disadvantages of this method are that the estimates available from records are not population based; reliability is open to question and lack of uniform procedures in recording the data. d) Questionnaire: it is simpler and cheaper and they may be sent. A certain level of skill and education is expected from respondents. There is usually high rate of non response. It is more time consuming also. 13. Other Routine Statistics Related To Health: Demographic: in addition to routine census data, statistics on other demographic phenomena as population density, movement and education level. Economic: consumption of consumer goods like tobacco, dietary fats, sales of drugs, employment and non-employment data. Social security schemes: medical insurance schemes make it possible to study the occurrence of illnesses in the insured population. 14. Non-Quantifiable Information: health planners require this information e.g. information on health policies, health legislation, public attitudes, programmed costs, procedures and technology. There should be proper storage, processing and dissemination of information.
325
BIBLIOGRAPHY: Park K ―Textbook of Preventive and Social Medicine‖ edition 19th, published by Banarasi Das Bhanot. Gulani KK ―Community Health Nursing Principles And Practices‖ edition 1st;published by Kumar Publishing House Basavanthapa BT ―Community health nursing‖ edition 1st; published by Jaypee Brothers. Www. Google.com
326
HEREDITY AND ENVIRONMENTAL FACTORS INFLUCING GROWTH OF EMBRYO Introduction: Embryology is the study of the development of an individual before birth. During first two months the developing individual is s called as Embryo. The orderly manner in which a single cell (fertilized ovum) develops into a fully fledged individual is not a miracle. The growth and development takes place in thousands of stages and there must be some mechanism to guide and control the various processes of differentiation and growth. Heredity and environment factors have got major influence on growth and development of embryo. Incidence and prevalance: About 80% of congenital malformation is produced by combination of genetic and environmental factors, of remaining 20% about half caused exclusively by genetic or chromosomal factors and half exclusively by environmental factors. Genetically determined biological variable: Heredity: Defect in specific chromosome: Anomalies caused by defect in specific chromosome or in specific gene. Chromosomal defect is due to absence in certain genes or presence of extraneous ones to them. A chromosome carries a large number of genes on it. Gene: A gene is structural unit which is responsible for transmission of particular character from parents to offspring. Locus of the gene: Every gene occupies a definite position on the chromosome to which it belongs. This position is called the locus of the gene. The genes of the individual are arranged in pairs. One gene derived from the father and other from the mother. Hereditary defect is caused by failure of cells to synthesize the right proteins (especially enzymes) at the right time. The individual begins its life when the sperm cell from the father penetrates the wall of the ovum, of mother The intricate maturational process called mitosis sets in as a result of the fertilization of the ovum by the sperm The inner core of the ovum, the nucleus breaks up releasing 23 chromosomes these further divides and called genes Genes are the carriers of heredity & these biological instincts are unchangeable Original fertilized ovum divides and subdivides itself until thousands of cells have been produced The cells begin to assume different function forming themselves as a part of different system of the body of the organism. E.g. Nervous, skeletal, muscular
327
Initially the embryo appears like an expanding ball; gradually it takes the shape the head, eyes, trunk arms and legs begins to appear. Characteristics Of Hereditary Transmission: The inherited characteristics are produced from the genes. They pass unchanged from generation to generation Characteristic depends on complex combination of gene pairs. In each individual , these genes are found in pairs When in pair the two genes are different one of them happens to be dominant and other recessive. Although the two genes of a pair control the same character, it is not necessary that their effect be identical. This is so because genes at particular locus may exist in two forms, each having different effect on character concerned. E.g. Genes that control the growth of fingers Genes exist in two forms Normal Abnormal Normal gene responsible for the proper growth of fingers and abnormal gene suppresses the growth. XX XY XX XY XX XY Both genes may be normal. Both genes may be abnormal. One gene may be normal and other abnormal. 1 Both Parents Homozygous: The two genes are alike then the individual is said to be homozygous. The children resembles the parents i.e., the same character children will get. If both the parents homozygous for the abnormal gene both parents and children will manifest the disease. The two genes of the parent are dissimilar and individual is said to be heterozygous. The person having one normal gene and one abnormal gene the off springs will be intermediate between normal and abnormal. Or abnormal gene may dominate over the normal gene and manifest the disease or it may be recessive and carries genes to the next generation. 2. Parents Both Heterozygous: 3. One Parent Is Heterozygous And The Other Is Homozygous: Alleles: Different forms of the gene. Genotype: Genetic contribution is referred to as genotype. Phenotype: Character manifested by genes is phenotype. I.e. physical and physiological characteristics. Mutation: Sometimes diseases appear suddenly in a perfectly normal family. This is because genes undergo physic chemical changes that alter their effect on the character controlled by them such a change is called mutation.
328
Mutation is an alteration of DNA sequence in gene. it may be in small way in alteration of a single base pair or gross. Even the gain or loss of entire chromosome. It may be caused through the action of damaging chemicals or radiation or through the errors inherent in DNA replication and repair reaction. The new gene formed by the mutation occupies the same locus, upon the same chromosome as the original gene. Facts about Mutation: The mutant gene transmitted to future generations just like the original gene. Only the effect changes. Most mutations are harmful but the useful mutations also take place. A reverse mutation from abnormal to normal can also occur. Mutations can occur both in somatic cells and in cells involved in gametogenesis. Somatic mutations produce localized changes in the tissue or organ in which they occur and affect the particular individual only. the changes can not be transmitted to subsequent generations. Somatic mutation may result in malignant growths. The effect of mutations in germ cells is seen in subsequent generations. if the character determined by the mutant gene is dominant , it will be evident in the next generation. if the condition is recessive several generation it may not manifest.. The frequency with which mutations are observed at a particular locus is more or less constant under natural circumstances. Mutation rate increases with increasing age of individuals and exposure to radiations and with the exposure of germ layers to high temperature. When the effect of mutation severe it leads to fetal death or abortion. And if effect is less severe results in numerous congenital malformations. Principles Identifying The Genetic Disorders: Negative family history is misleading. Environmental factors. Genetic heterogeneity. Similar phenotypes are produced due to different disorders. Pleiotrophy. Multiple phenotypes are produced because of similar disorder. Expressivity The effect produced by the gene may vary from individual to individual. Thus a dominant disease may manifest in different patients with varying degrees of severity. His is referred as expressivity. Penetrance A gene may fail to produce any effect the frequency with which the gene produces expected effect is called its pen trance. It varies from gene to gene. Not everything familial is genetic. Establishing patterns if inheritance requires extensive data. Genetic Disorders Classified Into Three Categories: Chromosomal Disorders: Chromosomal disorders are because of abnormality in the structure and function of the chromosome. Present in0.4% of live births. Ex. Trisomy21, Manosomy, Cri-du-chat syndrome. 329
Single Gene Disorders: These are due to single mutant gene. They are also called as Medellin disorders. they have four basic patterns of inheritance Autosomal dominant Autosomal recessive Sex /X linked inheritance Dominant Recessive 2 % of live births are affected by single gene disorders. E.g. Hemophilia, Thalassaemia Multifactorial Inheritence: The disorder is due to interaction of gene and environmental factors such as infectious agents, drugs or ionizing radiations. e. g. diabètes mellites, asthma, hypertension etc. Chromosomal Disorders: Are of two types:Abnormal chromosomal number. Structural abnormalities. The normal chromosomal complement in male is 46XY and in female is 46XX. Any deviation either in number or structure of chromosome is referred to as chromosomal aberration. Diploid: refers to normal chromosomal number in human beings. i.e.2n= 46. Haploid: Refers to n=23, it is found in gametes. Polyploid: Multiple of ‗n‘ i.e. 23 such as triploid= 69, tetraploid= 92 chromosomes these are referred as polyploidy ANEUPLOID: any number which is not the multiple of ‗n‘. I.e.23. Such as 2n+1(47) or 2n-1(45) Genesis of Aneuploidy: Less than or more number of chromosomes It results from non disjunction during meiosis. This causes unequal distribution of chromosomes in daughter cells. Instead of a member of homologous chromosome pair, the pair goes to one daughter cell, and the other daughter cell devoid of this chromosome. When this gamete with abnormal number of chromosome n-1=22 or n+1= 24 combines with another normal gamete, the resultant abnormality is aneuploidy. Like 45X0= Turners syndrome and 47XXY = Klinefelters syndrome may occur In the same manner trisomies of autosomes are also formed E.g.trisomy 21 or Down‘s syndrome. Numerical Abnormalities: Depending upon the type of chromosome Sex Chromosomes: Numerical abnormality in sex chromosome is called Nondisjunction Mosaicism: Numerical abnormality in somatic chromosomes.
330
No disjunction is failure of chromosomes to separate properly. I.e. it leads to an aberrant segregation leads to loss or gain of one or more chromosome. Structural Aberrations: Structural rearrangement in chromosomes essentially results from breaks fallowed by reconstitution. The factors responsible are:Ionizing radiations. Chemical agents. Viruses Structural aberrations are classified as under:1. Stable: délétions, inversion, translocation, iso chromosomes etc. 2. Unstable: décentrai, ring chromosomes. The aberrations that may be transmitted from parent to child include inversions or translocations. STABLE: Deletion: It involves loss of part of a chromosome Terminal deletion. Interstial deletion. Normal chromosome: Terminal deletion: It involves a single break and terminal part of chromosome lost. e. g. Cri du- chat syndrome Cri-du- chat syndrome: this results from deletion of short arm of chromosome. It is called so because the cry of the affected baby mimics the mewing of a cat. Classical features: Typical facial appearance, microcephaly, hypertelorism, antimangloid slant of palpebral fissures, low set ears, micrognathia. Intestinal deletion: It involves two breaks and intervening portion of chromosome lost E.g. Prader will syndrome, wilms tumor etc. TRANSLOCATION: Detachment of the chromosomal segment from its normal location and its attachment to another chromosome. Types: Robertson and translocation / centric fusion Break up at centromere with joining of two acrocentric chromosomes. Reciprocal Tran’s location: There is an exchange of chromosomal material distal to breaks and involves non homologous chromosomes. This accounts to a balanced translocation and no chromosomal material is lost. This leads to production of abnormal gametes present in an unbalanced chromosomal complement , which in turn results in either spontaneous abortion or a baby with congenital malformations. 331
Insertion: It is the rare non reciprocal type of translocation which involves three breaks. A fragment is transferred from a chromosome to a non homologous chromosome. Two breaks release the fragment from one chromosome and one break occurs in another chromosome to admit this fragment. Inversion: Double break in a single chromosome & reinsertion of chromosomal material that has been inverted. There are two types: Pericentric inversion. Paracentric inversion. In pericentric inversion both the arms are involved In paracentric inversion only one arm either the ‗p‘ or ‗q‘ is involved. Isochromosomes: It involves an abnormal split along the centromere leading to separation of arms Unstable: Ring Chromosomes: It involves two breaks at the terminal portion of the chromosome. Fallowed by fusion of cut ends. This is found in about 1/5th of cases of Turners syndrome SINGLE GENE Disorders: These are due to single mutant gene. They have four basic patterns of inheritance. Autosomal dominant Autosomal recessive Sex /X linked inheritance Dominant Recessive Autosomal Dominant Inheritence: A disease inherited by the dominant gene can be recognized by fallowing characteristics: Every diseased person has a parent who manifests the disease. The disease appears in every generation. Unaffected person cannot transmit the disease. When the diseased person marries the normal individual the chances of the children being normal or diseased are equal. The diseased person Ether the homozygote (with both genes abnormal) or a heterozygote. Both parents are homozygous dominant: Both parents are heterozygous: One parent is heterozygote and the other homozygote: Pedigree of Autosomal dominant inheritance: Autosomal Recessive Inheritence: The characteristics of a disease transmitted as a recessive character may be summarized as fallows Diseased individuals generally have parents who are apparently normal More than one brother or sister may be affected The abnormality is more commonly seen in children resulting from marriages between the close relatives. 332
Diseased person who marry normal individuals usually have normal children A diseased person is likely to have affected children if he marries a close relative If two diseased people marry, all their children are affected. Pedigree of Autosomal recessive inheritance: A recessive gene expresses itself only if it is carried by both the chromosomes of the pair concerned. The presence of one recessive gene produces no effect as the other gene is dominant. While a dominant disease can be inherited from one parent, the recessive disease can appear only if both the parents transmit it. Both parents are homozygous recessive One parent is homozygous diseased and other parent is heterozygous(apparently normal carrier) Both parents heterozygous (do not manifest the disease) Disease manifest only if carrier marries another carrier. The reason for this is that in families transmitting the recessive gene the majority of normal persons are likely to be heterozygous rather than normal homozygote. Marrying close relatives means marrying another heterozygote and children may manifest the disorder. So consanguineous marriages should be avoided. ► Affected person (homozygous recessive) marries a normal individual (homozygous dominant) All the children will be carrier & not manifest the disease but transmit it to future generation. E.g. Albinism, deafness, phenyl ketonuria. Intermediate Inheritence: Sometimes a character may not show either the dominant or the recessive inheritance properties in such cases heterozygous are intermediate between two homozygote. Example: Thalassaemia major & Thalassaemia minor A person with two abnormal genes suffers from this disease. A person with one abnormal gene has a much milder anemia called Thalassaemia minor Sickle cell anemia & sickle cell trait In heterozygote (with one normal and one abnormal gene) causes sickle cell trait. i.e., the person has no disability but on testing blood shows a peculiar defect. In homozygote (with two abnormal genes) causes sickle cell anemia that can lead to death in child hood. In persons with anemia all the hemoglobin is abnormal. In person manifest the trait only about 30% of the hemoglobin is abnormal. Both the parents of patient of sickle cell anemia must have sickle cell trait. And marriage of trait person to normal person will produce heterozygote‘s and normal individuals. Sex- Linked Inheritence: Sex chromosomes carry genes responsible for determination of sex. XX -females XY-males Homologous chromosomes: in a single gene disorder an abnormal or mutation is found in one or both the chromosomes if there is a identical allele it is considered homologous. 333
If the alleles are different then it is considered heterogonous. Because males have only one X chromosomes and most of the Gene in Y chromosome do not correspond to X it is considered to be homologous. The human X and Y chromosome are:The greater part of X chromosome (from b to c) is not homologous with Y. thus genes present on this part of X chromosome are not present in Y. in male there will be only one set of genes as no crossing over can occur between this region of X chromosome and Y chromosome, genes present here always move with X chromosome. They are said to be totally linked to the X chromosome Almost all the conditions that are described as sex linked are due to genes on this part of X chromosome. The parts of ‗a to b‘ of X and Y chromosomes are homologous and genes located here are said to be partially sex linked. There is a part of ‗bd‘ of Y chromosome which is not homologous with any part of X chromosome. A gene present on this segment is totally linked to the Y chromosome. But inheritance of character carried by these genes may be apparent only in one sex and not in the other. The male has only one X chromosome. As a result genes carried on it are unpaired and there is no question of the character controlled by gene being dominant or recessive. If gene is abnormal the abnormality will always manifest itself. The female has two X chromosomes. Therefore it may have dominance, recessive or intermediate manifestations just as in characters carried by Autosomal genes. Example:Hemophilia: A male only one gene at this locus. If the gene is normal the person is normal. And if the gene is abnormal he suffers from hemophilia. A female has two genes at the locus. When the both of these are normal the woman neither manifests hemophilia nor transmits it. If one gene abnormal and the other normal she still does not manifest the disease (as the abnormal gene is recessive) but she can pass on the abnormal gene to her children. If both the gene is abnormal she will suffer from hemophilia. Female hemophilic can be produced only if both the parents suffer from the condition. Or if the father is hemophilic and the mother a carrier (heterozygote). So it is very uncommon in female. As father transmits his X chromosome to his daughter and Y chromosomes to his sons an X linked disorder is never transmitted from father to son. Multi Factorial Inheritence: Character is influenced by environmental factors along with the gene abnormality then it is known as multifactorial inheritance. Members of families in which multifactorial inheritance is seen carry several genes that are predisposed to the disorder along with those environmental factors are also precipitate the disorder. E.g. cleft lip. Cleft palate, hypertension, asthma, diabetes mellitus etc. Non – Genetic Biological Variables: Various systems of the body, chemicals secreted by different kinds of glands, and the biochemicals affecting the body system all together make non- genetic variables have got impact on development of embryo. 334
The nature of functioning of different bodily systems and the variety of bio- chemical substances of mother has their impact on growing embryo Amniotic Fluid: Keeps the embryo floating in it and their by protects the embryo from any possible physical shock that the mother may have. Umblical Cord: Joins the section of the uterine wall where the uterus and the chorion join. Umbilical cord is called the life line of embryo Two arteries carry blood from embryo to placenta and one vein from placenta to embryo The nutrient substances sugar, fat, proteins permeate from mother‘s blood into the embryo through the placenta and also insufficient or excessive availability of oxygen (letrolental fibroplasias) Uterine Crowding: Uterine crowding may limit the fetal activity. Abnormal uterine environment due to an abnormal site of implantation due to presence of twins, because of an abnormal position of the fetus within the uterus Environmental Factors: Age Of The Mother: Before the female reproductive organs is not fully matured and hormones needed for reproduction have not reached their optimum levels and above 30 Yrs hormone gradually decreases Mal Nutrition: The developing fetus requires all the elements of nutrition, in adequate quantity, for normal development. In experimental elements deficiencies of vitamins, minerals and certain trace elements, and some of amino acids have been shown to cause anomalies
Infection: Some and disease producing organism (e.g. viruses) or harmful substances produced by them (toxins) can pass through the placental barrier and reach the fetus. Some of the diseases that can reach the fetus in this way are syphilis, measles toxoplasmosis and chicken pox. There is a well known co relation between a disease known as German measles and congenital anomalies. When mother suffer from this disease in early months of pregnancy, the offspring often has cataract, anomalies of heart, or deafness. Antigenic Reactions: The body of every animal contains a large number of proteins. The proteins differ not only from species to species, but even amongst individuals of same species. The body has the ability to recognize any protein which is foreign to it. A foreign protein is often called as antigen. Whenever such protein enters the body substances called antibodies are produced and their function is to destroy the antigen. 335
The protein present in one person may act as antigen when introduced to the other person, whose body does not contain it. One such protein present in blood of most persons is called Rh – antigen. Persons having it are Rh positive and those without it are Rh negative. It is sometimes possible for Rh negative mother to have Rh positive fetus. Some Rh – antigen from the fetus can enter the mother‘s blood. The mother‗s body produces antibodies against antigen. These antibodies pass back into fetal blood where they destroy the blood cells containing the antigen. This breaking-up of blood cells is called haemolysis and the disease is called hemolytic disease of the newborn
336
Drugs And Chemicals: Administration of certain drugs to a mother during the early months of, which produces varying degrees of agenesis of one or more limbs. Some other drugs known to have significant teratogenic effects are aminopterin (a folic acid antagonist); diphenylhydantoinand trimethadione (used for epilepsy); phenothiazine, lithium, meprobamate, chlordiazepoxide and diazepam (which are used as tranquillisers). Even aspirin in large doses and alcohol, can produce anomalies. Every new drug is tested against such teratogenic effects and it is recognized that no drug should be given to a pregnant women unless it is absolutely necessary.
Alcohol & Tobacco, Drug Abuse: If used frequently and heavily it likely to damage the embryonic development. it causes fetal alcohol syndrome, and low birth weight babies
Harmones: Administration of synthetic estrogens and progestins can cause mal formations. Progestin ehisteron and nor ehisteron can cause masculinizationof female genitalia. Fetuses exposed to diethylstilbestrol (a synthetic oestrogen) in intra uterine life, show increased incidence of carcinoma of the vagina and cervix in later life maternal diabetes can cause congenital malformations. 337
► Physical Factors: Physical environmental factors less likely to influence mammalian embryos that grow with in the uterus as compared to those that grow in eggs. Or in water however mammalian embryo is not completely immune to these influences. The greatest danger lies from radiations of various kinds, including X ray and radioactivity. These are capable of producing permanent changes (mutation in nature of genes, especially in germ cells and these in turn can lead to the production of congenital malformations.
Travelling: Traveling should be avoided Socio-Economic Conditions: If the socio economic conditions are not favorable like the quality of care decreases. Mothers will not give importance to balanced diet, lack of utilization of health care facilities, affect the health status of mother and has got negative impact on development of embryo. 338
Environmental Conditions: Sunshine, hygiene, living standard, polluted air and foul smell and other environmental conditions of mother has got impact on development of embryo. Altitude: In altitude places the supply of oxygen will be less and this decreased oxygen supply will affect the growth and development of embryo. Psychological Aspects: Maternal Stress:
Stress – a persistent form of heightened emotionally. Such emotions such as anger, fear, and grief may come from many causes‘ influences on embryonic development. Maternal Attitude: If it is unwanted pregnancy the mother is more likely to upset when it becomes so. Marital conflicts, adjustment problems, cause stress in the mother. The mother with satisfied marital life with +ve attitude regarding pregnancy will help in normal growth and development of embryo and with -ve attitude regarding pregnancy causes psycho somatic reaction. ► Attitude Of Other Family Members: Attitude of other family members is important as it serves as a basis for maternal attitudes. Family bitter experiences cause tension and frustration in the mother. CONCLUSION: Heredity and environmental factors plays an important role in the development of the embryo. So as nurses we need to know importance of these factors to promote the normal growth and development of the embryo. As well as to avoid the exposure to the factors which hinder the growth and development of embryo? 339
BIBLIOGRAPHY: Books: Inderbir singh, G. P .Pal ― Human Embryology‖, 7th edition, Rajiv Beri for Macmillan India Ltd. Pp373-87 Suraj Gupte , A short book of Pediatrics , 9th edition, Lordson Publishers, Delhi Pp 27-29 Jessie M Chellappa, ‗Pediatrics Nursing‘ 1st edition, Gajanana Book Publishers, Bangalore Pp11-12 Elizabeth. B. Hurlock, Child development, 6th edition, Tata McGraw- Hill Publishers, Bangalore Pp 17-21. Grace. J. Craig, Human development, 7th edition, Pp77-82. Journals: Prism’s Nursing practice, ‗journal of clinical nursing education, training, carrier development Birth defects, volume 2, July2007, Pp 137-46. Websites: www.answers.com www.google.com
340
341
342
343
344
345
POTENTIAL ROLE OF MODIFIER GENES INFLUENCING TRANSFORMING GROWTH FACTOR-ß1 LEVELS IN THE DEVELOPMENT OF VASCULAR DEFECTS IN ENDOGLIN HETEROZYGOUS MICE WITH HEREDITARY HEMORRHAGIC TELANGIECTASIA Annie Bourdeau*, Marie E. Faughnan , Merry-Lynn McDonald*, Andrew D. Paterson , Ian R. Wanless and Michelle Letarte* From the Cancer and Blood Program,* The Hospital for Sick Children and Department of Immunology, University of Toronto, Toronto; the Division of Respiratory Medicine, Department of Medicine, St. Michael‘s Hospital, University of Toronto, Toronto; The Centre for Applied Genomics, The Hospital for Sick Children and Department of Public Health Sciences, University of Toronto, Toronto; and the Department of Laboratory Medicine and Pathobiology, University of Toronto Health Network, Toronto, Ontario, Canada Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant disorder because of mutations in the genes coding for endoglin (HHT1) or ALK-1 (HHT2). The disease is associated with haploinsufficiency and a murine model was obtained by engineering mice that express a single Endoglin allele. Of a total of 171 mice that were observed for 1 year, 50 developed clinical signs of HHT. Disease prevalence was high in 129/Ola strain (72%), intermediate in the intercrosses (36%), and low in C57BL/6 backcrosses (7%). Most mice first presented with an ear telangiectasia and/or recurrent external hemorrhage. One-third of mice with HHT showed severe vascular abnormalities such as dilated vessels, hemorrhages, liver and lung congestion, and/or brain and heart ischemia. Disease sequelae included stroke, hydrocephalus, fatal hemorrhage, and congestive heart failure. Thus the murine model reproduces the multiorgan manifestions of the human disease. Levels of circulating latent transforming growth factor (TGF)-ß1 were significantly lower in the 129/Ola than in the C57BL/6 strain. Intercrosses and 129/Ola mice expressing reduced endoglin also showed lower plasma TGF-ß1 levels than control. These data suggest that modifier genes involved in the regulation of TGF-ß1 expression act in combination with a single functional copy of endoglin in the development of HHT.
346
Sexually Transmitted Diseases
YEAST INFECTION PICTURES Below is a collection of pictures of the effects caused by Yeast Infection. Some of these Yeast Infection pictures are highly graphic.
Vitalenz - Help your body Rids itself of unwanted Parasites, Bacteria and Fungi including Yeast Infections AIDS - Bacterial Vaginosis - Chancroid - Chlamydia Gonorrhea Genital Warts - Granuloma - Hepatitis - Herpes - Lymphogranuloma - Molluscum - Pelvic Inflammatory Disease - Pubic Lice - Scabies Syphilis - Trichomoniasis - Urinary Tract Infection - Vaginitis - Yeast Infection
Sexual Health Resource - STD Clinics & Support - Safe Sex - STD Dating Ask your questions on the Sexual Health Discussion Forum
YEAST INFECTION PICTURES Yeast Infection Information | Support
Candidal vulvovaginitis
347
Image Source: http://www.healthac.org/images/yeast.html
348
Yeast Infection Information | Support
AIDS - Bacterial Vaginosis - Chancroid - Chlamydia Gonorrhea Genital Warts - Granuloma - Hepatitis - Herpes - Lymphogranuloma - Molluscum - Pelvic Inflammatory Disease - Pubic Lice - Scabies Syphilis - Trichomoniasis - Urinary Tract Infection - Vaginitis - Yeast Infection
Sexual Health Resource - STD Clinics & Support - Safe Sex - STD Dating Ask your questions on the Sexual Health Discussion Forum
Vitalenz - Help your body Rids itself of unwanted Parasites, Bacteria and Fungi including Yeast Infections
Information and pictures on this site are provided for informational purposes and are not meant to substitute for the advice provided by your own physician or other medical professionals. You should not use the information contained herein for diagnosing or treating a health problem or disease, or prescribing any medication. If you have or suspect that you have a medical problem, promptly contact your health care provider.
Copyright© 2008 - Sexually Transmitted Disease Resource All Rights Reserved Use of content expressly prohibited
349
UNIT-V 350
SYLLABUS Unit
Hours
V
20
Content Bio-Psycho social pathology: �Path physiology and Psychodynamics of disease causation. �Life processes, homeostatic mechanism, biological and psycho-social dynamics in causation of disease, life style. �Common problems: Oxygen insufficiency, fluid and electrolyte imbalance, nutritional problems, hemorrhage] and shock, altered body temperature, unconsciousness, sleep pattern and its disturbances, pain, sensory deprivation. �Treatment aspects: pharmacological and pre- post operative care aspects, �Cardio pulmonary resuscitation. �End of life Care �Infection prevention (including HIV) and standard safety measures, bio-medical waste management. �Role of nurse- Evidence based nursing practice; Best practices. �Innovations in nursing.
351
OXYGEN INSUFFICIENCY Meaning: ―Oxygenation means the delivery of oxygen to the body‘s tissues and cells‖. It is necessary to maintain life and health. Physiology of Oxygenation: Oxygenation results from the co-operative function of 3 major systems: 1. Pulmonary. 2. Hematological. 3. Cardio Vascular System. Anatomy of system involved in oxygenation Process: The main organs involved in process of oxygenation are heart and lungs. As we all know that blood from all the body parts enters to the heart through superior and inferior vena cava to right atrium. During atrial systole the blood in ejected to right ventricle through tricuspid valve. From right ventricle pulmonary artery takes blood to lungs for oxygenation and oxygenated blood returns to left atrium and then ventricle via pulmonary vein. Left ventricle then supplies oxygenated blood to whole body via arteries. Now how Lungs help in oxygenation? For this we need to study anatomy of respiratory system first: Respiratory system is divided into two parts:1) Upper respiratory tract including mouth, nose, pharynx, and larynx. 2) Lower respiratory tract including trachea and lungs along bronchi, bronchioles, alveoli, pulmonary capillary network and pleural membranes. Air enters through nose, where it is warmed humidified and filtered. ↓ Inspired air passes from the nose through the pharynx. ↓ After this air moves to trachea passing through larynx. ↓ Trachea branches into two bronchi supplying right and left lungs. ↓ Through bronchi air enter into lungs and moves through primary bronchi, smaller and smaller bronchi ending with the terminal bronchioles. ↓ Air moves to respiratory bronchioles, alveolar ducts and alveoli, Here alveolar and capillary walls from respiratory membrane where the gas exchange occurs. Lungs are covered by a thin double layer called pleura. The covering which lines the thorax and surface of the diaphragm is called parietal pleura and that lining external surface of lungs is called visceral pleura. Physiology of Respiration: Pulmonary Ventilation: This means movement of air into and out lungs. Its main purpose is to supply fresh air. Ventilation is composed of:352
Inspiration- when air flows into the lungs. Expiration- when air moves out of lungs. Adequate ventilation depends upon: Clear airways. An intact central nervous system and respiratory center. An intact thoracic cavity capable of expanding and contracting. Adequate pulmonary compliance and recoil. Alveolar Gas Exchange: After the alveoli are ventilated the second phase of respiratory process is Diffusion. o Diffusion is movement of gases or other particles from an area of greater pressure or concentration to an area of lower pressure or concentration. o Here oxygen diffuses to pulmonary blood vessels. o Diffusion of gases depends upon pressure differences on both sides. As in inspired air concentration of CO2 is less, So CO2 diffuses from blood vessels to alveoli and eventually it comes out of body through expiration. Oxygen Transport and Delivery: The Oxygen needs to be transported from the lungs to the tissues and CO2 must be transported from tissues back to the lungs. Normally most of the oxygen combines loosely with hemoglobin (oxygen carrying red pigment) in the red blood cells and is carried to tissues as ox hemoglobin. Oxygen transport depends upon many factors. 1. Cardiac Output. 2. Number of erythrocytes and blood hematocrit. 3. Exercise. At Cellular level oxygen diffuses in response to concentration gradient towards the cells whereas carbon dioxide moves out of cells to blood vessels. Regulation of Respiration: Respiration is regulated by two mechanisms:1) Chemical. 2) Neural. The nervous system of the body adjusts the rate of alveolar ventilation to meet the needs of the body so that PO2 and PCO2 remain relatively constant. The control is through ―Respiratory Centre‖ which is actually a number of groups of nerves located in the medulla oblongata and Pons of brain. Chemo sensitive centre in the medulla oblongata is highly sensitive to increase the blood CO2 or H+ ion concentration. Outside the brain the chemoreceptor are also present in the carotid bodies and aortic bodies. Out of all three blood gases (hydrogen, oxygen, and carbon dioxide), increased carbon dioxide concentration normally stimulates respiration most strongly. Causes Of Oxygen Insufficiency Factors Affecting Oxygenation Are: 1. Developmental Factors: At birth, the fluid filled lungs drain first and PCO2 rises. This cause neonate to take first breath. Lungs are gradually expanding till 2 weeks of age. Changes in aging that affect respiratory systems of elders become especially important if the system is compromised by changes such as infection, physical or emotional stress. 353
Moreover in old age increased efforts are required to expend the lungs and also there is reduced alveolar gas exchange. 2. Physiological Factors: Various diseases can exert their effect on oxygenation including disease of respiratory system like COPD, pneumonia, any tumor in respiratory system , airway obstruction etc. Disease which leads to ineffective breathing pattern including Gullein Barre syndrome, myasthenia gravis, scoliosis, hypnosis, chest wall and pleural defects, any major abdominal or thoracic surgery can cause oxygen insufficiency. Disease of cardiovascular systems including anemia, congenital cardiac anomalies can also affect oxygenation. 3. Behavioral Factors: Whenever stress is there both physiologic and psychological responses can effect oxygenation. There may be hyper ventilation, in which PO2 rises and CO2 falls. The person may experience light headedness and numbness and tingling of the fingers, toes and around mouth. On other hand, there is release of epinephrine through sympathetic stimulation. Epinephrine causes the bronchioles to dilate, increases blood flow and oxygen delivery to muscles. Although these are adaptive responses but may become destructive, if continued for a long time. 4. Life Style Factors: Physical activity or exercise increase the rate and depth of respiration and hence supply of oxygen in body. But in sedentary people there is lack of alveolar expansion and essential deep breathing pattern. So these people are less efficient in responding to respiratory stressors. There are some occupational hazards, which can place a person in oxygen insufficiency e.g. silicosis is often seen in sand stone blasters. Smoking also adversely affects one‘s ability to maintain good oxygenation status. 5. Environmental Factors: Altitude, heat, cold and air pollution affect oxygenation. The higher the altitude and lower is the PCO2 a patient breathes. Air pollution can cause stinging of eyes, headache, dizziness, coughing and chocking even in healthy people. 6. Medication: Certain medications including sedatives, hypnotics and ant anxiety drugs (e.g. diazepam, flurazepam, Phenobarbital) and narcotics including morphine can cause respiratory depression. Pathophysiology of Hypoxia: Due to any factors (e.g. above mentioned) there is reduced oxygen in body called Hypoxia.
354
Hypoxia is evident by cyanosis, altered breathing patterns including tachypnea, dyspnea etc, anxious face and fatigue. As we know that adequate oxygenation is essential for cerebral functions. The cerebral cortex can tolerate hypoxia for only 3 to 5 minutes before the permanent damage occurs. Physiological Responses to Reduced Oxygenation: I. Increased Oxygen Extraction- Under normal conditions, the cells of body do not extract all oxygen carried by blood. But in response to oxygen insufficiency cells can extract more oxygen from arterial blood. II. Anaerobic Metabolism: In absence of oxygen for short period, cells can switch to anaerobic metabolism. But keep in mind that: Not all cells are capable of significant anaerobic metabolism (esp. brain cells). Anaerobic metabolism yields less energy per unit of fuel than does aerobic metabolism. Accumulation of acid by products and cell death. CO2 Transport and Excretion: When CO2 combines with water, it produces carbonic acid & H+ ions. Stimulate respiratory centers. Increase in rate, depth of breath. Tachypnea in order to bring back pH levels. Because of hypoxia, there will be rise in carbonic acid levels leading to respiratory acidosis. But sometimes in response to hypoxia hyperventilation may occur. Nursing Management: Assessment: I. Nursing Health History: In include exploration of present problem, any past respiratory disease, cough, pain, characteristics of cough and sputum, lifestyle & medication used for breathing. Table: Presenting Problems Qualifiers Cough
Onset: sudden or gradual, how long ago Nature: dry, moist, barking, hacking, productive, non productive Pattern: continuous, occasional, related to time of day, position or activity, weather severity Associated symptoms: pain, shortness of breath, wheezing. Alleviating factors: vaporizers, OTC medications.
355
Sputum Shortness of Breath
Amount, color, odor Presence of blood in sputum Onset: sudden or gradual Nature: precipitated by chocking or gagging Pattern: Associated with activity or position, continuous or intermittent. Associated symptoms: pain, cough, diaphoresis Alleviating factors Location/radiation Nature: stabbing, dull, aching, burning, squeezing, crushing Associated symptoms: dizziness, nausea, diaphoresis, palpitations Aggravating factors Alleviating factors
Physical Examination: a) Inspection: It includes noting of client‘s efforts at ventilation, especially anxious or distressed appearance, flaring of nostrils, position preferences and general best configuration. Perfusion deficits resulting in cyanosis because of poor circulation & edema. Changes in level of consciousness, confusion, agitation, stupor or coma indicate ischemia of neuronal cells because of oxygen deprivation. Hypoxia can be evident from clubbing of the fingers (flattened angle of the nail bed and a rounding finger tip). b) Palpation: It will reveal vocal fermatas and displacement of trachea. Perfusion deficits are noted by changes in pulse rate or character, clammy skin and ulcer in lower extremities. c) Percussion: It may reveal hyper resonance, dull percussion tone or changes in the density of lungs and surrounding tissues. Diagnostic Studies: PFT (Pulmonary Function Test):These are used to assess the respiratory function and to determine the extent of dysfunction. These are used to find:o Volume of air in the lungs at various phases of the ventilator cycle. o Speed and ease of airflow through the airways. o Strength of respiratory muscle.
356
Procedure: It is performed by technician using a spirometer that has a volume collecting device attached to a recorder that demonstrates volume and time simultaneously. Nurses Responsibility for PFT: Nurse should explain whole procedure to client in order to win his cooperation, which is very necessary to perform this procedure, because these tests are very tiring. So nurse should arrange, so that patient can take rest properly. ABG (Arterial Blood Gas Analysis): ABG helps in measurement of blood for patient‘s arterial oxygen and carbon dioxide tensions. PaO2 indicates the degree of oxygenation of blood. Pa CO2 indicates alveolar ventilation. Elevated levels of CO2 indicate inadequate alveolar ventilation. Procedure and Nurses Role: The sample of arterial blood is generally taken from radial, brachial or femoral artery, and then is sent for analysis. Nurses should obtain or assist the physician in drawing sample, labeling and transportation of sample to laboratory. After obtaining findings nurse should analyze the results and should use it to monitor and care for patient. Measurement Normal Arterial Values Clinical Significance pH 7.35-7.45 Indicates acid-base balance PCO2 35-45 mm of Hg Partial pressure of CO2, indicates adequacy of alveolar ventilation, represents respiratory component of acid-base balance. HCO3 22-26 mEq/l Bicarbonate level; indicates metabolic component of acid-base balance PaO2 80-100 mm of Hg Partial pressure of oxygen; represents oxygen dissolved in plasma SO2 96%-98% Saturation of hemoglobin with oxygen Sputum Studies: Sputum is obtained for analysis to identify pathogenic organisms and to determine malignancy or hypersensitivity which in turn is helpful to determine causes of oxygen insufficiency. The sputum may also be collected through endotracheal aspiration, bronchoscopic removal etc. The deepest specimens (those from the base of lungs) are obtained in early morning. In laboratory the specimen is tested for presence of micro-organisms e.g. mycobacterium tubercle. 357
Chest X-rays & CT: To assess fluids, tumors, foreign bodies and other pathologic conditions. Bronchoscopes: Bronchoscopes are direct inspection and examination of the larynx, trachea and bronchi through either a flexible fibrotic bronchoscope or a rigid bronchoscope. Therapeutic bronchoscopes are used to: 1. Remove foreign bodies from trachea bronchial tree. 2. Remove secretions obstructing the trachea esophageal tree which cannot be cleared by patient itself. 3. To destroy and excise tumors. Nurses Role: 1. Obtain informed written consent. 2. Withheld foods and fluids 6 hr prior to bronchoscopes. 3. Explanation of procedure to the patient and administration of preoperative medications (e.g. atropine) to inhibit vigil stimulation, suppress cough reflex, sedate the patient and relieve the anxiety. 4. Dentures must be removed. 5. Instruct the patient to take nothing by mouth till the cough reflexes returns after the procedure. 6. Assess the confusion and lethargy in patient because of an aesthesia. 7. Instruct family and caregivers to report any shortness of breath or bleeding immediately. Thoracentesis: A sample of pleural fluid is obtained by thoracentesis for both diagnostic and therapeutic purposes. By thoracentesis, pleural fluid is studies fir Gram‘s stain culture and sensitivity, acid-fast staining and culture, differential cell count, cytology, pH, specific gravity, total protein and lactic dehydrogenize. Nurses Role: 1. Assess the patient for allergy to local anesthetic. 2. Position the patient comfortably with adequate supports. 3. Support and reassure the patient during procedure. 4. Encourage the patient to refrain from coughing. 5. Record the total amount to fluid obtained during thoracentesis and sends it to laboratory for evaluation. Also record nature of fluid, color and its viscosity. 6. Monitor respiratory status of patient afterwards. Haematocrit and Hemoglobin are also measured in order to assess effectiveness of body‘s oxygen delivery to the tissues. Pulmonary Angiography: Pulmonary Angiography is most commonly used to investigate thrombotic disease of lungs, such as pulmonary emboli and abnormalities of vascular tree. Procedure: It involves the rapid injection of a radio opaque agent into the vasculature of the lungs for radiographic study of the pulmonary vessels through femoral vein, or branches of pulmonary artery and images are taken and analyzed. 358
Nursing Management Of Client With Oxygen Insufficiency: As mentioned above nursing assessment of the client is made from nursing history, physical assessment and results of diagnostic examination. Prioritize the problems on the basis of: A- Airway. B- Breathing. C- Circulation. Management of a client with oxygen insufficiency depends upon the underlying cause and manifestation. Following are the possible nursing diagnosis:1. Ineffective Airway Clearence: May be related to:Obstruction of airway by the tongue. Upper airway obstruction caused by edema of larynx or glottis. Obstruction of the trachea or a bronchus by foreign body aspiration. Partial occlusion of the bronchi and bronchioles by infection (bronchitis, bronchiolitis) or occlusion or compression by a tumor mass. Occlusion of the more distal airways by the changes associated with emphysema. Manifested by:Feeling shortness of breath or suffocation (air hunger) Use of accessory muscles. Difficulty in speaking. Cough Arles and Bronchi may have heard on auscultation. Diminished breath sounds over the peripheral lung fields (because of poor aeration) Complete obstruction of airway will result in loss of breath sound over the affected lung segments. Goal: To maintain a patent airway. Nursing Interventions: 1) Teach effective coughing to the client. a. Teach effective coughing to the client, preceded by series of slow, deep breath, one technique that may be useful is huffing(delivering a series of short, forceful exhalation, prior to actual coughing) This will help to raise the sputum to the level where it can be coughed out. b. Assess the sputum produced by coughing, noting the amount, color and odor. Special Considerations:1. In case of clients recovering from thoracic or abdominal surgery, splinting the incision by holding a pillow firmly against it will reduce the pain caused by coughing. 2. Client becomes fatigued after coughing and need a rest period. So offer oral care after sputum has been expectorated. 2) Initiate postural drainage and chest physiotherapy because it promotes drainage of secretions from lungs. Special considerations:1. Inhalation treatments containing bronchodilators or mucolytic drugs before postural drainage and chest physiotherapy. 359
2. Take Comfort of client into consideration. 3. Give pain medication accordingly in order to achieve maximum effect at time of procedure. 4. Some patients may not be able to tolerate certain positions e.g. patients with congestive heart failure or increased ICP will not be able to tolerate a head down position. 3) Monitor hydration status of the client as it will help in thinning of pulmonary secretions (helpful in case of pneumonia, bronchitis and asthma). Special Consideration:1. Clients experiencing CHF on the other hand, may require limitation of fluid intake to reduce pulmonary congestion due to fluid overload. 2. Need for humidification of inspired oxygen. 3. There is increased insensible fluid loss because of tachypnea / supplemental oxygen which is not adequately humidified or with artificial airways because these may lead to drying and inflammation of the respiratory mucosa. 4) Administer Medications: Drug Type Common Examples Actions Mucolytic/ Expectorant Mucomyst Thins respiratory ( Acetylcystiene) secretions by increasing the amount of fluid produced. Methylxanthiene Aminophylline, Dilates bronchi Theophylline Increases ciliary movement Beta-adrenergic Epinephrine Causes bronchial smooth sympathomimetic Isoproterenol muscle relaxation(dilates Albuterol bronchi) Terbutaline Mast cell stabilizer Cromolyn Sodium Prevents histamine release from mast cells Corticosteroid Beclometasone Anti-inflammatory action Prednisone Prednisolone Hydrocortisone 5) Monitor environment & life style conditions helpful as in case of Asthma because there may be dramatic improvement if allergens are identified and removed. e.g. Smoking Cessation. 6) Introduce artificial airways in case where obstruction cannot be removed by conservative means or who require mechanical support. These include:1. Nasal Airways: To keep upper airways open. It helps in nasal tracheal suctioning while minimizing trauma to nasal mucosa.
360
2. Oral Airways: Prevent tongue fall(not well tolerated in conscious individuals, because they may gag and vomit).E.T tube bypass the upper airway structures altogether via nose or mouth and are passed beyond the vocal cords into the trachea. Special Consideration:i. Humidification. ii. Infection. iii. Because both the tubes prevent movement through vocal cords. Speech is restricted. So use alternative methods of communication and prevent anxiety to patient. iv. Suctioning- Especially in ET and T tubes because coughing is impaired. 2. Ineffective Breathing Pattern: Which may be related to:Restrictive pulmonary disease or central nervous system disorder or thoracic surgery. Any major abdominal or thoracic surgery or restricted mobility. Neuromuscular disease that can weaken respiratory muscles e.g. Gullein- Barre disease and myasthenia gravis. Abnormal curvatures like alternations of spine (sclerosis, kyphosis, chest wall injuries and pleural defects). Goal: To promote lung expansion. Nursing Interventions: 1. Proper Positioning Fowler‘s positioning by supporting the client with elevation of the head of the bed or with pillows can reduce workload on heart and minimize fatigue. 2. Teach controlled breathing pattern Pursed Lip Breathing This technique involves forced exhalation against pursed (partially closed) lips in order to maintain positive pressure in lungs during the expiratory phase and prevents collapse of smaller airways and reduces the amount of air trapped. Deep Breathing and Abdominal Breathing Motivate the patient to use abdominal muscles to pull the diaphragm downwards. Apical & Basal Expansion Exercises Direct the client to focus on achieving maximum expansion of the upper lung lobes (apices) and lower lobes (bases). Incentive Spirometry This is the technique used to encourage deep breathing. Client draws air through the spirometer device, which measure the volume of air displaced by moving a float ball or similar device up a column. IPPV This machine delivers a volume of air under pressure through mouthpiece, when the client draws air through the mouthpiece. 3. Introduce Chest Drainage System: Improve breathing pattern by removing accumulations of air and/ or fluid from the pleural space, permitting the lungs to return to normal expansion. 4. Impaired Gas Exchange: May be related to:-
361
Ventilation perfusion mismatch Overall decrease in the amount of alveolar capillary surface area available for gas exchange in case of emphysema. Widespread shunting as with atelectasis. - Manifested by altered finings on ABG or Pulse Oximetery. Goal: Maintain and promote tissue oxygenation. Nursing Interventions: i. Administer oxygen to the client. Special Consideration a. Give low oxygen flow in clients who have chronic pulmonary disease associated with CO2 retention, because excessive O2 may obliterate the hypoxic drive resulting in apnea. b. O2 toxicity- prolonged administration of high O2 (greater than 50% for more than 24 hrs) may damage lung tissue and produce severe respiratory difficulties. ii. Administer blood components if the client‘s oxygenation is impaired because of decreased circulating volume, decreased hemoglobin concentration in the blood or hemorrhage. 5. Decreased Cardiac Output: May be related to:CHF causing pulmonary edema, heart failure or shock. Manifested by; low pressure, cool clammy skin, weak thread pulse, low urine output and a diminishing level of consciousness, crackles in case of pulmonary edema, pink frothy sputum. Goal: To maintain a normal cardiac output. Nursing Interventions: 1) Manage fluid balance by Limited sodium and reduced fluid intake in case of congestive heart failure. Give diuretics. Maintaining daily weigh and intake output. Monitoring electrolyte balance for diuretics. 2) Activity restrictions and assistance with activities of Daily Living in order to decrease oxygen demand on body. Set an activity schedule within tolerance limits of a patient and gradually increasing it. 3) Proper positioning preferably sitting or semi-sitting in order to decrease fluid load to heart and pulmonary edema. Administer medication- Medications to improve cardiac output including cardiac glycosides and other isotropic agents. Anti hypertensive, nitrates and vasodilator may be given to increase cardiac oxygen supply and or reduce the myocardial oxygen demand. 4) Emergency Interventions Complete airway obstruction, cardiac arrest and respiratory emergencies may result in death. In this case: -Remove airway obstruction. -Perform Heimlich maneuver. 362
-If unrelieved cardiopulmonary resuscitation may need to be initiated. 6. Associated Nursing Diagnosis Activity intolerance r/t dyspnea and hypoxia manifested by fatigue. Interventions related to lifestyle and activity has three purposes: To minimize energy and oxygen consumption. To reduces factors that contribute to disease process. To systematically increase activity tolerance. - For this provide assistance in daily living activities. - Encourage family members to cope with changing roles. - Plan the activity schedule with rest periods in between. Altered nutrition related to dyspnoea and cough. In case of CV disease reduces sodium intake and fat. Encourage patient to take small feeds. Food should be served in attractive manner. Discomfort related to ischemia manifested by pain. Remove or modify cause of pain. Rest the affected tissue. Improve delivery of oxygen to painful area. Oxygen Administration To A Client With Oxygen Insufficiency: Need of Oxygen Administration: Clients who have difficulty in ventilating all areas of their lungs, those whose gas exchange is impaired or people with heart failures may require oxygen therapy to prevent hypoxia. Methods of Oxygen Delivery:1. Nasal Cannula: It is the most common inexpensive method used to administer oxygen to client. It delivers a relatively low concentration of oxygen (24% to 45%) at flow rate of 26L/min. But this is not in use these days. Now a day‘s nasal prongs are used. 2. Face Mask: a) The simple face mask delivers oxygen concentrations from 40% to 60% at liter flow of 5 to 8L/min respectively. b) The partial retreater mask delivers oxygen concentrations of 60% to 90% at liter flow of 6 to 10L/min, respectively. In re breather mask the oxygen reservoir bag that is attached allows the client to re breath about first third of the exhaled air in conjunction with oxygen. Thus it increases FiO2 by recycling expired oxygen. 3. Non Breather Mask: It delivers the highest oxygen concentration possible 95% to 100% by means other than intubations or mechanical ventilation, at liter flow of 10 to 15L/min. 4. Venture Mask: It delivers oxygen concentration varying from 24% to 40% or 50% at flow rate of 4 to 5 L/min. The venture mask has wide bore tubing and color coded jet adaptors that correspond to a precise oxygen concentration and liter flow. 363
-Nurse should take care while selecting the mask as it should fit to the face of patient snuggly. 5. Trans tracheal Oxygen Delivery: This is used for oxygen dependent clients. Oxygen is delivered through a small, narrow plastic cannula surgically inserted through the skin directly into trachea. A collar around the neck holds the catheter in place. Advantage: With the method client requires less oxygen (0.5 to 2L/min) as all of flow is delivered to lungs directly. Special Consideration: The nurse keeps the catheter patent by injection 1.5 ml of normal saline with it, moving a cleaning rod in and out and then re-injecting, 5ml of saline twice or thrice a day. 6. Face Tents: Face tents can be used in clients who cannot tolerate masks. These provide 30% to 50% O2 concentration at a flow rate of 4 to 8L/min. Special Consideration:Nurse should frequently assess the client‘s facial skin for dampness or dryness. Methods Used In Case Of Pediatrics: In Case of Infants: Oxygen Hood: It is a rigid plastic dome that encloses on infant‘s head. It provides precise oxygen levels and high humidity. Special Consideration The gas should not be allowed to blow directly into the infant‘s face and hood should not rub against the infant‘s face, neck, chin or shoulder. In Case of Children: Oxygen Tent: It is made up of rectangular, clear, plastic canopy with outlets that connect to an oxygen source. Flow rate is adjusted at 10 to 15 L/min after flooding the tent for 5 minutes. At a rate of 15L/minuets. Special Consideration:Cover the child with gown or blanket and prevent dampness. Ambu Bag This concept was developed in 1953 by a German Engineer Dr. Holger Heve and his partner Danish anesthetist Henning Ruben in 1956. Ambu bag is a hand held device used to provide ventilation to a patient who is not breathing or breathing inadequately. The device is self filling with air, although additional oxygen can be added. - Squeezing the bag once every 5 seconds for an adult or once every 3 seconds for an infant or child provides an adequate respiratory rate. - Oxygen can also be delivered by inserting artificial airways like endotracheal tube etc. Nursing Responsibility for Administration of Oxygen: i.Check the name, bed number and other identification data of patient. ii.Confirm diagnosis and the need of oxygen therapy. iii.Assess the patient for any sign of clinical anoxia e.g. cyanosis and also assess the breathing pattern. 364
iv.Monitor for results of ABG. v.Since oxygen is a drug, so it should be monitored for toxicity. vi.Check that the oxygen is properly humidified. vii.Every precaution should be taken to prevent entry of infection to patient. viii.Discontinue oxygen therapy gradually. The patient is weaned from dependence on oxygen by reducing the dosage and administering it intermittently. ix.Place a calling signal near the patient in case if nurse is not near him. x.Pay attention to kinks in tubing, loose connection and faulty humidifying apparatus as it may interfere with flow of oxygen. xi.For fear of Retrolental Fibroplasias, give O2 to new born babies for a short period at very low concentration. xii.Since oxygen supports combustion, fire precautions are to be taken when oxygen is on flow. Give proper instructions to the relatives of client regarding this. Hazards of Oxygen Inhalation: 1. Infection: It may occur because of use of contaminated equipment. 2. Combustion: As oxygen supports combustion so fire is a potential hazard when oxygen is administered. 3. Drying of mucus membrane of the respiratory tract: If oxygen is administered without sufficient humidity, it causes drying and irritation of mucus membrane. 4. Oxygen toxicity: Symptoms of oxygen toxicity initially include those of a mild trachea bronchitis starting as a tracheal irritation and cough proceeded by dryness and irritation of mucus membrane, substernal pain, nausea, vomiting and formation of a membrane similar to hyaline membrane on the alveolar valve, which causes dysponea. 5. Atelectiasis: Increased oxygen concentration in inspired air leads to depletion of Nitrogen (as nitrogen helps to keep alveoli expanded). So atelectiasis may occur. 6. Oxygen induced Apnoea: Since carbon dioxide is washed off completely from the blood by high concentration of oxygen, the respiratory centre is not stimulated sufficiently which leads to cessation of respiration. 7. Retrolental Fibroplasias: Oxygen therapy may affect the eyes especially in infants. In infants very high conc. Of oxygen will develop fibrotic changes behind lens which impairs light penetration to retina. 8. Damage may also occur in adults leading to ulceration, edema and visual impairment. 9. Asphyxia: It may occur because of unexpected and unobserved depletion of oxygen in oxygen cylinders in case of patients getting oxygen by masks and closed tents. Mechanical Ventilation to a Patient with Oxygen Insufficiency: In case of oxygenation failure mechanical ventilation is used to restore and maintain lung volumes. Inspiration/ ventilation is usually supported to reduce oxygen requirements and increase patient comforts. Mechanical Ventilation: It is a positive or negative pressure breathing device that can maintain ventilation and oxygen delivery for a prolonged period. Indications: Continuous decrease in PaO2. Increase in arterial CO2 levels. Persistent acidosis. 365
Mechanical ventilator may be required in conditions such as thoracic or abdominal surgery, drug overdose, neuromuscular disorders, inhalation injury, COPD, multiple trauma, shock, multisystem failure, and coma because all these can lead to respiratory failure. A patient with apnea, which is not readily reversible, is also a candidate for mechanical ventilation. Types: 1. Negative Pressure Ventilation: This exerts negative pressure on the external chest; which in turn decrease intra-thoracic pressure during inspiration and allows the air to flow to lungs, filling its volumes. These are mainly used in case of clients with neuron-muscular conditions. Advantage: - Easy to use and do not require intubation. Disadvantage: - Unsuitable for patients who require frequent ventilator changes. 2. Positive Pressure Ventilation: These inflate the lungs by exerting pressure on the airways, forcing the alveoli to expand during inspiration. Expiration occurs passively which further includes time cycled ventilators, pressure cycled ventilators and volume cycled ventilators. Modes: CMV: - means conventional controlled ventilation, without allowances for spontaneous breathing. Assist Control: - where assisted breaths are facsimiles of controlled breaths. Intermittent Mandatory Ventilation: - which mixes controlled breaths and spontaneous breaths. Pressure Support: - where the patient has control over all aspects of his/her breathes except the pressure limit. High Frequency Ventilation:- where mean airway pressure is maintained constant and hundreds of tiny breaths are delivered/ minute. Nursing Care of Patient on Ventilator: i.Nurse should be except in pulmonary auscultation and interpretation of ABG analysis. ii.Nurse should administer analgesic agents judiciously to prevent suppression of respiratory drive. iii.Chest physiotherapy, frequent position changes and suctioning should be done frequently as positive pressure ventilation increases the production of secretions. iv.Humidification of airway via ventilator should be maintained. v.Administer bronchodilators to dilate the constricted bronchial tree. vi.Nurse should maintain every aseptic technique to prevent infection. vii.Encourage the patient for range of motion exercise every 6 to 8 hrs in order to improve mobility.
366
BIBLIOGRAPHY: Harison‘s ―Principles of Internal Medicine‖ Ed. 16th, Published by McGraw Hills Publishers, pp. 1495-1480. Kozier Barbaro, Glenora Erb, Audary Berman, Karen Burbe‘s ―Fundamentals of Nursing‖ Ed. 7th , Published by Darling Kindereley(India) Pvt. Ltd, pp. 1329-1368. Lewis, hutikemper, Dirkish ―Medical Surgical Nursing‖ Ed 6th, Published by Mosby‘s Publishers, pp. 545- 548, 667. Potter A Patrica, Anne Griffin Perry‘s ―Fundamentals of Nursing‖ Ed. 6th, Published by Elsevier India Private Limited, pp. 1066-1133. Saunder‘s Manual of Nursing Practice, Ed. 1st, Published by W.B Saunder Company, pp. 520, 963, 964. Smeltzer C. Suzzane & Brenda G. Bare‘s ―Medical Surgical Nursing‖ Ed 10 th, Published by Lippincott Williams and Wilkins, pp. 463- 488. Sr. Nancy ―Stephanie‘s Principles and Practice of Nursing‖ Ed. 4th, Published by N.R Brothers, pp. 163-175, 237-247. www.pubmed.com www.googlesearch.com
367
FLUID AND ELECTROLYTE IMBALANCE Introduction: “Our body consists of two type of fluid intracellular and extra cellular fluid. These fluids help to maintain our body‟s homeostasis. This is nothing but balance of fluid electrolyte or acid base balance of our body”. The body is contains lots of fluid and electrolytes which are the transporters and catalysts as well as solvents and solution for various reactions in our body. There is a required limit for every fluid type and electrolyte in our body, an increase or a decrease in the total or in dependent volume or concentration will result in the abnormalities contributing to systemic results. This seminar deals with such abnormalities. Central Objective: After the completion of the session the group will be able to gain knowledge about the fluid and electrolyte balance and inbalances in the body and will be able to appreciate the nursing practice in maintaining the body fluid. Specific Objectives: Define the various terminologies. Explain the mechanism of regulation of body fluid in various compartments. Explain fluid imbalances in various compartments Describe the factors influencing electrolyte balance. Specify the electrolyte imbalances. Definition and terminology: Homeostatic: The ability or tendency of an organism or cell to maintain internal equilibrium by adjusting its physiological processes. An abnormal increase in the acidity of the body's fluids, caused either by accumulation of acids or by depletion of bicarbonates. Hydrostatic Pressure: it is pertaining to the liquid in the state of equilibrium or the pressure exerted by a stationary fluid. Osmosis: a. Diffusion of fluid through a semi permeable membrane from a solution with a low solute concentration to a solution with a higher solute concentration until there is an equal concentration of fluid on both sides of the membrane. b. The tendency of fluids to diffuse in such a manner. 2. A gradual, often unconscious process of assimilation or absorption: learned French by osmosis while residing in Paris for 15 years. Osmolarity: The concentration of a solution in terms of osmoles of solutes per liter of solution. Diffusion: The process by which solutes move from an area of higher concentration to one of the lower concentration, without any expending extra energy. Isotonic: A solution with the same osmolality as serum and other body fluid. Osmolality: The number of osmoses (standard unit of osmotic pressure) per kilogram of solution. Hypotonic Solution: A solution with an osmolality lower than that of the serum. Hypertonic Solution: A solution with an osmolatiy higher than that of the serum. 368
Active Transport: The physiologic pump that moves fluid from an area of lower concentration to one of higher concentration; active transport requires ATP (adenosine triphosphate) for energy. Filtration: Passage through a filter or through a material that prevents passage of certain molecules, e.g. capillary wall, blood–brain barrier, radiographic grid. Body Fluids: The total body water in adults of average built is about 60 % of body weight. This proportion is higher in young people and in adults below average weight. It is lower in the elderly and in obesity in all Age groups. Fluid Compartments: Body water is located in two major fluid compartments the intra cellular fluid (ICF) compartment and the extra cellular fluid (ECF) compartment. Extra cellular: The ECF is composed of interstitial fluid (tissues) and the intra vascular fluid (plasma) interstitial fluid lies outside the vascular fluid and cells and comprises 28 % of total body water. It provides the cells with the external medium necessary for cellular metabolism. in the adult, approximately 60 % of body weight is water, two thirds of the water is intracellular and one third of water is extra cellular fluid. The extra cellular fluid consist of blood, plasma, lymph. Cerebrospinal fluid and fluid in the interstitial spaces of the body. Intracellular fluid: The ICF provides the cell with the internal aqueous medium necessary for its chemical functions. The composition if ICF therefore very different from ECF. Thus sodium levels are nearly ten times higher in the ECF than in the ICF this concentration gradient is essential for the function of excitable cells (mainly nerve and muscle). Many substances are found inside the cell in significantly higher amounts than outside E.g.: ATP, Protein and Potassium. Regulars of Fluid balance: Thirst, hormones, the lymphatic system, the nervous system and the kidneys assist the regulation of body fluids. Thirst: The thirst centre is located in the hypothalamus and is activated by an increase in ECF Osmolality (concentration). Thirst may result from hypotension, polyuria or fluid volume depletion. Physiological Components of Thirst Thirst is often viewed by physiologists and physicians as a central nervous system mechanism that regulates the body's water and minerals. The significance of the thirst drive is emphasized by three facts: 50 to 70 percent of adult body weight is water, the average adult ingests and loses 2.5 liters of water each day, and body weight is regulated within 0.2 percent from one day to the next. Clearly, water is essential to life and the body responds in a manner that ensures survival. In 1954, Edward Adolph and colleagues proposed a multiple-factor theory of thirst that has not been refuted to date. This theory states that no single mechanism can account for all drinking behavior and that multiple mechanisms, sometimes with identical functions, act concurrently. Because water is essential to life, the existence of redundant mechanisms has great survival value. Among these, thirst appears to be regulated 369
primarily by evaluation of changes in the concentration of extracellular fluid, measured as the osmolality of blood plasma. (Osmolality is a measurement that describes the concentration of all dissolved solids in a solution, that is, dissolved substances per unit of solvent. In research and clinical laboratories, the unit for osmolality of blood is mOsm/kg or milliosmoles per kilogram of water.) Below a certain threshold level of plasma osmolality, thirst is absent. Above this threshold, a strong desire to drink appears in response to an increase of 2 to 3 percent in the level of dissolved substances in blood. The brain's thirst center lies deep within the brain, in an area known as the hypothalamus. This anatomical site contains cells that respond to changes in the concentration of body fluids. When the thirst center is stimulated by an increased concentration of blood (that is, dehydration), thirst and fluid consumption increase. As the brain senses the concentration of blood, it allows a minor loss of body water before stimulating the drive to drink. This phenomenon has been named voluntary dehydration. Specifically, several research studies since the 1930s have observed that adults and children replace only 34 to 87 percent of the water lost as sweat, by drinking during exercise or labour in hot environments. The resulting dehydration is due to the fact that thirst is not perceived until a 1 to 2 percent body weight loss occurs. Inter-individual differences, resulting in great voluntary dehydration in some individuals, have caused them to be named reluctant drinkers. Reduced extracellular fluid volume, including blood volume, also increases thirst. Experiments (for example, reducing blood volume without altering blood concentration) have demonstrated that volume-sensitive receptors in the heart and blood vessels likely regulate drinking behavior by increasing the secretion of hormones. This effect is relatively minor, however. Animal research suggests that a change in extracellular fluid concentration accounts for most (for example, 70 percent) of the increased fluid consumption that follows moderate whole-body dehydration, whereas a decrease of fluid volume per se plays a secondary role. Thus, thirst is extinguished when body fluid concentration decreases and fluid volume increases. Osmolality-sensitive nerves in the mouth, throat, and stomach also play a role in abating thirst. As fluid passes through the mouth and upper gastrointestinal tract, the sense of dryness decreases. When this fluid fills the stomach, stretch receptors sense an increase in gastric fullness and the thirst drive diminishes. As dehydration causes the body's extracellular fluid to become more concentrated, the fluid inside cells moves outward, resulting in intracellular dehydration and cell shrinkage, and the hormone arginine vasopressin (AVP, also known as the ant diuretic hormone) is released from the brain. AVP serves two purposes: to reduce urine output at the kidneys and to enhance thirst; both serve to restore normal fluid balance. Other hormones influence fluid-mineral balance directly and thirst indirectly. Renin, angiotensin II, and aldosterone are noteworthy examples. As dehydration reduces circulating blood volume, blood pressure decreases and renin is secreted from blood vessels inside the kidneys. Renin activates the hormone angiotensin II, which subsequently stimulates the release of aldosterone from the adrenal glands. Both angiotensin II and aldosterone increase blood pressure and enhance the retention of sodium and water; these effects indirectly reduce the intensity of thirst. Angiotensin II also affects thirst directly. When injected into 370
sensitive areas of the brain, it causes a rapid increase in water consumption that is followed by a slower increase in sodium chloride consumption and water retention by the kidneys. Food & Culture Encyclopaedia: Thirst is a conscious sensation that results in a desire to drink. Although all normal humans experience thirst, science can offer no precise definition of this phenomenon because it involves numerous physiological responses to a change in internal fluid status, complex patterns of central nervous system function, and psychological motivation. Three factors are typically recognized as components of thirst: a body water deficit, brain integration of central and peripheral nerve messages relating to the need for water, and an urge to drink. In laboratory experiments, thirst is measured empirically with subjective perceptual scales (for example, ranging from "not thirsty at all" to "very, very thirsty") and drinking behavior is quantified by observing the timing and volume of fluid consumed. Psychologists classify thirst as a drive, a basic compelling urge that motivates action. Other human drives involve a lack of nutrients (for example, glucose, sodium), oxygen, or sleep; these are satiated by eating, breathing, and sleeping. Clark Hull published a major, relevant theory describing the nature of human drives in 1943. He observed that learned habits, in addition to the thirst drive, influence drinking strongly. If a behavior reduces thirst, that behavior is reinforced and learned as a habit. Irrelevant behaviors (for example, sneezing, grooming) provide no reinforcement, have no effect on drinking, and do not become habits. Further, Hull realized that external incentives, such as the qualities or quantity of a fluid, also influence fluid consumption. On a hot summer day, for example, a cold beverage is more attractive than a cup of hot tea. Yet when chilled to a very low temperature, a cold beverage becomes an aversive stimulus to drinking behavior. Physiologists have popularized the term alliesthesia (from Greek root words referring to altered sensation) to describe the fact that the sensation of thirst may have either pleasant or unpleasant qualities, depending on the intensity of the stimulus and the state of the person. Numerous investigations have verified that thirst and drinking behavior are complex entities. For example, drinking behavior (that is, the timing and the amount of fluid consumed) is not linearly related to the intensity of perceived thirst. Nor should we infer that individuals experience thirst simply because they drink. These facts indicate that thirst and drinking behavior are distinct entities that influence each other and are influenced by numerous internal and external factors. Hormonal influences: The anti diuretic harmone and aldosterone are the two major harmones that influence fluid balance. ADH promotes water reabsorption from the renal tubules. Stimulation of the thirst mechanism and ADH release usually occur concurrently in response to body fluid deficit. Aldesterone is secreted by the adrenal cortex and promotes sodium reabsorption and potassium excretion from the kidneys. Aldosteron secretion is stimulated primarily by the rennin – angiotensin system. Aldosteron is stimulated by an increase in potassium or a decrease in sodium concentration in interstitial fluids and by the release of 371
adrenocorticotropic harmone from anterior pituitary gland. Hypovolemia is a common clinical condition in which aldosterone is secreted to maintain homeostasis. Lymphatic system: Plasma Protein and fluid that escapes from the tissue spaces cannot be directly reabsorbed into the blood vessels. The lymphatic system plays an important role in returning Excess fluid and protein from the interstitial spaces to the blood. Kidneys: The kidneys maintain fluid volume and the concentration of urine by filtrating the ECF through the glomeruli. Re-absorption and Excretion of ECF occurs in the renal tubules. Nervous system: When the FCF volume increases, Mechanoreceptors in the wall of the left atrium respond to atria distention by increasing cardiac stroke volume and triggering a sympathetic response in the kidney. Stimulation of the renal sympathetic nerve decreases renal Excretion of sodium, both by increasing rennin release and through a direct effect on the kidneys. Movement of substances within the body: Diffusion Diffusion refers to the movement of a chemical substance from an area of high concentration to an area of low concentration and occurs mainly in gases, liquids and solutions. Osmosis is the movement of water down its concentration gradient across a semi permeable membrane when Equilibrium cannot be achieved by diffusion of solute molecules. Fluid Imbalances: 1) Extra Cellular Fluid Volume Deficit (ECFVD): An ECFVD is a decrease in intravascular and interstitial fluids. ECFVD is a common and serious fluid imbalance that results in vascular fluid volume loss (hypovolemia). ECFVD can lead to cellular fluid loss owing to fluid shifting from the cells to the vascular fluid to restore fluid balance. Etiology: ECFVD: commonly occurs with severe vomiting, or Diarrhea, Traumatic injuries with Excessive blood loss, third space fluid shifts & insufficient water or fluid intake. Risk factors: - In diabetic ketoacidosis. - Loosing large volume of blood. - Experiencing severe vomiting or diarrhea. - Having difficulty swallowing. - Elderly, confused persons. Clinical Manifestations: - Mild ECFVD – 1 to 2l of water & 2% of body weight is lost. - Moderate ECFVD – 3 to 5 l of water loss & 5% of weight loss. - Severe ECFVD – 5 to 10 l of water loss & 8% weight loss - Thirst. - Decreased skin burger. - Dry mucous membrane. 372
- Dry cracked lips or tongue. - Eye balls sunken & soft. - Restlessness, Coma in severe deficit. - Elevated temperature. - Tachycardia. - Postural, systolic blood pressure > 15 mm Hg Diastolic fall < 10 mm Hg. - Weight loss. - Oliguria (< 30 ml/hr) Laboratory findings: - Increased Osmolality. - Increased or normal serum sodium level. - BUN (> 25 mg/d1) - Hyperglycemia (> 120 mg / dl) - Elevated hematocrit (>55%), Increased Specific gravity. Medical Management: Pharmacologic Management: - An intravenous solution of 5% Dextrose in water (D5W) or 5% Dextrose in 0.2% saline (D5/0.2% Nacl) may be prescribed. - If hemorrhage is the cause of ECFVD blood replacement may be necessary if blood losses greater than 1L. - In situation in which the blood losses are less than 1L, normal saline & lactated Ringers solution may be used to restore fluid volume. Dietary management: Clients experiencing fluid loss from diarrhea should avoid fatty or fried foods and milk products. Nursing Diagnosis: Fluid volume Deficit R/T insufficient fluid intake, vomiting, diarrhea, hemorrhage. 2) Extra Cellular Fluid Volume Excess: ECFVE is increased fluid retention in the intravascular & interstitial spaces. Etiology: - Increase in the total body sodium content - Heart failure - Renal disorders. - Cirrhosis of liver. - Excessive amounts of IV fluids contain sodium. - Increased ingestion of foods that contain high amount of sodium. Clinical Manifestations: Respiratory: Constant irritating cough - Dyspnea. - Cyanosis. - Crackles lungs. Cardiovascular: Neck vein Engorgement in semi fowlers position - Head vein Engorgement. - Elevated Blood Pressure. - Pitting Edema of lower Extremities. 373
- Sacral Edema. - Weight gain. Neurological: Change in level of consciousness Laboratories findings: -Serum osmolality < 275 mosm / kg -Serum sodium < 135 meq to 145 meq -Decreased hematocrit - Specific gravity below 1.010 Medical management: Pharmacologic Management: -Loop and potassium wasting diuretics and digitalis preparation are Frequently prescribed for the treatment of ECFVE. - These potent diuretics cause potassium to be excreted along with the sodium and water. - To preserve potassium, a combination of potassium wasting and potassium sparing diuretics is frequently prescribed. - Digoxin, a digitalis preparation is ordered to increase the force of myocardial contraction or to slow the heart rate if heart failure is the cause of ECFVE. Dietary management: - A low sodium diet is prescribed in order to reduce fluid retention Nursing Diagnosis: - Fluid volume Excess R / T compromised regulatory mechanisms or hypovolemia 3) Extra Cellular Fluid Volume Shift: Third Space fluid A fluid volume shift is basically a change in the location of extra cellular fluid between the intravascular and the interstitial spaces. There are two types of fluid shifts 1. Vascular fluid to interstitial space. Fluid that shifts into the interstitial space and remains there is referred to as third space fluid. Third space fluid occurs in cases of tissue injury resulting from altered capillary permeability (e.g. - inflammation, traumatic injury) and from increased vascular fluid volumes. Increased vascular fluid volume appears in the abdomen (Ascitis), peritoneal cavity and pericardial sac. Etiology: Clinical causes of fluid shift from the vascular to the interstitial spaces may be –simple blister or sprain. -Crushing injuries. -Extensive burns. -Perforated peptic ulcer. -Intestinal obstruction. -Large venous thrombosis. -Lymphatic obstruction. Risk factors: - Clients at risk for third space fluids are those who have sustained major trauma or had major surgery. Path physiology: Tissue injury causes the release of histamine and bradykinin, which increases capillary permeability, allowing fluid, protein and other solutes to shift into the interstitial spaces. 374
The first phase is the fluid shift from vascular to interstitial spaces leading to a fluid volume deficit (hypovolemia). The second phase is the shift from the interstitial to the vascular space, leading to a fluid volume excess (hypervolemia) Clinical Manifestations: Typical clinical manifestations include:- Skin pallor, cold extremities. - Weak and rapid pulse, hypotension. - Oliguria and decreased level of consiuousness. Diagnostic Assessment: Laboratory results may include an elevated hematocrit and BUN later after fluids return to blood stream; laboratory results may indicate decreased hematocrit and BUN levels. Medical Management: - Medical management begins with the determination of the cause of the fluid volume shift - When hypovolemia results from tissue injury such as burns or crush injury a large volume of intravenous (iso – Osmolar) fluid administration is required. - The amount of fluid infusion may be three times greater than the urinary output. - During the second phase, fluid administration and intake may need to be limited because of fluid influx from the tissue spaces to the vessels. - If third space fluid has occurred as a result of other process such as pericarditis and bowel obstructions the fluid may have to be removed in order for the organ to retain its function: e.g. :- pericenthesis. Nursing Management: - Clients vital signs should be assessed every 1 – 8 hours. - IV fluid replacement should be monitored. If fluids are administered too rapidly, hyper volemia (fluid overload) may occur. - Frequent checks for chest crackles, difficulty in breathing & neck vein engorgement are essential to prevent pulmonary edema with fluid volume excess. - The abdominal girth of clients with ascitis should be measured every 8 hours. - If the extremities are involved, the circumference of the extremities and the peripheral pulses should be measured every hour. - The level of consciousness should be monitored and precautions taken for seizures. - Frequent skin care to edematous areas during fluid shift is essential to prevent skin break down. - As the fluid shifts back with the repair of tissue damage, IV fluid replacement is decreased. - Urine output should be monitored every hour to ensure at least 25 ml per hour. Urine output is usually reduced after tissue injury because of decreased renal circulation and the fluid shift into the injured tissue spaces. - The serum levels of BUN and Ammonia should be monitored in clients with ascitis. 4) Intracellular Fluid Volume Excess: water intoxication Hypo Osmolar disorders result from either water excess or solute deficit and are mainly due to sodium loss. In the case of water excess, the number of solutes is normal, but they are diluted by excessive water. In the case of solute deficit, the amount of water is 375
normal, but there are too few particles per liter of water. In both cases hypo-osmolality of vascular fluids exists and cellular swelling occurs. The most common cause of ICFVE is the administration of Excessive amounts of hypoOsmolar fluids such as 0.45 % saline or 5 % dextrose in water. ICFVE may occur in clients who receive continuous D 5W IV fluids, in those with brain injury or disease that causes an increased production of ADH, which increases water reabsorption from renal tubules. Clinical Manifestation: - Head ache, Nausea, Vomiting. - Papillary changes. - Behavioral changes, irritability, disorientation. - Confusion, drowsiness, decreased co-ordination. - Weight Gain. - Bradycardia with increased systolic BP. - Increased respiration, projectile vomiting. - Convulsions. Laboratory findings: - Serum sodium level < 125 meq / lt. - Decrease hematocrit. Management: - ICFVE is treated by the addition of solutes to IV fluids. - Use of D5 / 0.45 % Nacl will help to correct ICFVE when the cause is water excess. - Oral fluids such as water and soft drinks should be given in addition to water and ice chips - Reflexes and Papillary response should be assessed - IV therapy should be monitored every hour. - Monitor vital signs and intake; output Evert 1-8 hrs. - Weight should be checked daily to measure fluid gain or loss. - Administer prescribed antiemetic as needed to allow food and fluids to be ingested. - Safety measures are necessary when the client displays behavioral changes Electrolytes: Electrolytes are substances found in extra cellular and intracellular fluid that dissociate into electrically charged particles known as ions. Cat ions are that carry a positive charge and anions are ions that carry a negative charge. The positively charged electrolytes (cat ions) are sodium, potassium, calcium and Magnesium. The negatively charged electrolytes (anions) are chloride, phosphate and bicarbonate. The electrolytes that are most plentiful in the cells are potassium, magnesium, and phosphate. The most plentiful ions in the ECF are Sodium, calcium, chloride and bicarbonate. Electrolytes have major influences on 1) Body water regulations 2) acid-base regulation 3) enzyme reactions4) Neuromuscular activity. Sodium concentration in the extra cellular fluid assists in the maintenance of fluid balance. The captions are necessary for transportation of nerve impulses and stimulation of muscle activity.
376
Factors that influence Electrolyte balance: 1) Active Transport: The use of energy to move ions across a semi permeable membrane against a concentration, chemical or electrical gradient 2) The Sodium Pump: This active transport mechanism maintains homeostasis of the electrolytes sodium (Na+) and potassium (K+). It may utilize up to 30 % of ATP required for cellular metabolism. The Principal cat ions are K+ intracellular & Na+ Extra cellular. There is a tendency for these ions to diffuse down their concentration gradients. K+ outwards & Na+ into the cell. Homeostasis is maintained as excess Na+ is pumped across the cell membrane in exchange for K +. 3) Diffusion: The process in which particles in a fluid move across a semipermeable membrane from an area of greater concentration to an area of lesser concentration. 4) Aldosterone feedback mechanism: Adrenal cortex secretes the steroid hormone aldosterone when extra cellular fluid sodium concentrations decrease or potassium Concentrations increase. Aldosterone stimulates kidney tubules to reabsorb sodium; potassium reabsorption decreases as sodium reabsorption increases. This mechanism helps preserve normal sodium and potassium concentrations in extracellular fluid. 5) Parathyroid regulation of calcium: Parathyroid glands secrete parathormone when extracellular fluid calcium concentration decreases. Parathormone stimulates the release of calcium from bone, calcium reabsorption in the small intestine (Vit. D required) and Calcium reabsorption in Kidney tubules. Increased extracellular fluid calcium concentrations result in decreased secretion of parathormone and gradual loss of excess calcium Electrolytes Imbalances: 1) Hyponatremia: Hyponatremia is a serum sodium level below 135 meq / l Etiology: - Occur when total body water is decreased. - Kidneys inability to excrete sufficiently diluted urine. - Diuresis (increased urine excretion). - Diuertics. - GI suction. - Excessive perspiration followed by increased water intake. Clinical Manifestation: Gastro intestinal: Nausea, vomiting, Diarrhea, bowel sounds, Abdominal cramps. Cardiovascular: Decrease in diastolic pressure tachycardia, orthostatic Hypotension weak pulse. Pulmonary: Changes in rate of respirations. 377
Neurologic: Headache, lethargy, confusion slowed problem solving, diminished muscle tone on extremities, weakness and tremor. Integumentary: Dry skin, pale, dry mucous membrane. Medical Management: - Determine cause of hyponatremia and to correct it. - Correct body water Osmolarity - If client has hyponatremia due to fluid volume excess, intake of fluids will be restricted to allow the sodium to regain balance. - If the serum sodim level falls below 125 meq / L, sodium replacement is needed. Pharmacologic Management: - For client with moderate hyponatremia 125 meq/ L iv saline solution (0.9% Nacl) or lactated Ringers solution may be ordered. - When the serum sodium level is 115 meq / L or less, a concentrated saline solution such as 3 % Nacl is indicated. Dietary Management: - A balanced diet is usually adequate for mild hyponatremia (126 to 135 meq) - More severe hyponatremia may require sodium replacement - If the clients have hyponatremia due to excess fluids, a fluid restricted diet may be prescribed. - Fluids may be restricted 800 to 1000 ml / day. 2) Hypernatremia: Hypernatremia is a serum sodium level over 145 meq / L Etiology: - Diabetes inspidus. - Excess NaCl IV fluid intake. - Accidental or international salt intake. - Hypertonic feedings. - Canned vegetables. - Renal losses. Clinical Manifestations: Gastro Intestinal: Anorexia, nausea & vomiting. Integumentary: Dry skin & flushed, mucous membranes dry and Sticky, thirst. Neurologic: Restlessness, agitation, irritability, lethargy, coma, tremor, seizures Cardiovascular: Trachycarida, hypotension or hypertension. Renal: Oliguria. Laboratory Findings: Serum sodium > 145 meq /L.
378
Medical Management: - To decrease total body sodium and replace fluid loss either a hypo-Osmolar electrolyte solution (0.2 % or 0.45 % Nacl) or D5w is administered - Hypernatremia caused by sodium excess can be treated with D5w and diuretic such as furosemide. Dietary management: - Dietary restrictions of sodium are useful to Prevent hypernatremia in high risk clients - Clients with renal disease may need to have their sodium intake restricted to 500 to 2000 mg / day. 3) Hypokalemia: Hypokalemia is a serum potassium level of less than 3.5 meq /L Etiology: - Diarrhoea vomiting, Nasogastric suctioning. - Malnutrition, starvation potassium free diet. - Potassium wasting diuretics. - Diabetic acidosis. Clinical Manifestations: Gastro internal: Anorexia, vomiting, diarrhea. Masculoskeletal: Muscle weakness, paralysis, leg cramps. Cardiovascular: Dysrhythmis, vertigo, postural hypotension, flattened T wave. Respiratory: Shallow respiration shortness of breath. Neurologic: Fatigue, lethargy, decreased tendon reflexes, confusion. Laboratory findings: Serum potassium <3.5 meq / L. Medical management: - Determing & correcting the cause of the imbalance. - Extreme hypokalemia requires cardiac monitoring. Pharmacologic Management: - Oral potassium replacement therapy is usually prescribed for mild hypokalemia ( serum potassium 3.3 to 3.5 meq/l) - Potassium is extremely irritating to gastric mucosa; therefore the drug must be taken with Glass of water or jute or during meals. - Potassium chloride can be administered intravenously for moderate or severe hypokalemia & must be diluted in IV fluids. - Administration of potassium by IV push may result in cardiac arrests. Potassium can be given in doses of 10 to 20 meq/ hour diluted in IV fluid if the client is on heart monitor. - High concentration of potassium is irritating to heart muscle. Thus correcting a potassium deficit may take several days. 379
Dietary management: The administration of foods that are high in potassium help to correct the problem as well as prevent further potassium looses. The adult recommended allowance of potassium is 1875 to 5625 mg. Common sources of food containing potassium – Cabbage, Carrot, Cucumber, Mushrooms, Spinach, Tomato, Fruits- Banana, Guava, Orange. Nursing Diagnosis: Hypokalemia R/t vomiting, diarrhoea, Cushing‘s syndrome, or decreased intake. Risk for injury R/t muscle weakness & hypotension. Imbalanced nutrition less then body requirement R/t insufficient intake of foods rich in potassium. 4) Hyperkalemia: Hyperkalemia is an Elevated potassium level over 5.0 meq/l. Etiology: Retension of Potassium – Renal insufficiency, renal failure, decreased urine output, potassium sparing diuretics. Exessive release of Cellular Potassium - severe traumatic injuries. Severe burns, severe infection, metabolic acidosis. Excessive IV infusions or Oral administration of potassium. Clinical Manifestations: Cardiovascular: First trachycardia then bradycardia. - Electro Cardiagraphic changes Peaked narrow T waves, wide QRS complex, depressed ST Segment, Widened PR interval. Gastrointestinal: Nausea, Diarrhea, Hyperactive bowel sounds. Neuromuscular: Muscle weakness, muscle cramps, Tingling sensation (Paresthesia) Renal: Oliguria & later anuria Laboratory findings: Serum potassium > 5.0 meq/l Serum Osmolality > 295 Mosm/ Kg Serum creatinine > 1.5 mg/dl BUN > 25 mg/dl Medical Management: - When serum potassium level is 5.0to 5.5 meq/l restriction of dilatory potassium intake. - If potassium Excess is due to metabolic acidosis, correcting the acidosis with sodium bicarbonate promotes potassium uptake into the cells. - Improving urine output decreases elevated serum potassium level. - When hyperkelemia is severe, immediate actions are needed to be taken to avoid severe Cardiac disturbances. 380
- Intravenous calcium gluconate infusions to decrease the antagonistic effect of potassium excess on the myocardium. - Infusion of insulin and glucose or sodium bicarbonate to promote potassium uptake into the cells. Nursing Diagnosis: - Hyperkalemia R/T renal dysfunction, shock from traumatic injuries or burns. - Potential for dyrhythmias R/T hyperkalemia. 5) Hypocalcemia: Hypocalcemia is serum calcium below 4.5 meq/l or 8.5 mg/dl Etiology: - In adequate dietry calcium intake, vitamin D deficiency. - Malabsorption of fat in intestine. - Metabolic alkalosis. (less lonized calcium) - Renal failure with hyperphsophatemia, accute pancreatitis. Burns, Cushing‘s disease, hypoparathyrodism. - Medications – Magnesium sulfate. Clinical manifestation: Neuromuscular: Tetany symptoms: Twitching around mouth, tingling and numbness of fingers, facial spasm, convulsions. Respiratory: Dyspnea, laryngeal spasm. Gastrointestinal: increased peristalsis, diarrhoea. Cardiovascular: dysrhythmias, palpitations Hematologic: prolonged bleeding time. Medical Management: - Determining & correcting the cause of hypocalcemia. - Asymptomatic hypocalcemia is usually corrected with oral calcium gluconate calcium lactate or calcium chloride. - Administer calcium supplements 30 minutes before meals for better absorption and with glass of milk because vitamin D is necessary for absorption of calcium from the intestine. - Intravenous calcium chloride or calcium gluconate (10%) is given slowly to avoid hypertension, bradycardia & other arrhythmias. Dietary Management: - Chronic or mild hypocalcemia can be treated in part by having the client consume a diet high in calcium: Eg: Cheese, milk, spinach - If hypocalcemia is secondary to parathyroid deficiency the client must avoid high phosphate foods (Eg: Milk products, carbonated beverages) Nursing Diagnosis: - Hypocalcemia R/T Diarrhea, pancreatitis, renal failure or decrease intake. - Risk for injury R/T increase neuromuscular irritability resulting from hypocalcemia - Altered healthy maintenance R/T knowledge deficit regarding foods high in calcium. 6) Hypercalcemia: Hypercalcemia is a serum level over 5.5 meq/Lor 11 mg/l
381
Etiology: Metastatic malignancy-lung, breast, Ovarian, Prostatic, bladder, leukemia, Kidney. Hyperparathyroidism. Thiazide diuretic therapy. Prolong immobilization. Excessive intake of calcium supplements and vitamin D. Clinical Manifestations: Gastrointestinal: Anorexia, Vomiting, Constipation, decreased peristalsis Neuromuscular: Mild to moderate hypercalcemia-weakness, fatigue, depression, difficulty to concentrate. Severe hypercalcemic state-Extreme lethargy, Confusion and Coma Cardiovascular: Dysrhythmias, heart block. Electro-cardiographic Changes: Shortened ST Segment and lengthened QT interval. Renal: Polyuria, kidney stones, renal failure. Musculoskeletal: Bone pain, fracture. Laboratory findings: Serum Calcium > 5.5 meq/l(> 11.5 mg/dl) Arterial blood gasses- PH < 7.45 HCO3> 26 meq/l Medical Management: Treatment consists of correcting the underlying cause. Intravenous normal saline (0.9% Nacl) given rapidly with furosemide to prevent fluid overload, Promote urinary calcium excretion. Calcitonin decreases serum calcium level by inhibiting the effects of PTH on the osteoclasts and increasing urinary calcium excretion. Corticosteroid drugs decrease calcium levels by competing with vitamin D thus resulting in decreased intestinal absorption of calcium. If the cause is excessive use of calcium or vitamin D supplements or calcium containing antacids these agents should be either avoided or used in reduced dosage. A newer form of drug therapy is etidronate disodium. This drug reduces serum calcium by reducing normal and abnormal bone reabsorption of calcium and secondarily by reducing bone formation. Dietary Management: - Forcing fluids will assist in adequately hydrating the client and flushing excess calcium through the kidney. Nursing Diagnosis: - Hypercalcemia R/T metastatic lesions hyper parathyroidism, Thiazide therapy or increased intake of calcium. - Health maintenance altered R/T excessive ingestion of calcium supplements and calcium- containing antacids. 382
- Risk for injury R/T potential pathologic fractures, mental confusion and immobility. - Conclusion: - Fluids are essential for life. Homeostatis is sustained by very many processess. Which was dealt in the session. The abnormalities wehre also discussed in the session. As nurses, one of our main responsibility in dealing with most kind of patient is the maintainence of fluid volume and electrolyte balance. Thus it is very essential to know regaring the fluid and electrolyte balance and imbalances. I hope by this session the group could gain knowlkedge and will be able to practice more efectively.
383
BIBLIOGRAPHY: 1. Arlene.L.Polaski. Core principles and practice of Medical surgical nursing. 1st edition. W.B. Saunders Company 196 Pg No. 35-79. 2. Joyce.M. Black. Medical surgical Nursing, 5th edition, Singapore, W.B. Saunders Company; 1998 3. Gerard J. Tortora, Sondra Reynolds Grabawski; Principles of anatomy and Physiology, 10th edition, Newyork; John wiley and Sons. 2003. 4. Sharton mantik lewis, Idolia Cox Collier, Margaret. M. Het kemper, Medical surgical nursing, 4th edition, Missori; Mosbi publisher 1996. 6. Anne Waugh.allison grant.Ross and Wilson, Anatomy and Physiology in health and illness, 9th edition, Elsevier science; Spain, 2003. Pg. 17-29. 5. The Nightingale Nursing Times, 1st editionn, 5th edition.
384
Hemorrhage and shock Hemorrhage Introduction: Hemorrhage is the loss of blood from blood vessel. The blood loss is described as extra vacated (outside the vessel) It may lie on the surface of body, on patient‘s clothing or on the floor. Blood may be lost from all three types of vessels, the arteries, the veins or capillaries. The type of hemorrhage is named accordingly. Bleeding which occurs as soon as vessel is divided is known as primary hemorrhage. If the patient is collapsed the vessel may not bleed immediately, but as recovery takes place, the blood pressure rises and bleeding occurs. This is known as reactionary or intermediate hemorrhage. Hemorrhage can involve all the blood vessels. Natural arrest of hemorrhage: Adequate amount of calcium is required and all the clotting factors are essential for the natural arrest of hemorrhage. The blood in the circulation is kept fluid by a fine balance between clotting and fibrinolysis. When a tissue is damaged ↓ Pro thrombin is converted into its active form thrombin (In the presence of calcium) ↓ Fibrinogen then transformed by thrombin to fibrin ↓ Mesh is formed by platelets and other blood cells to form clot Factors affecting clotting: Calcium: - calcium helps in the clotting of blood. Calcium can be displaced from the blood by 3.8% solution of sodium citrate, acid citrate dextrose solution, citrate phosphate dextrose solution, ethylene demine tetra-acetic acid (EDTA). Acid citrate dextrose and acid citrate phosphate solutions are used to prevent clotting of stored blood. Pro thrombin: - it is formed from vitamin K, a fat soluble vitamin absorbed from small intestine. A patient suffering from obstructive jaundice will not absorb vitamin k and therefore they are liable to bleed if operated upon. For this reason vitamin k injection is given so as to restore the pro thrombin level of blood. Fibrinogen: - It is the precursor of fibrin. In the absence of fibrinogen severe bleeding may occur, fibrinogen is the substances which dissolve fibrin by a phenomenon known as fibrinolysis. The fibrinolytic activity of blood may be increased: In complicated obstetric cases associated with hemorrhage. After strenuous activity. In presence of some malignant growth. The patient suffering from increased fibrinolysis will show reduced evidence of clotting. They may be treated by neutralization of the fibrinolysis by the administration of fibrinogen.
385
Types of hemorrhage: (According to the vessels involved) 1. Arterial hemorrhage. 2. Capillary hemorrhage. 3. Venous hemorrhage. 1) Arterial hemorrhage: - When blood loss is from artery is known as arterial hemorrhage. The blood is bright red and spurts with the heart beat. The escape is from both ends of vessels not only from nearer to the heart. Blood loss is more rapid from a vessel of corresponding size. 2) Capillary hemorrhage: - The blood oozes over the surface of capillary and is darkish red in color oozing over several hours can result in considerable blood loss. 3) Venous hemorrhage: - When the blood loss is from vein then it is known as venous hemorrhage. The blood is dark red in color, there is no spurting and rate of loss is much less severe than arterial hemorrhage. When there is injury to large vessels then it will be a serious matter. A further danger is that air may be sucked into the damaged vein giving rise to fatal air embolism which the blood and air form ―foam‖. (According to the time of wound) 1. Primary hemorrhage. 2. Reactionary or intermediate hemorrhage. 3. Secondary hemorrhage. 1) Primary hemorrhage: - It is immediate hemorrhage which occurs when there is damage to any blood vessel and bleeding occurs immediately. E.g. cut on a finger or operative incision. 2) Reactionary or intermediate hemorrhage: - It occurs in first 24 hours after operation. The more severe the operation the more likely it is to occur especially after the patient has recovered from circulatory collapse, operation on kidney, the thyroid and the breast as well as total hysterectomy are particularly liable to be followed by reactionary or intermediate hemorrhage. 4) Secondary hemorrhage: - It is due to sloughing off the wall of blood vessel. The commonest cause is bacterial infection, but in the absence of infection it may cause by action of enzyme e.g. acid pepsin on peptic ulcer. In this type the thinnest vessels burst first and blood may be found on the dressings. This should be reported immediately because larger vessels can also be eroded in another few days. (Clinical classification of the hemorrhage) 1. Revealed or external. 2. Concealed or internal. 1.) Revealed hemorrhage: - it is a type when bleeding can be seen externally. 2.) Concealed hemorrhage: - it is that type when bleeding cannot be seen externally. The bleeding occurs into one of the body cavities such as the abdomen, into the lumen of hollow organ such as intestine or into the tissues. It may later become obvious e.g. by being vomited or per rectum or by bruising and swelling on the surface of the body. Since it must be diagnosed on the presence of symptoms and signs alone.
386
Signs and symptoms of hemorrhage:Early signs and symptoms: Restlessness and anxiety. Faintness. Coldness (temp. slightly subnormal 98 degree Fahrenheit). Slightly increased pulse. Pallor. Patient feels thirsty. Signs and symptoms after severe hemorrhage: Extreme pallor (face will be ashen, white and clammy with cold sweat) Coldness (temp. 97degree Fahrenheit). Air hunger (patient literally gasps for breaths and respirations will be rapid). Rapid thread pulse. Extremely low blood pressure. Extreme thirst. Diminished urine volume (acute renal failure). Blindness, tinnitus and coma occur prior to death. Effects of hemorrhage: Cardiac cycle: - cardiac cycle is the repetitive pumping action that produces pressure changes that circulates blood throughout the body. It will get disturbed i.e. it pumps less amount of blood to different organs. Cardiac output: - normal cardiac output is 5-6 lt/min The total amount of blood separately pumped by each ventricle per minute usually expressed in lt per minute. It can be increases up to 30 lt/ min. In the time of exercise. It is determined by multiplying the heart rate by volume of blood ejected by each ventricle during each beat. Control of external hemorrhage: Pressure will control all types of external hemorrhages. According to its severity there is a choice of methods. Pad and bandage: - this is the simple method of applying direct pressure to a bleeding wound and is applicable to vast majority of cases. It is effective and causes no damage. Digital pressure: - it is the pressure applied on the point of artery supplying blood to the area of wound. This will control hemorrhage temporarily and is called indirect pressure. It is particularly valuable in the neck where other methods are not applicable. Elevation of the limb: - it will control venous hemorrhage. This is a classical method of dealing with a sudden hemorrhage from a ruptured varicose vein of leg. Application of tourniquet: - this is rarely required except for control of a torrential hemorrhage from the limb. A temporary tourniquet may have to be devised in sudden emergency. It should be 3-4 inches wide. It can be a hanker chief, scarf or a tie. The great danger of tourniquet is that if it is left on for more than 30 minutes then gangrene of the limb may occur. The time of application and removal of tourniquet should be recorded. The limb on which tourniquet is applied should be kept elevated afterwards to control edema which may result from venous congestion. Surgical ligation: - it is necessary if the bleeding is persistent. 387
Coagulation: - it is the coagulation of bleeding point with the electro country. It can be used to coagulate the blood from small blood vessels. Pack: - it will temporarily control severe hemorrhage. This method is used in operation theatre to control temporary or sudden hemorrhage. The theatre nurse should always have a pack readily available for this emergency. Styptics: - these are also used to control bleeding and they act as astringents. Such as snake venom or adrenaline may be used locally in certain cases. Thrombin and gel foam can be used in some cases such as in low pressure bleeding from venues and capillaries. First aid treatment in case of severe external bleeding: Bring the sides of wound together and press firmly. Press on the pressure point for 10-15 min. Place the causality in comfortable position and raise the injured part and reassure him. Apply a clean pad larger than the wound and press it firmly with the palm until bleeding becomes less. If bleeding continues do not take off original dressing but add more pads. Bandage it but not too tightly. Control of internal hemorrhage: The following methods can be used to control bleeding: The organ is emptied of blood cloy if possible: in case of severe bleeding from bladder, a catheter is passed and bladder is emptied. The vessels are encouraged to contract: a lot of saline or sodium bicarbonate to which a few drops of adrenaline solution have been added, is of great value in washing the organ. This can be repeated every two hourly. The use of ergometrine after the birth of placenta is an example of stimulating the vessel to contract. Pittosin i/v may be effective in control of bleeding from esophageal varies. Packing: it can be done with gauze soaked in adrenaline is effective. Surgical ligature: surgical ligation can be done in case of ruptured spleen. Internal pressure: this may be applied by the balloon of triluminal tube in bleeding esophageal varies or by the balloon of Foley‘s catheter in the prostatectomy cavity. First aid treatment in case of internal bleeding: Lay the causality down with head low; raise his legs by use of pillow. Keep him calm and relaxed. Reassure him. Do not allow him to move. Keep up the body heat with thin blankets or coat. Do not give anything to eat or drink aspiration may occur. Do not apply ice bags or hot water bottles to chest or abdomen. Take him to the hospital as early as possible. Transport gently. Restoration of blood volume: Blood volume can be restored by blood transfusion. Indications for blood transfusion are:1. To counteract the effect of severe hemorrhage and replace blood loss. 2. To prevent shock in operations where blood loss is considerable such as rectal resection, hysterectomy and arterial surgery. 388
3. In severe burns to make up for blood lost by burning but only after plasma and electrolyte have been replaced. 4. To correct severe anemia from cancer, marrow aphasia and similar condition and from slow continuous hemorrhage. In blood transfusion as in all intravenous injections, the tubing and other portion of the delivery apparatus must be free from air. Transfusion under increased pressure: In some circumstances usually of large rapid blood loss it may be necessary to transfuse blood more quickly than possible by the simple gravity drip method. Following methods can be used: Pressure cuff: - this is an inflatable cuff placed around the bag of blood, when it is inflated it exert external pressure on the bag of blood, thus increasing the flow of blood into the patient. Pressure pump administration: - some transfusion giving sets permits either gravity or pressure pump administration of blood. Precautions during blood transfusion: Patient and transfusion apparatus should be kept under constant supervision. Blood must be transfused according to the rate prescribed by the doctor. Approx.25 drops per minute. Is the casual rate of blood transfusion which means that bag is transfused in four hours? Sufferers from cardiac, pulmonary diseases or sever anemia must be transfused at the slow rate sometimes at 12 drops per minute. Half an hourly pulse rate and temperature should be recorded. If blood transfusion is for shock, the blood pressure and pulse rate should be recorded after each unit of blood. All the patients should be watched for symptoms of transfusion reaction after first few ml of blood from each unit of blood, such as allergic reaction, pyrexia, air embolism , overloading , thrombophlebitis etc. Hemorrhages from Special Sites: The occurrence from special sites is designated by special terms: Epistaxis: it is the bleeding from nose. Haemoptysis: it is the expectoration of blood from lungs. Haematemesis: it is the vomiting of blood. Malaena: it is the passage of dark blood per rectum from a site high in intestinal tract. Haematuria: it is the presence of blood in the urine. Haemothorex: it is the bleeding into the chest. Haemoperitonium: bleeding into the peritoneum. Menorrhagia: excessive menstruation at normal interval. Haemopericardium: it is the bleeding into the pericardium. Hematomyalia: it is the bleeding into the spinal cord.
389
Shock Introduction: shock is the life threatening condition. It is characterized by inadequate tissue perfusion that if untreated results in cell death. The supply of oxygen to tissues is essential in the maintenance of life and this can be ensured when circulatory system is functioning normally. Historical background: In 1923 Walter and Canner first worked for all conditions of shock. Definition: Shock can be defined as a condition in which systemic blood pressure is inadequate to deliver oxygen and nutrient to supply to vital organs and cellular functions. Shock is defined as a failure of circulation to supply adequate oxygen to the tissues. Significance of shock: shock affects all the body systems. It may develop slowly or rapidly depending upon the underlying causes. During shock body struggles to survive, calling on all its haemostatic mechanism to restore blood flow and tissue perfusion. Therefore any patient with any disease sate may be at risk of developing shock. Nursing care of patient with shock requires ongoing systemic assessment. Many interventions required in caring for the patient with shock call for close collaboration with other members of health care team and a physician‘s order. The nurse must anticipated such orders because need to be executed with speed and accuracy. Causes of circulation failure: Circulation may fail from:1. Sudden malfunction of heart : This may occur as a result of: Coronary artery occlusion with acute myocardial ischemia. Trauma with structural damage to heart. Toxemia – viral or bacterial. Effects of drugs. 2. Deficient oxygenation of blood in lungs: - amongst many causes the following are the most important surgically. Post operative atelectasis Thoracic injuries particularly of chest , i.e. pneumothorax, crushing and laceration of lung Obstruction of pulmonary artery by an embolus. Disturbances of lung function following surgery and anesthesia. 3. reduction in blood volume ( oligaemia and hypovolemia ) :- this may occurs from loss of : Whole blood – hemorrhage (internal or external). Plasma – this is particularly significant in burns. Water and electrolytes which occurs from – peritonitis, intestinal obstruction, paralytic ileus, acute dilation of the stomach, severe diarrheas and vomiting . 4. Miscellaneous: there are number of other conditions that may lead to shocked state with low blood pressure. Faintness. Acute anaphylaxis. 390
Acute adrenal deficiency (Addison‘s disease). Over dosage of drugs e.g. analgesics like pethidine. Following therapy with beta blocking agents. Noxious stimuli such as pain, if severe will cause vasodilatation particularly of splenetic vessels with pooling of blood in the area. This is the mechanism of primary shock. Compensatory Mechanism: Whatever the cause of sudden collapse there are certain compensatory physiological mechanism which occur. Posture: A patient in acute circulatory failure falls down; he should be lie flat on the floor or better in head down position so that circulation can be improve towards heart. Contraction of skin vessels: Contraction of arterioles and venues of the skin is usual so as to conserve the blood supply to the more vital organs. The application of heat dilates the skin vessels thereby aggravating the condition and should not be used. Insensitivity: A much collapsed patient usually have little pain. Large quantities of pain relieving drugs are unnecessary and in case are ineffective because they cannot be absorbed unless given by intravenous route. Urinary secretions: These are diminished to conserve fluid in the body but it is also a sign that tissue perfusion is inadequate. Heart rate accelerates: It occurs in most forms of circulatory failure with the important exception of faint. It is an attempt to ensure that remaining fluid is circulated as rapidly as possible thereby providing sufficient oxygen to tissues. Subnormal temperature: This reduces the requirements of the tissues for the diminishing amount of oxygen available. The core temperature actually is rising. The difference between the two is a measure of the degree of shock. All these compensatory mechanisms are temporary in their beneficial effects and if the condition of circulation is restored to normal without delay irreversible changes set in. Pathophysiology: Lack of oxygen supply and nutrient in cells ↓ Cells produce energy through anaerobic metabolism to produce ATP ↓ Low energy yielding from nutrients and produces acidic intracellular environment ↓ Normal cell function affected, cells swells and cell membrane become more permeable, allowing fluid and electrolytes to move out and into the cells ↓ Sodium potassium pump impaired due to this ↓ Cell structure damage ↓ Ultimately death of cells
391
Stages of shock: There are three stages of shock that are commonly identified. 1) Compensatory stage, Non progressive stage, early stage. 2) Progressive or Intermediate stage. 3) Irreversible or Late stage. 1) Compensatory stage:- In this stage , the patient‘s blood pressure remains within normal limits, increased heart rate to maintain the cardiac output and this results from the stimulation of sympathetic nervous system with the subsequent release of epinephrine and nor epinephrine. The body shunts blood from skin, kidneys and gastrointestinal tract to the brain and heart to ensure adequate blood supply to these vital organs. As a result the patient‘s skin will be cold and clammy, bowel will be hypoactive and urine output will decrease in response to release of aldosterone and ADH. Signs and symptoms :- Changes in the level of consciousness, increased depth of respiration, irritability ,anxiety ,restless ,decreased urine output , dilated pupils , thirst , rapid respirations , sepsis , tachycardia, cold skin , decreased cardiac output. 2) Progressive stage: - It is the second stage of shock, the mechanism that regulates the blood pressure can no longer compensate, systolic blood pressure falls and diastolic pressure rises, decreasing blood flow to myocardium. Another effect on oxygen requirement is body‘s ability to meet increased oxygen requirement is body‘s inability to meet increased oxygen requirement produce ischemia oxygen deprivation to brain causes the patient to become confused and disoriented. Organs especially lungs, heart and kidneys deteriorate. Signs and symptoms :- decreased response to pain , dilated and sluggish pupils , increased thirst, rapid and shallow breathing , tachycardia, cool moist skin , possible cyanosis , lowered body temperature , muscle weakness and lowered urine output. 3) Irreversible stage:- The irreversible stage of shock represents the point along the shock continuum at which organ damage is so severe that patient does not respond to treatment and cannot survive. Multisystem failure develops. Cells in organs and tissues throughout the body damaged and dying. It is the end point of shock that is the patient‘s death is sure. Signs and symptoms :- Unconsciousness, absence of all reflexes , dilated pupils , severe thirst , bradycardia , cardiac arrhythmias, cold clammy skin, immune system collapse, renal failure, shallow respiration. Classification of shock : Shock can be classified according to the etiology and can be described as: 1. Hypovlemic shock. 2. Carcinogenic shock. 3. Circulatory shock. 4. Septic shock. 5. Obstructive shock. 6. Neurogenic shock. 7. Anaphylactic shock. 1.) Hypovolemic shock: This is the most common type of shock, due to insufficient circulatory volume. In hypovolemic shock there is decreased in circulatory volume to level that is inadequate to meet body‘s need for tissue oxygenation. This occurs when there is loss in the intravascular fluid upto 15% to 25%. This would represent a loss of 392
750 to 1300 ml of blood in a 70 kg person. Common causes of shock are: exercise, fluid loss from circulatory system e.g. bleeding, burns, and blood loss from G I or severe diarrhea. Pathophysiology: Decreased blood volume ↓ Decreased venous return ↓ Decreased cardiac output ↓ Decreased tissue perfusion ↓ Decreased cellular metabolism 2.) Carcinogenic shock: It is caused by the failure of heart to pump an adequate amount of blood to vital organs. This will lead to reduction in cardiac output. After due damage of heart muscles, heart‘s ability to contract and pump blood is impaired and the supply of oxygen is inadequate for the heart and muscles. It can be the result of myocardial infarction. Other causes include arrhythmias, cardiomyopathy, congestive heart failure, and cardiac valve problems. Pathophysiology: Decreased cardiac contractility ↓ Decreased stroke volume and cardiac output ↓ ↓ ↓ Pulmonary congestion decreased tissue perfusion decreased coronary artery perfusion volume 3.) Circulatory shock or distributive shock: In this there is no blood loss but the shock is due to the dilation of the blood vessels. This displacement of blood causes a relative hypovolemia because not enough blood returns to heart which leads to subsequent inadequate tissue perfusion. The varied mechanisms leading to the initial vasodilatation in circulatory shock is subdivided into septic shock. It is the most common type of circulatory shock and caused by wide spread infection due to sepsis called by an overwhelming infection leading vasodilatation. E.g. Infections by bacteria. They release toxins which produce adverse biochemical, immunological and neurological effects. The most common causative organism of septic shock is gram negative bacteria. Pathophysiology: Vasodilatation ↓ Mal distribution of blood volume ↓ Decreased venous return ↓ Decreased stroke volume 393
↓ Decreased cardiac output ↓ Decreased tissue perfusion 4.) Obstructive shock: Obstruction of blood flow results from cardiac arrest. E.g. Cardiac tapenade, pneumothorax, pulmonary embolism, and aortic stenos. 5.) Neutrogena shock: this is very uncommon type of shock. It is most often seen in patients who have had and extensive spinal cord injuries. The loss of autonomic and motor reflexes below level of injury results in loss of sympathetic control. This leads to relaxation of vessels and peripheral dilation and hypotension. This is characterized by warm and dry skin, bradycardia, rather than other type of shock. 6.) Anaphylactic shock: Anaphylactic shock is caused by severe reaction to an allergen, antigen, drug or foreign protein. When a patient who has already produced antibodies to a foreign substance develops a systemic antigen antibody reaction. Antigen antibody provides mast cells to release vasoactive substance such as histamine or breadykinin that cause vasodilatation. Risk factors: - immunosuppressant, invasive procedures and psychological trauma. Diagnosis of shock: - Diagnosis of shock is essential for proper treatment and management. An accurate history and assessment of patient symptoms must be done before commencing treatment. Conduct head to toe examination for signs of shock. Assess neurological status of the person by assessing the level of consciousness. Assess the cardiovascular status. Blood pressure varies with the stages of shock. Assess for renal status. Anuria and renal failure can occur. Assess for integumentary status. Check for skin color, cold and clammy skin, cyanosis. Assess GI status. Hypoactive bowel sounds. Assess for the metabolic status. Metabolic acidosis will be there. Diagnostic studies:- Blood studies reveals overly acidic blood ph with low circulatory carbon dioxide, blood pressure monitoring. First aid in case of shock: Principals involved in first aid: 1) Remove the cause of accident from near the causality. If possible remove the causality from danger such as burning house, room with poisonous gases. 2) Handling the patient with due care and attention to reduce pain and to prevent worsening of the condition. 3) Constant observation should be provided to the causality to identify failure of breathing, bleeding and then to take appropriate measures to treat problems. 4) Using material available at hand. 5) Clear the crowd around the causality. 6) Take the help of the bystanders to give first aid. 7) Reassure the causality. 8) Transport the causality to the doctor as early as possible. 394
First aid in shock: Reassure the causality. Lay him down on his back comfortably with head low and turned to one side except in case of head injury. Loosen the clothing around the neck, chest and waist. Keep the causality warm. Give him sips of water if he is thirsty. Never give any alcoholic drinks. Never use hot water bag or massage the limbs. Arrest hemorrhage by adequate measures. Check pulse, respiration and level of consciousness. Transport the causality to the hospital immediately. Treatment of shock: - Pharmacological interventions. 1.) Hypovolemic shock: Volume expanders Desmopression ( in case of diabetes) Antidiarrheal agents for diarrhea 2.) Carcinogenic shock: Volume expanders Positive cardiac inotropics Vasodilators Vasiactive and antiarrythmia medication 3.) Distributive shock: Volume expanders Positive cardiac inotropics Vasoconstrictors 4.) Obstructive shock: Volume expanders Septic shock Broad spectrum antibiotics 5.) Neurogenic shock: Hypoglycemia – glucose is rapidly administered. Management of shock: Administration of intravenous fluids, blood products, and medication. They are helpful in treating shock. These include : Crystalloids: these are used for intravenous fluid replacement in early stages of shock .e.g. ringer‘s solution and normal saline most commonly used.. Inotripoic agents: like dopamine, dobutamine and epinephrine to improve myocardial contractility, adequate cardiac output and improve tissue perfusion. Vasodilators: nitroglycerine, sodium nitroprusside used to dilate the coronary arteries. Diuretics: these are used to treat oliguria and increase urine output. Antibiotics: used to treat septic shock because they are bactericidal. Antihistamines: epinephrine used in anaphylactic shock. Steroids: used to decrease fluid shifts out of vasculature by stabilizing capillary walls. Sodium bicarbonate: it is used to treat metabolic acidosis that occurs as shock progress. 395
Bronchodilators: like atropine, aminophyline, used to relieve bronco constriction in case of anaphylactic shock. Nursing management in case of shock: Maintain ABC of the patient. Provide supplemental oxygen therapy to the patient. Do not deliver more than 2 lt. of oxygen per minute if person has history of chronic pulmonary diseases. Monitor for ABG value to assess the patient response to oxygen therapy. Continuous monitoring of vital signs should be done. Check for urine output of the client. Maintain nutritional status of the patient. Administer prescribed medication to the patient. Give psychological support to the patient and the relatives. Nursing diagnosis in case of shock: 1. Fluid volume deficient related to hemorrhage. Nursing interventions: Monitor the signs and symptoms of internal bleeding. Check for blood pressure. Give comfortable position. Keep the patient warm and monitor temperature hourly. Administer intravenous fluids as ordered. Monitor urine output. Administer oxygen as ordered. 2. Decreased cardiac output related to ineffective cardiac function. Nursing interventions: administer IV fluids Monitor urine output. Monitor blood pressure and pulse rate. Administer inotropic agents to correct ventricular function. 3. Risk for infection related to interruption of skin integrity from invasive procedures. Nursing interventions Take precautions to prevent nosocomial infections. a) Wash hands frequently. b) Use aseptic techniques. c) Monitor sites of insertion for signs of infection. d) Change the intravenous cat every three days. e) Provide indwelling catheter care frequently. f) Monitor for white blood cell count for elevation greater than 10,000 per mm3. 4. Altered nutrition less than body requirement related to decrease oral intake. Nursing interventions: Monitor daily weight and identify weight loss. Consult nutritionist for recommendations about diet. Check for gastric residuals every 4 hourly; notify the physician if it is greater than 100 ml. 396
Monitor for hematocrit, hemoglobin to assess the adequacy of nutritional replacement. 5. Altered peripheral tissue perfusion related to edema from stasis of blood in the capillaries and vasoconstriction. Nursing interventions: Monitor the extent of fluid retention. Monitor daily weight of the patient. Determine the severity of edema. Watch for elevation in central venous pressure. Check signs and symptoms of fluid overload. Prevention of shock: Preoperative measures: circulatory collapse should be assessed by strenuous measures if at all possible. Preoperatively the patient should be as fit as possible and from the point of view from circulatory system. His blood should be adequate in quantity and volume. His tissues should be adequately hydrated. He should be mobile so that there should be no stagnation in the circulatory system. Patient should be kept warm on his journey from ward to theatre. Post operatively: Fluid and electrolyte replacement should be done with normal saline, dextrose 5%, plasma and rest and relief from the pain continues. Gentle handling by nursing staff will help in prevention of shock. Diuretics like mannitol an osmotic diuretic which is neither absorbed in the renal tubules nor metabolized. If oliguria persists frusemide can be given. Dopamine can be given to improve blood pressure.
397
BIBLIOGRAPHY: Saunder‘s Manual of Nursing Practice, edition 1st , published by W.B Saunders, printed in 1997, pp 364-380 Brunner and Suddarth‘s Textbook of Medical Surgical Nursing edition 13th published by Lippincott publishers, printed in 2009, pp 216-234 Joyee M Black and Hawks J.H. Medical Surgical Nursing clinical management for positive outcomes, edition 7th , printed in 2009, pp 2443-2477. American Academy of Orthopedic Surgeons, Emergency, Care and Transportation of the Sick and Injured, Published by Jones and Barlett, 7th edition, printed in 1998,pp 541 – 550. www.google .com
398
SHOCK & ITS MANEGEMENT Definition: Shock is defined as a condition in which tissue perfusion is inadequate to deliver oxygen and nutrients to support vital organs and cellular function called as shock. Classification of shock: There are 4 types of shock:1. Hypovolemic shock. 2. Carcinogenic shock. 3. Distributive shock. (a) Septic shock. (b) Anaphylactic shock. (c) Neutrogena shock. 4. Obstructive shock. (a) Cardiac dampened. (b) Massive pulmonary embolism. (c) Aortic stenosis. Recently a fifth form of shock has been introduced:5. Endocrine shock. (a) Hypothyroidism. (b) Thyrotoxicosis. (c) Acute adrenal insufficiency. Stages of shock: There are 4 stages of shock:1. Initial stage 2. Compensatory stage 3. Progressive (or) (decompensate) 4. Refractory (Irreversible) 1.) Initial stage: During this stage
399
The process of removing these components from the cells by the liver requires oxygen (Which is absent?) 2.) Compensatory stage: This stage is characterized by the body employing physiological mechanisms including neural hormonal and bio-chemical mechanism in an attempt to reverse the condition
400
Clinical manifestation: - Normal blood pressure. - Metabolic acidosis. - Respiratory alkalosis - deep rapid res pid Flat neek vein - Changes in LOC. - Irritability. - Restlessness dilated reactive pupil. - Tachycardia bounding pulse. - Dry warm skin. Medical management: Medical treatment is directed toward identifying the cause of the shock correcting the underlying disorder measures such as - Fluid replacement and medication therapy Must be initiated to maintain the adequate BP and re establish and maintain adequate Tissue perfusion 3. Progressive stage (de compensating):
401
Clinical manifestation: - Confusion response to pain. - Dilated sluggish pupil. - Thirst, rapid shallow breathing. - Tachycardia cool moist skin. - Slow capillary refill muscle weakness. - Hypotension. Management: To restore the perfusion by following Method:- optimizing intravascular volume - supporting the pumping action of the heart - improving the competence of the vascular system - supporting the respiratory system 4.) Refractory (irreversible): At this stage the vital organs have failed and the shock cam no longer be reversed brain damage and cell death have 0ccured – death will 0ccur immediatelyClinical manifestation: - Unconsciousness, absent of reflexes. - Dilated sluggish pupil severe thirst. - ARDS, DIC brad cardio. - Cyanosis. - Absence of bowel sounds. - Immune system collapse. - Anuria. Management: Management same like progressive stage:402
Hypovolemic Shock: It is occurs as a result of the loss of intravascular fluid volume due to the fluid loss the body cells cannot get the oxygenation it leads to shock. The degree of shock depends upon - Volume lost – compensatory mechanism. - The rate of lost – age & physical condition. Etiology: it may be Internal fluid loss External fluid loss - Trauma (ruptured spleen) - Gastro intestinal bleed - Long bone fracture -Burns dehydration - Lesions causing hemorrhage - Diuresis in hyperglycemic (Ulcer) - Surgical procedures - Diabetic coma - Through fistula Pathophysiology:
Clinical manifestation: - If fluid loss occurs internally the cause or effects may not visible immediately. - External loss is after more greedily visible to the nurse. - Anxiety restlessness alters mental state due to caribel perfusion-hypoxia. - Hypo tension. - A rapid weak thread pulse. - Cool clammy skin. - Rapid shallow respiration. - Hypothermia. - Thirst and dry month. - Fatigue. - Distracted look in the eye (pupils dilated). Cardio Genic Shock: This type of shock is caused by the failure if the heart to pump effectively. Etiology: This can be damage of the heart Cardiac:Muscle due to Lange myocardial infarction (AWMI) 403
Non cardiac:- severe hypoxemia - Tension pneumothorax - cardiomyopathy - Congestive heart failure - Massive pulmonary embolism Pathophysiology:
Clinical Manifestation: - Distended jugular veins. - Absence of pulse due to tachyarrthmia. - Anginal pain. - Haemodynamic instability. Distributive Shock-Vasogenic: In hypovolemic shock there is an insufficient intravascular volume of blood this form of relative hypovolaemia is the result of dilatation of blood vessels systemic vascular resistance Septic Shock: Etiology: This is caused by an over whelming infection leading to vasodilatation such as gram negative bacteria e.g., E. coli, pneumococcal, streptococci -Certain fungi. -Gram positive bacteria. -Viruses. 404
Pathophysiology:
Clinical manifestation: -Hypotension. -Tachycardia. -Tachypnea. -Warm skin. -Hyperthermia. -Polyuria. -Hyperglycemia. -Metabolic acidosis. -Pale skin. -Worsening mental status. -Nausea and vomiting. -Diarrhea Neurogenic Shock: It is the rarest form of shock. It is caused by allergens, spinal anesthesia, surgeries and drugs that inhibit the sympathetic nerve stimulation. 405
Etiology: -Spinal cord injury. -Spinal anesthesia. -Head injury. -Extreme pain. Pathophysiology:
Clinical manifestation: -Bradycardia. -Hypotension. -Extreme pain. -Altered body temperature. -Placid paralysis. -Loss of bladder and bowel function. -Decreased skin perfusion. Anaphylactic Shock: It is caused by a severe anaphylactic reaction to an allergen, antigen, drug or foreign protein. Risk factor: -Penicillin sensitivity. -Transfusion reaction. 406
-Bee sting allergy. -Severe allergic to food and medicine. -Pollen hypersensitivity. Pathophysiology:
Clinical manifestation -Feeling of uneasiness. -Head ache. -Severe anxiety. -Disorientation. -Decreased LOC. -Laryngeal edema. -Hoarseness. -Dyspnea, wheezes, coughing. -Pruritis. -Angi edema. Obstructive Shock: In this situation the flow of blood is obstructed which impedes circulation and can result in circulatory arrest. Severe conditions result in this form of shock i. cardiac tapenade ii. Tension pneumothorax iii. Massive pulmonary embolism iv. Aortic stenosis Endocrine Shock: Recently 5th form of shock has been introduced based on endocrine disturbances. -Hypothyroidism. -Thyrotoxicosis. 407
-Acute adrenal insufficiency Diagnostic Evaluation: -Clinical history-A thorough history of patient with vomiting, diarrhea, trauma, any hemorrhage from wound, fever, history of Bee sting. Physical examination: A thorough examination from head to foot to be done for to assess the tachypnea, tachycardia, rapid shallow breathing, purities, hypotension, Fever, vomiting, sweating, altered consciousness. Laboratory examination: a.) CULTURE-culture fiord blood, sputum, urine, surgical and non surgical wound to rule out the organism. b.) BLLOD-Elevated WBC decreased Hb it may decreases with progression of shock. c.) ABG-To rule out respiratory alkalosis d.) ECG-To rule out dysarrthmias, MI. e.) ECHO CARDIOGRAM-To rule out aortic stenosis and pulmonary embolism. f.) CT SCAN-Sie of abscess. g.) CHEST AND ABDOMEN RADIO GRAPHY-Infection process. h.) CARDIAC MONITOR-SpO2, pulse, temp, BP. monitored continuously. i.) CVP-Fluid loss. Management of Shock: Medical management: a.) Non Invassive. b.) Invassi a.) Non Invassive: -To identify the causes -To control the external hemorrhage via pressure. -Use of military antis hock garments Mast Garmen: - It also called pneumatic antis hock garments. There are three chambers one piece lower part of the body, second for leg chambers one for abdomen. Suit from the lower costal to the ankles. - External pressure provided by MAST. It cause increases the vascular resistance and reduces the diameters of blood vessels in the abdomen and leg. It results decrease in blood leakage so tissue perfusion increases to the vital organ. Intraballoon Pump: -It is used the client with carcinogenic shock after open heart Surgery. External Counter Pulsation: It is same principle of intra abdomen balloon pump .But applied externally to the legs insisted in air water filled tubular bags connected to a pumping unit. Pressure is applied to legs during diastole and is released systole. Modified Trenlenberg Position: In this lower extremities 30to 45 devoted neck straight trunk to be horizontal neck comfortably positioned it promotes increase venous return From lower extremities without compressing the abdominal organ against the diaphargm increase cardiac out put – BP 408
5. use of cordiac monitoring 6. BPonitoring 7. maintain airway and breathing 8. frequent physical assessment b.) Invasive intervention: - Continuous hemodynamic monitoring. - Monitor means arterial pressure. - Administration of IV fluids, blood products. - Oxygen administration. - Continuous monitoring urine output. - Ventricular ass‘s devices. - External / parenteral nutrition support. Pharmacological Management: 1. Crystalloids – RL, NS. 2. Colloids- albumin, plasma substitute, PRBC, Wb.haemocele. 3. Inotropic- dopamine, dobitamin. 4. Vasodilators – NTG, sodium nitrofruside. 5. Dauretics –frusemide. 6. Antibiotics – gentamycin, aminoglycosides. 7. Antihistamines – epineprene. 8. Brinchodilators- aminophyline atropine. 9. Anticoagulants- heparine. 10. Steroids- prevent intra cellular release of enzymes. Surgical Management: 1. wound debridement: In case of chronic infected wound, burns wound debridement tube done for fast healing. 2. Amputation: In case of diabetic foot amputation to be performed 3. Angioplasty: In case of acute myocardial infarction angioplasty can be performed 2. Tracheotomy For bronco spasm. Nursing Management: - Asses the patient level of conscious. - Close monitoring of vital signs. - Oxygen administration. - Ventilator care. - IV fluid administration. - Continuous cardiac monitoring. - Administration of medication. - Skin care. - Support the family members. Nursing Diagnosis: 1. In effective breathing pattern related to hypoxia, bronco spasm. 2. Impaired tissue perfusion related to decrease cardiac output, decreased venes return. 409
3. Fluid volume deficit related to vomiting hemorrhage. 4. Acute pain related to myocardial infarction. 5. Imbalanced nutrition less then body requirement related to vomiting, low intake of food. 6. Impaired skin integrity related to purities. 7. Fear related to hospitalization. Nursing Intervention: ASSESSSMENT NURSING GOALS INTERVENTION DIAGNOSIS Rapid shallow In effective Improve -asses the patient characteristic of breathing breathing the breathing pattern related breathing (rate, rhythm, volume, depth) to hypoxia pattern -asses the patient vital signs -provide fowler‘s position -provide oxygen therapy -administered bronco dilators ( asthalin, deriphyline) -give nebulization therapy -in case of bronco spasm indotraochial intubation can be don -administered intravenous therapy -to assess the ABG Dry skin Impaired tissue cyanosis, cold perfusion clammy skin related to decreased venous return, hypoxia
Maintain normal tissue perfusion
-asses the patient skin integrity, color , appearance -provide intra venous therapy -provide cool environment -maintain personal hygiene -apply emollients to prevent skin breaking -administered oxygen for cyanosis -advice the patient to drink more fluid -change the linen frequently -change the position frequently
Complication: ARDS- (acute respiratory distress syndrome) In case of septic shock patient may go for ARDS DIC - disseminated intravascular coagulation Due to ineffective perfusion, decrease venous return Multiple Organ Failure: Due to in adequate tissue perfusion and decreased venous return. Multiple organ failure occurs. 410
BIBLIO GRAPHY: 1. Lippincott CRITICAL CARE NURSING‘ , A holistic approach, sixth edition, page no 935-9422. saunders, MANUAL OF NURSING CARE edited by joan luckmann,page no 364380 3. brunner and suddarth‘s TEXT BOOK OF MEDICAL-SURGICAL NURSING, 11EDITION, VOLUME ONE PAGE NO 356-377 4. Watson‘s MEDICAL SURGICAL NURSING AND RELATED PHYSIOLOGY 4th edision page no 222-233
411
ALTERATIONS IN BODY TEMPERATURE Body temperature reflects the balance between the heat produced and the heat loss from the body. Abnormal body temperature can be slight, such as low grade fever or life threatening, as in severe cases of hypothermia or hyperthermia. The nurse is often the person to monitor client‘s temperature, to identify deviations and to report significant findings to the physician, so that appropriate therapy can be instituted. Body temperature: In humans the traditional normal value for the temperature is 37C. Various parts of the body are at various temperatures. Physiology: the body temperature is the difference between the amount of heat produced by the body processes and the amount of heat loss to the external environment. Heat produced- Heat lost= Body temperature. Types: Core temperature: - is the temperature of the interior body tissue below the skin and subcutaneous tissue. The sites of measurement of core temperature are rectum, tympanic membrane, esophagus, pulmonary artery, urinary bladder. Shell temperature: - it refers to body temperature at the surface that is of the skin and subcutaneous tissue. The sites of measurement of shell temperature are skin, axillae and oral. Oral: 37C (98.6F) Rectal: 37.5C (99.5F) Tympanic: 37.5C (99.5F) Axillary: 36.5C (97.6F) Heat is continually produced in the body as a by-product of the chemical reactions called metabolism. Regulation: The balance between the heat lost and heat produced or thermoregulation is regulated by physiological and behavioral mechanisms. Neural control: Body temperature is controlled by the hypothalamus. The hypothalamus detects minor changes in body temperature and maintains the body temperature within the critical level referred as ―set point‖. Neurons in both the preoptic anterior hypothalamus and the posterior hypothalamus receive two kinds of signals; one from peripheral nerves that reflect warmth/cold receptors and the other from the temperature of the blood bathing the region. These two types of signals are integrated by the thermoregulatory centre of hypothalamus to maintain normal body temperature. When these neurons detect the temperature of blood is too warm, signals radiate to the ―heat loss centre‖ located in the anterior portion of the hypothalamus which is mainly composed of parasympathetic nerves that when stimulated initiate mechanism to decrease body heat. If cold is detected signals are sent to the heat promoting centre in the posterior hypothalamus which operates mainly through sympathetic nervous system which stimulates mechanisms to produce body heat. In a neutral environment, the metabolic rate of humans constantly produces more heat than is necessary to maintain the core body temperature t 37C. Vascular control: the circulatory system functions as a transportation mechanism responsible for carrying heat from body core to the skin surfaces from where it is transferred to the air through radiation, evaporation, conduction and convection. In order 412
to cool the body the superficial blood vessels dilate which leads to increased blood flow to the skin and is controlled by PNS. SNS produces vasoconstriction when body needs to conserve heat. Heat production: heat is produced in body by metabolism, which is the chemical reaction in all body cells. Food is the primary fuel source for metabolism. As metabolism increases heat production increases and as it decreases less heat is produced. Heat production occurs during rest, voluntary and involuntary shivering and no shivering thermo genesis. Rest: basal metabolism accounts for the heat produced by the body at absolute rest. The average basal metabolic rate (BMR) depends on the body surface area. Thyroid hormones also affect the BMR by promoting the breakdown of body glucose and fat they increase the chemical reactions in almost all the cells of the body. Stimulation of SNS by nor epinephrine and epinephrine also increase the metabolic rate of body tissues. These chemical mediators cause blood glucose to fall which stimulates cells to manufacture glucose. The male sex hormone testosterone increases BMR. Men have higher BMR than women. Voluntary movements: such as muscular activity during exercise require additional energy. The metabolic rate can increase up to 2000 times normal during exercise. Heat production can increase up to 50 times normal. Shivering: is an involuntary body response to temperature differences in the body. The skeletal muscle movement during the shivering requires significant energy. Shivering can increase heat production up to 4-5 times greater than normal. The heat that is produced assists in equalizing the body temperature, and the shivering ceases. No shivering thermo genesis: occurs primarily in neonates. Because neonates cannot shiver, a limited amount of vascular brown tissue present at birth is metabolized for heat production. Heat loss: heat loss and heat production occurs simultaneously. The skin‘s structure and exposure to the environment result in constant, normal heat loss through radiation, conduction, convection and evaporation. Radiation (60%): is the transfer of heat from the surface of one object to the surface of another without direct contact between the two. Radiation occurs because heat transfers through electromagnetic waves. Heat radiates from skin to any surrounding cooler object. Radiation increases as the temperature difference between the object increases. Blood flows from the core internal organs carrying heat to skin and surface blood vessels. The amount of heat carried to the surface depends on the extent of vasoconstriction and vasodilatation regulated by the hypothalamus. Peripheral vasodilatation increases blood flow to the skin to increase radiant heat loss. Peripheral vasoconstriction minimizes radiant heat loss. Up to 85% of the human body‘s surface area radiates heat to the environment. However if the environment is warmer than the skin, the body absorbs heat through radiation. The nurses increase the heat loss through radiation by removing the clothing or blankets. The client‘s position enhances radiation heat loss e.g. standing exposes a greater radiating surface area and lying in a fetal position minimizes heat radiation. Covering body with dark, closely woven clothing reduces the amount heat lost from radiation. 413
Conduction (3%): it is the transfer of heat from one object to another with direct contact. When a warm skin touches a cooler object, heat is lost. When the temperature of two objects is same, the conductive heat loss stops. Heat conducts through contact with solids, liquids and gases. Conduction normally accounts for small amount of heat loss. The nurse increases the conductive heat loss when applying an ice pack or bathing a client with cools water. Applying several layers of clothing reduces conductive loss. The body gains heat by conduction when contact is made with materials warmer than skin temperature. Convection (15%): it is the transfer of heat away by air movement. Heat is first conducted to air molecules directly in contact with skin. Air currents carry away the warm air. As the air current velocity increases, convective heat loss increases. I Evaporation (22%): it is the transfer of heat energy when a liquid is changed to a gas. The body continuously loose heat by evaporation. About 600-900ml a day evaporates from the skin and lungs, resulting in water and heat loss. This is normal loss and considered insensible water loss and does not play a major role in temperature regulation. When the body temperature rises, the anterior hypothalamus signals the sweat glands to release sweat. Sweat evaporates from the skin surface resulting in heat loss. During exercise and emotional and mental stress sweating is one way to lose excessive heat produced by the increased metabolic rate. Skin in temperature regulation: the skin‘s role in temperature regulation includes insulation of the body, vasoconstriction and temperature sensation. The skin, subcutaneous tissue and fat keep heat inside the body. In the human body the internal organs produce heat and during exercise and increased sympathetic stimulation. The amount of heat produced is greater than the usual core temperature. Blood flows from the internal organs carrying heat to the body surface. The skin is well supplied with the blood vessels esp., the areas of hands, feet and ears. Blood flow through these vascular areas of the skin may vary from minimal flow to as much as 30% of the blood ejected from the heart. Heat transfers from the blood through vessel walls, to the skin‘s surface and is lost to the environment through the heat loss mechanisms. The body‘s core temperature remains within the safe limits. The degree of vasoconstriction determines the amount of blood flow and heat loss to the skin, if the vasoconstriction is too high, the hypothalamus inhibits the vasoconstriction. As a result the blood vessels dilate and more blood reaches the skin‘s surface. On a hot humid day the blood vessels in the hands are dilated and easily visible. In contrast if the vasoconstriction becomes too low, the hypothalamus initiates the vasoconstriction and blood flow to the skin lessens. Thus body heat is conserved. The skin is well supplied with heat and cold receptors. As the cold receptors. Are plentiful the skin functions primarily to detect cold surface Temperatures. When the skin becomes chilled, its sensors send information. To the hypothalamus, this initiates shivering to increase body heat. Production, inhibition of sweating, and vasoconstriction. Behavioral control: humans voluntarily act to maintain comfortable body temperature when exposed to temperature extremes. The ability of person to control body temperature depends no: degree of temperature extreme, the person‘s ability to sense feeling comfortable or uncomfortable, thought processes or emotions. And the person‘s mobility or ability to remove or add clothes. 414
Infants can sense uncomfortable warm conditions but need assistance in changing the environment. Older adults may need the help in detecting cold environments and minimizing heat loss. Mechanisms Activated By Cold: Increased heat production: increase in BMR, muscle activity, thyroxin output, epinephrine, nor epinephrine and sympathetic stimulation, fever. Decreased heat loss by coetaneous vasoconstriction, curling up. Mechanisms Activated By Heat: Increased heat loss by coetaneous vasodilatation, sweating, increased respiration Decreased heat production: manifested by anorexia, apathy, illness. Factors Affecting The Body Temperature: Many factors affect the body temperature. Changes in body temperature within an acceptable within an acceptable range occur when the relationship between the heat production and the heat loss is altered by physiological or behavioral variables. 1. Age: at birth the newborn leaves a warm, relatively constant environment and enters one in one in which temperature fluctuates widely. Temperature control mechanisms are immature. An infant‘s temperature may respond drastically to changes in the environment. Extra care is needed to protect the newborn from environmental temperatures. Clothing must be adequate and exposure to the temperature extremes must be avoided. A newborn loses up to 30% of body heat through the head and therefore needs to wear a cap to prevent heat loss. The newborn‘s body temperature is maintained within 35.5-37.5C (95.9-99.5F). Heat production steadily declines as the infant grows into childhood. Children‘s temperatures continue to be more variable than those of adults until puberty.Older adults are particularly sensitive to temperature extremes because of deterioration in control mechanisms particularly poor vasomotor control (control of vasoconstriction and vasodilatation), reduced amounts of subcutaneous tissue, reduced sweat gland activity and reduced metabolism, reduced intake of diet. 2. Exercise: muscle activity requires an increased blood supply and an increased fat and carbohydrate breakdown that causes increases in heat production. Any form of exercise increase the heat production and thus the body temperature. Prolonged strenuous exercise, such as long distance running, can temporarily raise body temperatures up to 41C (105.8F). 3. Hormone level: women generally experience greater fluctuations in body temperature than men. Hormonal variations during the menstrual cycle cause body temperature fluctuations. Progesterone levels rise and fall cyclically during the menstrual cycle. When progesterone levels are low, the body temperature is a few tenths of a degree below the baseline level. The lower temperature persists until ovulation occurs. During ovulation, greater amounts of progesterone enter the circulatory system and raise the body temperature to previous baseline levels or higher by 0.3-0.6(0.5-1.0F). Body temperature changes also occur in women during menopause (cessation of menstruation). Women who have stopped menstruating may experience periods of intense body heat and sweating lasting from 30 second to 5 minutes. There may be intermittent increases in skin temperature of up to 4C (7.2F) during these periods, referred to hot flashes. This is due to the instability of the vasomotor controls for vasodilatation and vasoconstriction. 415
4. Circadian rhythm: body temperature normally changes 0.5-1C (0.9-1.8F) during a 24 hour period. The temperature is usually lowest between 1.00- 4.00 am. During the daytime the body temperature rises steadily up to 6.00pm and then declines to early morning levels. 5. Stress: physical and emotional stress increase body temperature through stimulation of sympathetic nervous system due to increase in production of epinephrine and nor epinephrine thereby increasing metabolic activity and heat production. A client who is anxious could have an elevated body temperature for that reason. 6. Environment: extremes of environment can affect a person‘s temperature regulatory systems. If temperature is assessed in a warm room, a client may be unable to regulate body temperature by heat loss mechanisms and the body temperature will be elevated. Similarly, if the client has been outside in extremely cold weather without suitable clothing the body temperature may be low. Fever: Fever is an elevation of body temperature that exceeds normally daily variation and occurs in conjunction with an increase in the hypothalamic set point for e.g. 37C-39C. Once the hypothalamic set point is raised, neurons in the vasomotor centre are activated and vasoconstriction commences. The individual first notices vasoconstriction in hands and feet. Shunting of blood away from the periphery to the internal organs essentially decreases heat loss from the skin and the person feels cold. For most fevers body temperature increases by 1-2C. Shivering which increases heat production from muscles may begin at this time. Heat production from liver also increases. In humans behavior e.g. putting on more clothing or bedding help raise body temperature. The process of heat conservation (vasoconstriction) and heat production (shivering and increased metabolic activity) continue until the temperature of blood bathing the hypothalamic neurons match the new thermostat setting. Once the point is reached, the hypothalamus maintains he temperature at febrile levels by same mechanism of heat balance that are operative in a febrile state. When the hypothalamic set point is again reset downward due to either the reduction in concentration of pyrogens or use of antipyretics. The process of heat loss through vasodilatation and shivering are initiated. Loss of heat by sweating and vasodilatation continues until the body temperature at the hypothalamic level matches the lower settings. A fever of less than 41.5(less than 106.7 f) is called hyperpyrexia. This extraordinary high fever can develop in patient with severe infection. But mostly occur in C.N.S. hemorrhage. In some rare cases, the hypothalamic set point is elevated as a result of local trauma, hemorrhage, tumor or intrinsic hypothalamic malfunction. The term hypothalamic fever is sometimes used to describe elevated temperature caused by abnormal hypothalamic function. However most patients with hypothalamic damage have subnormal or equal but not supernormal body temperatures. Causes of fever: Hot environment. Excessive exercise. Neurogenic factors like injury to hypothalamus. Dehydration after excessive dieresis. 416
As an undesired side effect of a therapeutic drug. Chemical substances e.g. caffeine and cocaine directly injected into the bloodstream. Injection of proteins or other products. Infectious disease and inflammation. Severe hemorrhage. Symptoms of fever: Flushed face; hot dry skin; anorexia; headache; nausea and sometimes vomiting; constipation and sometimes diarrhea; body aches and scant highly colored urine. Clinical signs of fever: Increased heart rate, respiratory rate and depth; shivering; pale cold skin; cyanotic nail beds; cessation of sweating Classification or patterns of fever: 1. Intermittent fever: the temperature curve returns to normal during the day and reaches its peak in the evening. E.g.: in septicemia 2. Remittent fever: the temperature fluctuates but does not return to normal. E .g: TB, viral diseases, bacterial infections 3. Sustained fever: the temperature remains elevated with little fluctuation. 4. Relapsing fever: periods of fever are interspersed with periods of normal temperature. Tertian- when paroxysm occurs on 1st and 3rd days Quatrain- fever associated with paroxysm on first and fourth day. E.g. in malaria Pathogenesis of Fever: 1. Pyroxenes: progeny is any substance that causes fever. Exogenous pyroxenes are derived from outside the patient; most are microbial products, toxins or micro-organisms. E.g.: lip polysaccharide end toxin produced by all gram negative bacteria. Enter toxins of gram positive like staphylococcus aurous and Group. A and B Streptococcal toxins 2. Phylogenic cytokines: cytokines are small proteins that regulate immune, inflammatory and hematopoietic processes. For e.g. stimulation of lymphocyte proliferation during any immune response to vaccination is the result of the cytokines interleukin (IL) 2, IL-4, IL-6, TNF (Tumor Necrosis Factor). Some cytokines cause fever and are called phylogenic cytokines including IL-1, IL-6, and interferon (IFN) alpha. Each cytokine is encoded by a separate gene and each phylogenic cytokine has been shown to cause fever. The synthesis and release of endogen progeny cytokines are induced by exogenous progeny which has recognizable bacterial or fungal sources. Viruses induce progeny cytokines by infecting cells. In absence of microbial infection, inflammation, trauma, tissue necrosis or antigen antibody complexes can induce the production of progeny cytokines which individually or in combination trigger the hypothalamus to raise the set point to febrile levels. The cellular sources of cytokines are primary monocytes, neutrophils, lymphocytes although many other types of cells can synthesize theses molecules. 3. Elevation of hypothalamic set point by cytokines: during fever, levels of prostaglandin E2 (PGE2) are elevated in hypothalamic tissue. Cytokines pass from circulation to brain. The endogenous and exogenous pyroxenes interact with the endothelium of hypothalamus and raise set point of febrile cells. 417
4. Production of cytokines in CNS: several viral diseases produce active infection in the brain. Glial or neuronal cells synthesize IL-1, IL-6, and TNF. Therefore CNS production of cytokines raises hypothalamic set point. Chronology Of Events Required For Induction Of Fever:
Grades of Fever: 1. low grade fever: 37.1-38.2C(98.8-100.6F) 2. high grade fever: 38.2-40.5C(100.6-104.9F) 3. hyperpyrexia: >40.5C(104.9F) Phases of Fever: A febrile episode has three distinct phases:1. Chill phase: the body‘s heat producing, mechanism attempt to increase the core temperature. The client experiences cold and may shiver. Goose flesh caused by contraction of erector Pilli muscles in an attempt to trap air around body hairs, is evident. Skin becomes pale and cool due to vasoconstriction. 2. Fever phase: it occurs when fever reaches the new higher set point. The client‘s skin feels neither hat nor cold. Cellular degeneration leads to fluid and electrolyte losses. If fluid volume deficit has occurred the client may experience thirst. Complains of aching muscles, general malaise weakness can be there due to increased of protein catabolism. Client may be drowsy or restless. An uncontrolled fever can make the patient delirious and to suffer from convulsions due to cerebral nerve cell irritation. 3. Flush or crisis phase: during this phase the client experiences profuse diaphoresis, decreased shivering and possible fluid volume deficit. The client‘s skin appears flushed and warm to touch because of vasodilatation. Hyperthermia: Hyperthermia is characterized by an unchanged (normothermic) setting of the thermoregulatory center in conjunction with an uncontrolled increase in body temperature that exceeds the body‘s ability to lose heat. Exogenous hest exposure and endogenous heat production are two mechanisms by which hyperthermia can result in dangerously high internal temperatures. Excessive heat production can easily cause hyperthermia despite physiologic and behavioral control of body temperature. For e.g.: work and exercise in a hot environment can produce heat faster than peripheral mechanisms can lose it. Although most patients with elevated body temperature have fever, there are few circumstances in which elevated body temperature represents not fever but hyperthermia. 418
Causes of Hyperthermia Syndromes: 1. Heat stroke: caused by thermoregulatory failure in association with an arm environment may be categorized as exceptional and non exceptional. Exceptional: it occurs in younger individuals who exercise in higher than normal heat or humidity, dehydration Non exceptional: it is caused by anti cholinergic, including antihistamines, anti parkinsonian drugs, diuretics, phenothiazines. It occurs in either in very young or elderly during heat waves, bedridden patients, elderly and taking drugs confined to poorly ventilated and non AC environment. 2. Drug induced hyperthermia: due to increased use of psychotropic drugs. Monoamine oxidizes inhibitors, tricycle antidepressants, amphetamines, phencyclidine, lysergic acid diethylamide or cocaine. 3. malignant: occur in individuals with inherited abnormality of skeletal muscle sarcoplasmic reticulum that cause rapid increase in intracellular Ca level in response to halothane and other inhalation anesthetics or to succinylcholine. In this there is elevated body temperature, increased muscle metabolism, muscle rigidity, rhabdomyolysis, acidosis and cardiovascular instability and is often fatal. 4. The narcoleptic malignant syndrome (NMS): occur due to use of narcoleptic agents like antipsychotic phenothiazines, haloperidol, pro chlorprazine, meto chlopramide or withdrawal of dopaminergic drugs and is characterized by muscle rigidity (lead pipe), extra pyramidal side effects, autonomic deregulation and hyperthermia. It is caused by inhibition of central dopamine receptors in hypothalamus which results in increased heat generation and decreased heat dissipation 5. serotonin syndrome: seen in selective serotonin uptake inhibitors(SSRIs), MAO‘s and serotonergic medications have overlapping features including hyperthermia but distinguished by presence of diarrhea, tremors, myoclonous rather than lead pipe rigidity. 6. endocrinopathy: thyrotoxicosis and pheochromocytoma can lead to increased thermogenesis 7. central nervous system damage: cerebral hemorrhage, status epileptics, hypothalamic injury can cause hyperthermia Aproach To The Patient: 1. History: history of use of OTC medications, or treatment such as surgical/dental procedures. Nature of prosthetic materials or dental procedures. Occupational history, exposure to animals, infectious agents, febrile or infected individuals in the home, workplace/O geographic areas patient traveled. Use of tobacco, IV drugs, trauma, animal bites, immunization. Family history of TB, arthritis, infectious disease, anemia. Ethnic origin e.g. blacks are more likely to have haemoglobinopathies 2. Physical examination: vital signs, check skin, lymph nodes, eyes, nail beds, CVS, chest abdomen, musculoskeletal system, nervous system, penis, scrotum, testes should be examined carefully. Pelvic examination for PID and tubo-ovarian abscess. 3. laboratory tests: if a patient reveals more than a simple viral illness or pharangitis then lab testing is done:
419
Clinical pathology: CBC, DLC. Neutrogena is present in some viral infections, drug reactions, SLE, typhoid, leukemia. Lymphocytosis with typhoid, brucellosis, TB and viral diseases. Monocytosis in typhoid, TB, brucellosis, lymphoma. Eosinophilia in hypersensitivity and drug reactions, Hodgkin‘s disease, adrenal insufficiency. Blood smear for malarial pathogens, ESR. Urinalysis. Any abnormal fluid accumulation like pleural fluid, peritoneum, joint is examined. Bone marrow biopsy for histopathologic studies as well as culture in infiltration of marrow by pathogens or tumor cells. Stool for occult blood, inspection for ova, parasites. Chemistry: electrolytes, blood glucose, BUN, creatinine, LFT Microbiology: smears and cultures of specimen from throat, urethra, anus, cervix, vagina. When there are no localized findings or when findings suggest the involvement of pelvis, GIT. If respiratory infection than sputum evaluation (Gram staining, staining for AFB, culture). Cultures of blood, abnormal fluid collection, urine if fever reflects more then uncomplicated viral illnesses. CSF examined and cultured if meningismus, severe headache or change in MSE is there. Radiology: a chest X-ray is part of evaluation for any significant febrile illness. Medical management: It is important to distinguish between fever and hyperthermia since hyperthermia can be rapidly fatal and doesn‘t respond to antipyretics. Pharmacological management: 1. Acetaminophen: adult: 325-650 mg PO q 4-6 hrs. Children: 10-15mg/kg body weight q4-6 hrs. 2. Ibuprofen (NSAID) - dosage: adult-200-400mg PO q6hrs; children: 5mg/kg body wt for temp. <102.5F; 10 mg/kg body wt. for temp 102.5F (not to exceed 40 mg/kg/day). 3. Indomethacine and naproxen (NSAID). 4. Aspirin: adult 325-650 mg PO q6hrs; children 10-20 mg q 6hrs. 5. Glico corticosteroid: potent antipyretic inhibit PGE2 synthesis. 6. Mepridine, morphine sulphate, chlorpromazine. To manage severe rigors: treatment of underlying cause, nutrition, rest, physical cooling: tepid bath, hypothermia blankets Management of hyperthermia: Cause of hyperthermia should be treated. Dandroline and procainamide should be given for malignant hyperthermia. The attempt to lower the already normal hypothalamic set point is of little use. Physical cooling with sponging, cooling blankets, cooling mattress or even ice bags should be initiated immediately in conjunction with appropriate pharmacological agents and intravenous fluids. Internal cooling can be achieved by gastric or peritoneal lavage by iced saline. In extreme circumstances, hemo dialysis or even CPB with cooling of blood may be performed. Nursing management of fever and hyperthermia: Monitor vital signs. Assess skin color and temperature. Monitor white blood cell count, hematocrit value, and other pertinent laboratory reports for indication of infection or dehydration. 420
Remove excess blankets when the client feels warm, but provide extra warmth when the client feels chilled. Provide adequate nutrition and fluids to meet the increased metabolic demands and prevent dehydration. Measure intake and output. Reduce physical activity to limit heat production especially during the flush stage. Administer antibiotics as ordered. Provide oral hygiene to keep the mucous membranes moist. Provide a tepid sponge bath to increase heat loss through conduction. Provide dry clothing and bed linens. During chill phase: Risk for altered body temperature as evidenced by shivering and feeling cold: Monitor vital signs, restrict activity, monitor skin color and temperature, apply extra blankets, increase fluid intake, apply extra blankets, supply oxygen if client has preexisting cardiac or respiratory problem. During fever phase: Hyperthermia as evidenced body temperature >38.5C, irritability, increased respiratory rate and dry skin: Remove excess clothing and covers, cover with light warm clothing to avoid chilling, monitor temperature as needed, encourage cool fluids, apply lubricant to dry lips and nasal mucosa, increase air circulation to encourage cooling, control environmental temperature not too cold, administer antipyretics as prescribed, cool with tepid bath, adjust cooling measures on the basis of temperature, notify physician of significant change. Altered comfort as evidenced by restlessness: Promote rest, restrict activity, assess client‘s response to pain management, and take safety precautions if patient is delirious, monitor for decreasing level of consciousness. Altered nutrition related to fever as evidenced by anorexia and lack of food intake: Provide high calorie diet, encourage fluid intake, reduce iron intake During flush phase: Altered fluid and electrolyte balance related to excessive sweating: Monitor intake and output, monitor electrolytes, replace fluids and electrolytes lost through sweating, monitor temperature, and provide rest. Heat cramps: These painful muscle cramps occur most commonly in the legs of young people following vigorous exercise in the hat weather. There is no elevation of core temperature. The mechanism is considered to be extracellular sodium depletion following electrolyte loss a result of persistent sweating with replacement of water but no salt. The syndrome is also encountered in miners undertaking heavy physical work in hat conditions with very limited ventilation, which impairs the effect of evaporative heat loss from sweating. Symptoms usually respond to salt replacement. Heat exhaustion: Heat exhaustion occurs when there is an elevation in core (rectal) temperature to between 37-40C and is usually seen when the individual is undertaking vigorous physical work in a hat environment. A high work rate, extreme ambient temperature, impairing 421
evaporative heat loss due to high humidity or inappropriate clothing may all combine to overcome thermoregulatory control. The diagnosis is based no the findings of an elevated core temperature associated with hyperventilation and symptoms of tiredness or fatigue, muscular weakness, dizziness and collapse. The blood analysis may show evidence of dehydration with mild elevation of blood urea, sodium concentration and hematocrit. Treatment involves removal of patient from the heat, active cooling using cool sponging, and fluid replacement. This may be achieved by oral dehydration mixtures containing both salt and water or intravenous isotonic saline . Adult patients may require 5 liters or more positive fluid balance in the first 24 hours. Frequent monitoring of blood electrolytes is important, esp. in patients receiving I.V. replacement therapy. Heat stroke: Heat stroke occur when the core body temperature rises above 40C and is a severe and life threatening condition provoked by failure of heat regulatory mechanisms. The symptoms of heat exhaustion progress to include headache, nausea and vomiting. Neurological manifestations include a coarse muscle tremor and confusion, which may progress to loss of consciousness. The patient‘s skin feels very hat, and sweating is often absent due to failure of thermoregulatory mechanisms. The condition may progress from heat exhaustion or present acutely in a patient who has become progressively dehydrated without symptoms. Coincidental illness age and drug therapy, particularly phenothiazines diuretics and alcohol may be the contributory factors. Complications include Hypovolemic shock, lactic acidosis, and disseminated intravascular coagulation. Rhabdomyolisis, hepatic and renal failure and cerebral edema. The patient should be managed in ICU with rapid cooling using ice packs, careful fluid replacement and appropriate intravascular monitoring. Investigations reflect the complication sand include coagulation studies and muscle enzymes and in addition to routine hematology and biochemistry Fever of Unknown Origin: Definition: Fever of unknown origin (FUO) was defined by Peterson and Benson in 1961 as (1) temperatures of > 38.3 degree Celsius (>101 degree Fahrenheit) in several occasions; (2) a duration of fever of > 3 weeks and; (3) failure to reach a diagnosis despite 1 week of inpatient investigation. Classification of FUO: Derrick and Street have purposed a new system for classification of FUO:1. Classic FUO: same as above criteria. E.g. infections, malignancy, inflammatory diseases, drug fever. 2. Nosocomial FUO: a temperature of >= 38.3 C (>=101 F) develops on several occasions in a hospitalized patient who is receiving acute care and in whom infection was not present at time of admission. For e.g. septic thrombophlebitis, sinusitis, drug fever. 3. Neutropenic FUO: a temperature of >= 38.3 C (>=101 F) develops on several occasions in a patient whose neutrophil count is < 500/micro liter or is expected to fall to that level in 1-2 days. 4. HIV- associated FUO: a temperature of >= 38.3 C (>=101 F) develops on several occasions over a period of > 4 weeks for outpatients or > 3 days for hospitalized patients with HIV infection. 422
Causes of FUO: 1. Infections: Localized phylogenic infections: appendicitis, cholecystitis, dental abscess. Intravascular infections: bacterial endocarditic. Systemic bacterial infections: typhoid fever. Mycobacterium infections: tuberculosis. Fungal infections: candidacies. Viral infections: dengue, hepatitis A, B, C, D and E, HIV infection. Parasitic infections: amebiasis, malaria. Rikettsial infections. Mycoplasmal infections. Chlamydial infections. 2. Neoplasm’s: (a) malignant: colon cancer, gall bladder carcinoma, leukemia, renal cell carcinoma.(b) benign: castle man‘s disease 3. Habitual hyperthermia: exaggerated circadian rhythm 4. Collagen vascular/ Hypersensitivity diseases: rheumatic fever, rheumatic arthritis, systemic lupus erythematous 5. Granulomatous Diseases: crohn‘s disease 6. Miscellaneous conditions: drug fever, gout, haemo globinopathies, tissue infarction or necrosis 7. Inherited and metabolic diseases: adrenal insufficiency, familial cold urticaria 8. Thermoregulatory Disorders: (a) Central: brain tumor, Cerebro vascular accident, encephalitis; (b) Peripheral: hyperthyroidism, pheochromocytoma Diagnosis of FUO: History and physical examination, blood investigations, tumor markers, PPD for TB, serological studies, peripheral smears, multiple samples for culture and sensitivity, X-Ray studies, bone marrow biopsy, Liver biopsy, GI contrast studies, CT scan, MRI, ultrasonography. Treatment: The patients with classic FUO are continually observed and examined and not given the empirical therapy. The antibiotic therapy given to the patient can delineate the ultimate cause of FUO. If neutropenia and vital sign instability are present then empirical therapy with fluroquinolone and piperacillin is given. If PPD test is positive or granuloma hepatitis is confirmed then isoniazid and rifampcin for 6 weeks is given. When no underlying source of infection is found even after 6 months the prognosis is generally good. The debilitating symptoms are treated by NSAIDSs and glucocorticoids. Hypothermia: Hypothermia is a state in which the core body temperature is lower than 35 degree Celsius and 95 degree Fahrenheit. At this temperature many of the compensatory mechanism to conserve heat begin to fall. Classification: 1. Primary hypothermia: it is a result of the direct exposure of a previously healthy individual to the cold. 2. Secondary hypothermia: it is hypothermia that results due to a complication of a serious systemic disorder. 423
3. Accidental hypothermia: it results from unintentional exposure to cold or wet and windy climate with an ambient temperature less than 16 degree Celsius. 4. Induced hypothermia: it is deliberate lowering of temperature to a range of a 7890F (26-32.5C) to reduce oxygen need during surgery (esp. cardiovascular and neurosurgical procedures) and in hypoxia, to reduce blood pressure and to alleviate hyperthermia by administering drugs that depress the hypothalamic thermostat or by encasting the client in a cooling blanket. Causes: 1. Exposure to cold environment in winter months and colder climates. 2. Occupational exposure or hobbies that entail extensive exposure to cold for e.g. hunters, skiers, sailors and climbers. 3. Medications like ethanol, phenothiazines, barbiturates, benzodiazepines, cyclic antidepressants, anesthetics. 4. Endocrine dysfunction: hypothyroidism, adrenal insufficiency , hypoglycemia 5. Neurologic injury from trauma, Cerebral vascular accident, Subarachnoid hemorrhage 6. Sepsis Risk factors for Hypothermia: 1) Age extremes: elderly, neonates. 2) Outdoor exposure: occupational, sports-related, inadequate clothing. 3) Drugs and intoxicants: ethanol, phenothiazines, barbiturates, anesthetics, neuromuscular blockers and others. 4) Endocrine related: hypoglycemia, hypothyroidism, adrenal insufficiency, and hypopituitarism. 5) Neurologic related: stroke, hypothalamic disorders, Parkinson‘s disease, spinal cord injury. 6) Multisystem: malnutrition, sepsis, shock, hepatic or renal failure. 7) Burns and exfoliative dermatologic disorders. 8) Immobility or debilitation. Clinical presentation: Hypothermia leads to physiological changes in all organ systems. Seve Body CNS CVS Respiratory Renal and Neuromu rity temp system endocrine scular Mild 35Decreased Tachycardia Tachypnea, Diuresis, Increased 32.2C cerebral , bradypnea, increase preshiveri (95Metabolism, vasoconstric decline in ng 90F) amnesia, tion, Oxygen metabolism Muscle Apathy, increase in consumption with tone, Dysarthria, cardiac , shivering fatiguing, Impaired output and bronchospas ataxia judgement Blood m pressure Mod <32.2- EEG Decrease in Hypoventilat 50% Hyporefle erate 28C abnormalitie pulse and ion, 50% Increase in xia, (90s, cardiac decrease renal Diminishi 82.4F) decreasing output, in carbon blood flow ng 424
level of consciousne ss, pupillary dilatation, hallucinatio ns
Seve re
increased atrial and ventricular arrhythmias, prolonged systole
<28C (82.4F )
dioxide per 8 C drop in temp, Absence of protective airway reflexes, 50% decrease in oxygen consumption Pulmonic congestion and edema, apnea
impaired insulin action
shiveringinduced thermogen esis, rigidity
Loss of Decrease in Decrease in No cerebroBP, heart renal motion, vascular rate and blood flow, peripheral auto cardiac Extreme areflexia. regulation, output, oliguria decline asystole in cerebral blood flow, coma, loss of reflexes There is progressive deterioration, with apathy, poor judgment, ataxia, dysarthria, drowsiness, pulmonary edema, acid-base abnormalities, coagulopathy, and eventual coma. Shivering may be suppressed below a temperature of 32.2C (90F), because the body‘s self warming mechanisms become ineffective. The heartbeat and blood pressure may be so weak that peripheral pulses become undetectable. Diagnosis: Hypothermia is confirmed by measuring the core temperature, at two sites. Rectal probes should be placed to a depth of 15 cm and not adjacent to cold faces. A simultaneous esophageal probe should be placed 24cm below the larynx; it may lead to falsely high during heated inhalation therapy. Management: Management consists of continuous monitoring, rewarding, and removal of wet clothing, insulation, and supportive care. Monitoring: the ABC‘s of basic life support are a priority. The patient‘s vital signs, CVP, urine output, arterial blood gas levels, blood chemistry determinations (BUN, creatinine, glucose, electrolytes), and chest X-Rays are evaluated frequently. Body temperature is monitored with an esophageal, bladder, or rectal thermostat. Continuous ECG monitoring is performed because cold induced myocardial irritability leads to conduction disturbances, esp. ventricular fibrillation. An arterial line is inserted and maintained to record BP and facilitate blood sampling. Rewarming: rewarding methods include active core (internal) rewarding, active external rewarming, and passive or spontaneous rewarding. 425
Core rewarming: methods include cardiopulmonary by-pass, warm fluid administration, and warm humidified oxygen by ventilator, and warmed peritoneal lavage. Core rewarming is recommended for severe hypothermia i.e. poikilothermia. Monitoring for ventricular fibrillation as the patient passes through 31C-32C (88-90F) is essential. Passive external rewarding: includes the use of warm blankets or over-the-bed heaters. Passive rewarming of the extremities increases blood flow to the acidosis, anaerobic extremities. Supportive care: External cardiac compression (only as directed in very cold patient). Defibrillation of ventricular fibrillation. It is ineffective in patients with temperatures lower than 31C (88F). Mechanical ventilation with positive end-expiratory pressure (PEEP) and heated humidified oxygen to maintain tissue oxygenation. Administration of warm intravenous fluids (normal saline) to correct hypotension and maintain urine output and core rewarding. Administration of sodium bicarbonate to correct metabolic acidosis Administration of antiarrythmic medications bretylium tosylate is safe. Low dose dopamine (2 -5 microgram/kg) to treat hypotension. Gastric tube insertion to prevent dilation secondary to decreased bowel motility. Indwelling catheter to facilitate cold induced diuresis. Nursing management of hypothermia: Nursing diagnosis: hypothermia as evidence by body temperature <35C, shivering, cool skin, irritability etc. Nursing interventions: Provide extra covering and monitor temperature. Cover head properly. Use heat retaining blankets. Keep patient‘s linen dry. Control environmental temperature. Provide extra heat source (heat lamp, radiant warmer, pads, and blankets). Carefully assess for hyperthermia or burn. Regulate heat source according to physical response. Hypothermia In Newborn Babies: New born babies are often not able to keep themselves warm with low environmental temperature resulting in hypothermia. Hypothermia continues to be a very important cause of neonatal morbidity and mortality due to lack of attention by the health care providers. i. Handicaps of newborn in temperature regulation: A newborn is more prone to develop hypothermia because of a large surface area per unit of body weight. A low birth weight baby has decreased thermal insulation due to less subcutaneous fat and reduced amount of brown fat. Brown fat is a site of heat production. It is localized around the adrenal glands, kidneys, nape of neck, inter scapular and axillary region. Metabolism of brown fat results in heat production. Blood flowing through the brown fat becomes warm and through circulation 426
transfers heat to other body parts of the body. This mechanism of heat production is called as non-shivering thermo genesis. LBW babies lack this effective mechanism of heat production. ii. Mechanism of heat loss: Newborn looses heat by evaporation (particularly soon after birth due to evaporation of amniotic fluid from skin surface), conduction (by coming in contact with cold objects – cloth, tray etc), convection ( by air currents in which cold air from open windows replaces warm air around babies), and radiation(to cooler solid objects in vicinity walls). The process of heat gain is by conduction, convection and radiation in addition to nonshivering thermo genesis. Why newborns are prone to develop hypothermia? Large surface area. Decreased thermal insulation due to lack of subcutaneous fat. Reduced amount of brown fat. Nursing responsibility in preventing the heat loss in newborns and infants: Evaporation: keep the child dry, remove wet nappies, and minimize exposure during baths. Conduction: e.g. weighing a baby. Put the baby on prewar med sheet and cover scales and X-Ray diapers with warm diaper or blanket. Radiation: keep the babies cots and incubators away from outside walls, air conditioners; cover the baby if stable. Convection: avoid currents of air, manage babies inside incubator, and organize work to minimize opening portholes, provide warm humidified oxygen. Frost Bite: Frost bite is the condition in which the tissue temperature drops below 0 degree Celsius. It is trauma from exposure to freezing temperatures and actual freezing of the tissue fluids in the cell and intracellular spaces. It results in cellular and vascular damage. Body parts more frequently affected by frostbite include the digits of feet and hands, tip of nose, and earlobes. Predisposing factors: Contact with thermal conductors such as metal or volatile solutions, constrictive clothing or shoes, immobility, careless application of cold packs, vaso constrictive medications, Raynaud‘s phenomenon Pathophysiology:
427
Classification of frost bite: 1. First degree frost bite: causes only anesthesia and erythematic. 2. Second degree frost bite: appearance of superficial vesiculation surrounded by edema leads to very cold extremities. 3. Third degree frost bite: hemorrhagic vesicles due to serious microvasculature injury which further leads to cyanosis. 4. Fourth degree frost bite: damage in sub cuticular, muscular and osseous tissue. Symptoms: The injured area is white or mottled blue white, waxy and firm to the touch. There is tingling and redness followed by pallor and numbness of the affected area. There are three degrees: transitory hyperemia following numbness, formation of vesicles and gangrene. The affected area is insensitive to touch. Diagnosis: Angiography and MRI to assess the potency of large vessels. Ultrasonography, plethismography, thermography to evaluate perfusion after rewarming. Technetium scientigraphy to assess perfusion. Management of frost bite: Before thawing: remove the client from cold environment. Stabilize core temperature and treat hypothermia. Protect the frozen part and do not apply friction or massage. During thawing: provide parental analgesia e.g. keratolac. Immerse part in 37-40 C circulating water containing an antiseptic soap for 10-45 minutes. Encourage patient to gently move the part. Provide ibuprofen 40 mg PO. After thawing: gently dry and protect the part and elevate it. Apply pledges between toes; if macerated. If clear vesicles are intact aspirate the fluid or the fluid will reabsorb in days; if broken then debride and dress with antibiotic. Leave hemorrhagic vesicle intact to prevent infection. Continue analgesics Ibuprofen 400mg 8-12 hourly. Provide tetanus prophylaxis and hydrotherapy at 37C. The patient should be stimulated with orally administered hot fluids such as tea and coffee. The patient should not be allowed to smoke. Artificial respiration should be administered if the patient is unconscious. Non freezing cold injury: Trench foot or immersion foot this less severe form of cold injury resulting from prolonged exposure to cold and damp conditions the limb appears cold ischemic and numb but there is no freezing of tissue no rewarding the limb appears mottled. There after becomes hyperemic swollen and painful recovery may take many months and there may be chronic pain and sensitivity to cold. The pathology provably involves endothelial injury. The pain and associated par aesthesia may be difficult to control with normal analgesic.
428
BIBLIOGRAPHY: Koziar Barbaro, Glenora Erb, Andray Berman, Karen Burbe‘s ―Fundamentals of Nursing‖; Edition 7th; Published by Darling Kindereley Pvt.Limited, pp.523-536 Kasper, Braunwald, Fauci, Hauser, Longo, Jameson ―Harrison‘s Principles of Internal Medicine‖; Edition 16th; Published by Macgraw Hill 104-110. Potter A Patrica, Anne Griffen Perry‘s ―Fundamental Of Nursing‖, Edition 6th; Published By: Elsevier India Private Limited, Pp 619-637 Saunder‘s Manual Of Nursing Practice, Edition Ist ; Published By W.B. Saunder Company, Pp 620-625 Smeltzer C. Suzzane And Brenda Bare‘s ―Medical Surgical Nursuing‖; Edition 10th; Published By Lippincott ; Pp 481-489 Sr. Nancy ―Principles And Practice Of Nursing‖ Edition 4th; Published By N.R. Brothers; Pp 198-203 Www. Google.Com
429
SLEEP PATTTERN AND ITS DISTURBANCES Introduction: One third of human life is spent sleeping. Periods of rest may account for major portion of the life span. Sleep has long been assumed to have a restorative function and recently many people believed sleep to be a passive state of decreased stimulation. . A widely publicized 2003 study performed at the University of Pennsylvania School Of Medicine demonstrated that cognitive performance declines with fewer than eight hours of sleep. However, the purposes of sleep are only partly clear and are the subject of intense research. Sleep: Sleep is a naturally occurring altered state of consciousness characterized by decreases in awareness and responsiveness to stimuli. Sleep is distinguished from abnormal states of consciousness by being readily reversible. Physiology of Sleep: Two systems in brain stem, the reticular activating system and the bulbar synchronizing region are believed to work together to control the cyclic nature of sleep. The reticular formation is found in the brain stem and comprises many nerve cells and fibers. The fibers have connections that relay impulses into the cerebral cortex and into the spinal cord. It facilitates reflex and voluntary movements as well as cortical activities related to a state of alertness. Wakefulness occurs when the reticular system is activated with stimuli from the cerebral cortex and from periphery sensory organs and cells. The hypothalamus has control centers for several involuntary activities of the body, one of which concerns sleeping and waking. Injury to the hypothalamus may cause a person to sleep for abnormally long periods. Circadian Rhythms: Biological rhythms that follow a cycle of about 24 hours are termed circadian rhythms. The word circadian taken from the Latin words circa means ―about‖ and dies means ―day‖. The sleep-awake cycle is closely linked with other circadian rhythms such as body temperature, gastric acid and hormone secretion. Sleep is one of the body‘s most complex biologic rhythms. Circadian synchronization exists when an individual‘s sleep-wake patterns follow the inner biologic clock. That is, when physiologic and psychological rhythms are high or most active, the person is awake and when these rhythms are low, the person is sleep. Problems of resynchronizations occur when sleep-wake patterns are frequently altered and an individual attempts to sleep during high activity rhythms and to work when the body is physiologically prepared to rest. Physiologic Function: The physiology of sleep can be discussed in relation to two basic research approaches, each of which has provided building blocks for developing concepts relating to mechanisms and functions of sleep. The approaches are the electro- physiologic approach and neurotransmitter balance. Electro- physiologic Approach: Polygraph recording of electro-physiologic changes in brain waves, eye movements, and muscles show five sleep stages. The first four stages are classified as non-rapid eye movement (NREM) sleep and the other stage is called REM sleep.
430
Non-Rapid Eye Movement Sleep: Stage 1: stage 1 is the transitional stage between drowsiness and sleep, indicated by a shift from alpha waves to low-voltage, fast theta waves on the EEG. Muscles relax, respirations become even and pulse rate decreases. This stage usually lasts only a few minutes and if awakened the person may say he or she was not asleep. Stage 2: Stage2 is still a relatively light sleep from which the person is easily wakened. Bursts of sleep spindles appear on the EEG. Rolling eye movements continue and snoring may occur. Stage 3 and stage 4: These stages constitute ―deep‖ sleep, some-times termed slow-wave sleep or delta sleep after characteristics waves seen on the EEG. These two stages are differentiated primarily by the amount of delta waves and they are usually discussed together. During slow wave sleep, the muscles are relaxed but muscles tone is maintained, respirations are even and blood pressure, pulse, temperature, urine formation and oxygen consumption by muscle decrease. In these stages snoring, sleepwalking and bed wetting are most likely to occur. Strong stimuli are necessary to awaken people during these stages. Rapid Eye Movement: REM sleep closely resembles wakefulness except for very low muscle tone, indicated by a reduction in amplitude of the EMG. The rapid eye movement sleep documented through EOG recording but may also be noted by careful observation of tiny eye movements detectable through closed lids. Blood pressure and pulse rate show wide variations and may fluctuate rapidly. Respirations are irregular and oxygen consumption increases. Vaginal secretions increases in women and erections may occur in men. Sleep Rhythm: Electro physiologic recordings of nocturnal sleep show a rhythmic pattern of approximately 90 minute cycles during which people progress in sequence through the sleep stages. The usual pattern is fairly rapid progression through stages 1 to 4 and then back through stages 3 and 2, from which the person then enters REM sleep. During the early part of the night, periods of slow-wave sleep (stages 3 and 4) are longer. In contrast, the time spent in REM sleep during the first cycle may be only 3 to 4 minutes, where as much as 45 minutes, balanced with shorter periods of slow-with stage 1. Sleep Cycle: Normally during a sleep cycle, a person passes consecutively through the four stages of NREM sleep. Then the person reverses this pattern and returns from stage 4 to stage 3 to stage 2. Instead of reentering stage 1 and awakening, the person enters into the stage of REM sleep, after which he or she reenters NREM sleep at stage 2 and returns to stages 3 and 4. If a person is awakened from sleep at any time, he or she returns to sleep again by starting at stage 1 of NREM sleep. It is typical to go through four or five cycles of sleep each night. On the average, each cycle lasts about 90 to 100 minutes.
431
Neurotransmitter Balance: Sleep is an active process involving the reticular activating system (RAS) and a dynamic interaction of neurotransmitters. The RAS consists of a network of interconnecting neurons in the medulla, pones and midbrain with projections to the spinal cord, hypothalamus, cerebellum and cerebral cortex. It is in a strategic location for stimulation from a wide variety of inputs. The RAS includes the ascending facilitators area, which is intrinsically active and a less well understood inhibitory area, which appears to be particularly involved in decreasing muscle tone during REM sleep. As with other parts of the nervous system, communication between neurons in the RAS primarily involves the release of specific neurotransmitters from axon terminals and their attachment to specific receptors on other cells. Serotonin is a major neurotransmitter associated with sleep. Serotonin is thought to decrease the activity of the RAS, thereby inducing and sustaining sleep. Other neurotransmitters acetylcholine and nor-epinephrine appear to be required for the REM sleep cycle. Psychological Function: Psychological functions of sleep are thought to include the following: Sorting and discarding of neurophysiologic data. Much short-term memory is filled with inconsequential detail that the brain sifts through and discards. A person can usually remember what he or she ate for breakfast that day or how long the bus took to come, but a month later those data will probably be beyond recall. Character reinforcement and adaptation. The REM stage of sleep appears to be important for mental and emotional stability. Through REM dreaming, a reprocessing of knowledge and memories is thought to occur. An increased need for REM sleep has been found in people experiencing stress, worry, or new learning situations. Lifespan Considerations: Developmental variations in sleep patterns are evident. Circadian rhythms develop in the first few months of life are well established throughout childhood and adulthood and gradually decrease with advancing age. Newborn and Infant: Two major sleep states can be observed in newborns. Closed eyes, regular respirations and absence of eye and body movements characterize quite sleep. Newborns sleep an average of 16 to17 hours per day, divided into seven sleep periods distributed fairly throughout the day and night. Infants‘ sleep patterns differ from those of adults in that the sleep cycle is shorter (50 to 60 minutes), the proportion of active or REM sleep is higher and the initial stage is active. Toddler and Preschooler: By one year of age, napping has usually been reduced to once or twice a day. Some sleep disturbance is observed in almost all children between 1 and 2.5 years of age, which is believed to relate to children‘s rapidly developing mental abilities. Total sleep time drops from an average of 13 to 14 hours at age 2years to 12 hours by the end of fifth year. School-Age Child and Adolescent: Sleep and rest needs fluctuate somewhat for school-age children and adolescents in relation to growth and activity patterns. Adolescents actually require slightly more rest 432
than they did before puberty. The cardiovascular and respiratory systems mature less rapidly than other system, contributing to fatigue from inadequate oxygenation. Adult and Older adult: Adults vary widely in the number of hours of sleep that they require and in their preferred portion of the 24 hour period for sleeping. By middle age, the frequency of nocturnal awakening tends to increase and satisfaction with quality of sleep tends to decrease. Circadian rhythms become less prominent with increasing age. Older adults frequently express concern about taking longer to fall asleep, awakening more frequently, feeling sleepy during daytime and needing longer to adjust to changes in schedule. Timing: Sleep timing is controlled by the circadian clock, by homeostasis and in humans, within certain bounds, by willed behavior. The circadian clock, an inner time-keeping, temperature-fluctuating, enzyme-controlling device, works in tandem with adenosine, a neurotransmitter which inhibits many of the bodily processes that are associated with wakefulness. Adenosine is created over the course of the day; high levels of adenosine lead to sleepiness. In diurnal animals, sleepiness occurs as the circadian element causes the release of the hormone melatonin and a gradual decrease in core body temperature. The timing is affected by one's chronotype. It is the circadian rhythm which determines the ideal timing of a correctly structured and restorative sleep episode. Homeostatic sleep propensity, the need for sleep as a function of the amount of time elapsed since the last adequate sleep episode must be balanced against the circadian element for satisfactory sleep. Along with corresponding messages from the circadian clock, this tells the body it needs to sleep. Sleep offset, awakening, is primarily determined by circadian rhythm. A normal person who regularly awakens at an early hour will generally not be able to sleep much later than the person's normal waking time, even if moderately sleep deprived. Optimal amount in humans: Adults: The optimal amount of sleep is not a meaningful concept unless the timing of that sleep is seen in relation to an individual's circadian rhythms. A person's major sleep episode is relatively inefficient and inadequate when it occurs at the "wrong" time of day. The timing is correct when the following two circadian markers occur after the middle of the sleep episode but before awakening: Maximum concentration of the hormone melatonin, and Minimum core body temperature. The National Sleep Foundation in the United States maintains that seven to nine hours of sleep for adult humans is optimal and that sufficient sleep benefits alertness, memory and problem solving, and overall health, as well as reducing the risk of accidents. A widely publicized 2003 study performed at the University Of Pennsylvania School Of Medicine demonstrated that cognitive performance declines with fewer than eight hours of sleep. Hours by Age: Children need a greater amount of sleep per day than adults to develop and function properly: up to 18 hours for newborn babies, with a declining rate as a child ages. A newborn baby spends almost 9 hours a day in REM-sleep. By the age of five or so, only a bit over two hours is spent in REM. 433
Age and condition
Average amount of sleep per day
Newborn
up to 18 hours
1–12 months
14–18 hours
1–3 years
12–15 hours
3–5 years
11–13 hours
5–12 years
9–11 hours
Adolescents
9-10
Adults, including elderly 7–8 (+) hours Pregnant women 8 (+) hours Factors Affecting Sleep: Physical activity: Activity and exercise influence sleep by increasing fatigue. It appears that physical activity increases both REM and NREM sleep. Psycho logic stress: Illness and situations in daily living that cause Psycho logic stress tend to disturb sleep. Generally Psycho logic stress affects sleep in two ways. 1. The person experiencing stress tends to find it difficult to obtain the amount of sleep he or she needs. 2. REM sleep decreases in amount which tends to add to anxiety and stress. Motivation: A desire to be wakeful and alert helps overcome sleepiness and sleep. E.g. a tired person may be wakeful and alert when at a party or when attending an interesting play and when there is minimal motivation to be awake, sleep generally follows. Diet: IT has long been believed that the dietary amino acid L-tryptophan acts to promote sleep. A small protein snack before bed time was frequently recommended for clients with insomnia. Protein may actually increase brain energy alertness and concentration, while carbohydrates appear to have an effect on brain serotonin levels and promote feeling of calmness and relaxation. Alcohol Intake: Alcoholic beverages when used in moderation seem to help induce sleep in some people. However, large quantities have been found to limit REM and delta sleep. Caffeine-containing Beverages: caffeine is a central nervous system stimulant. For many people, beverages containing caffeine interfere with the ability to fall asleep e.g. coffee, tea and chocolate etc. Smoking: Nicotine has a stimulating effect and smokers usually have a more difficult time falling asleep. They are more easily aroused once asleep and may describe themselves as light sleepers. The total withdrawal from smoking may be associated with sleep disturbances. Clients who stop smoking have an increase in periods of day time sleepiness and report restlessness at night. Environmental Factors: most people sleep best in their usual home environments. Sleeping in a strange or new environment tends to influence both REM AND NREM sleep. Lifestyle: Various lifestyles affect the ability to sleep well. Alward and Monk (1995) describe the nurses who work rotating shifts. Sleep disorders are the major problem 434
associated with shift work and developing a sleep pattern is difficult if the shift changes periodically. Illness: Illness act as a physiologic and psycho logic stressor, as a result influences sleep. Certain illnesses are more closely related to sleep disturbances e.g. Gastric secretions increases during REM sleep. Many people with peptic ulcers awaken at night with pain and they find that eating a snack to help neutralize stomach acidity is often helpful to relieve discomfort and promote sleep. Medications: sleep quality is also influenced by certain drugs. The drugs which decrease REM sleep are barbiturates, amphetamines and antidepressants. Short-acting benzodiazepines are used to initiate and maintain sleep. These drugs may act by stimulating an inhibitory neurotransmitter called gamma-amino butyric acid (GABA) and induce the rapid onset of sleep but they suppress deep sleep as well as REM sleep. Sleep Disorders: Impaired sleep is a global and nonspecific term used to describe an alteration in sleep cycles and day time functioning. One half of adults in United States experiences at least intermittent sleep disorders. However at least 15-20% of adults report chronic sleep disorders or misalignment of circadian timing which can lead to serious impairment of daytime functioning. Sleep disorders were divided into four major categories based on an individual‘s symptoms. Gradually this system became unsatisfactory because individuals reported sleep-related symptoms that fell into more than one category. In 1990, a new classification system with more discrete categories was published (American Sleep Disorder Association, 1990). The major diagnostic categories are: 1. Dyssomnias: A broad category of sleep disorders characterized by either hyper somnolence or insomnia. The three major subcategories include intrinsic (i.e., arising from within the body), extrinsic (secondary to environmental conditions or various pathologic conditions), and disturbances of circadian rhythm. A. Intrinsic sleep disorders: Psycho physiological insomnia, Sleep-state misperception, Idiopathic insomnia, Narcolepsy, Recurrent, hypersomnia, Idiopathic, hypersomnia, Post-traumatic hypersomnia, Obstructive sleep apnea syndrome, Central sleep apnea syndrome, Central alveolar hypoventilation, Periodic limb movement disorder, Restless legs syndrome. B. Extrinsic sleep disorder: Inadequate sleep hygiene, Environmental sleep disorder, Altitude insomnia, Adjustment sleep disorder, Insufficient sleep syndrome, Limit-setting sleep disorder, Sleep-onset association disorder, Food allergy insomnia, Nocturnal eating (drinking) syndrome, Hypnotic-dependent sleep disorder, Stimulant-dependent sleep disorder, Alcoholdependent sleep disorder, Toxin-induced sleep disorder. C. Circadian rhythm sleeps disorder: Time zone change syndrome, Shift work sleep disorder, Irregular sleep phase syndrome, Delayed sleep phase syndrome, Advanced sleep phase syndrome, Non 24-hour sleepwake disorder. 2. Parasomnias: A. Arousal disorders: Confessional arousals, Sleep walking, Sleep terrors. 435
B. Sleep-wake transition disorder: Rhythmic movement disorder, Sleep talking, Nocturnal leg cramps. C. Parasomnias usually associated with REM sleep: Nightmares, Sleep paralysis, impaired sleep- related penile reactions, Sleep related painful reactions, REM sleep-related sinus arrest, REM sleep behavior disorder. D. Other Parasomnias: Sleep bruxims, sleep enuresis, sleep-related abnormal swallowing syndrome, nocturnal paroxysmal dystopia, sudden unexplained nocturnal death syndrome, primary snoring, infant sleep apnea, congenital central hypoventilation syndrome, sudden infant death syndrome, benign neonatal sleep myoclonus. 3. Medical / Psychiatric Sleep Disorder: A. Associated with mental disorder: Psychosis, mood disorders, anxiety disorders, panic disorders and alcoholism. B. Associated with neurological disorders: Cerebral degenerative disorders, dementia, Parkinsonism, fatal familial insomnia, sleeprelated epilepsy, sleep-related headaches C. Associated with other medical disorders: Sleeping, sickness, nocturnal cardiac ischemia, chronic obstructive pulmonary disease, peptic ulcer disease. 4. Proposed Sleep Disorder: Short sleeper, long sleeper, sub-wakefulness syndrome, menstrual associated sleep disorder, pregnancy associated sleep disorder, sleep choking syndrome, sleep related laryngospasm, sleep related neurogenic tachypnea. Common Sleep Disorders: Primary Sleep Disorders: Primary sleep disorders are those in which the sleep disturbance is the main symptom or sign of the problem. It includes insomnia, hypersonic, narcolepsy and sleep apnea. Insomnia: It is most common sleep disorder. Insomnia is a perception of inadequate sleep and characterized by difficulty in initiating sleep and frequent awakening from sleep. Insomnia may be classified as idiopathic or psycho physiological. Idiopathic insomnia usually begins in childhood. It may be caused by a neurochemical imbalance of the sleep-onset mechanisms or the sleep-maintenance system. The syndrome is usually associated with a decreased feeling of wellbeing during the day, a deterioration of mood and motivation, decreased attention span, low levels of energy and concentration and increased fatigue. Psycho physiological insomnia can occur from a variety of causes including stress and tension. Individuals with disorder are usually not sleepy during the day but function poorly in terms of cognitive skills and also report fatigue. Hypersomnia: Hypersomnia is a condition characterized by excessive sleep, particularly during the day. Although this may result from medical conditions, it is frequently used as a coping mechanism when someone has no desire or energy to face a new day. 436
Narcolepsy: Narcolepsy is a condition characterized by an uncontrollable desire to sleep. The person with narcolepsy can literally fall asleep standing up, while driving a car or while swimming. This disabling condition should not to be confused with hyper somnolence, which is excessive sleeping for long periods. Although the diagnosis of narcolepsy generally requires a multiple sleep latency test and polysomnography. Sleep Apnea: Sleep apnea refers to periods of no breathing between snoring intervals. The person may not breathe for periods of 10 to 20 seconds to as long as 2 minutes. Obstructive sleep apnea results when the airway is occluded due to collapse of the hypo pharynx. During long periods of apnea, there is a drop in the oxygen level of the blood, the pulse usually becomes irregular and the blood pressure often increases. The accumulation of carbon dioxide and the fall in oxygen cause brief periods of awakening throughout night. Parasomnias: Parasomnias are patterns of waking behavior that appear during sleep. Parasomnias are conditions associated with activities that cause arousal or partial arousal usually during transitions in NREM periods of sleep. They are not life threatening but they disturb others. The examples of parasomnias are: Somnambulism: sleep-walking. Nocturnal enuresis: bedwetting. Sleep-talking. Nightmares and night terrors. Bruxism: grinding of teeth. Sleep Deprivation: Sleep deprivation refers to a decrease in the amount, consistency and quality of sleep. It may result from decreased REM sleep or NREM sleep. The manifestations progress from irritability and impaired mental abilities to a total disintegration of personality. Partial sleep deprivation may result in loss of concentration and pose serious safety risks. The strange environment of the hospital, physical discomfort and pain, the effects of medications and the need for 24 hour nursing care may all contribute to sleep deprivation in the hospitalized client. Hospital-Acquired Sleep Disturbances: Clients in the hospital may report difficulty with sleep onset, latency, awakening frequently with difficulty getting back to sleep and early morning awakening. Sleep Onset Difficulty: Sleep onset difficulty is a common problem in hospital because of the strange environment and the anxieties associated with illness and hospitalization. A sleep latency time of 20 to 30 minutes is normal range for most adults. Sleep Maintenance Disturbances: Sleep maintenance disturbances may be associated with sustained use of or withdrawal from a variety of medications and related substances. Alcohol hasten sleep onset but leads to awakening later in the night. Other factors that contribute to sleep fragmentation include stimuli that tend to awaken people in the middle of night. Internal stimuli such as pain, discomfort and urge to void are frequent causes of disturbed sleep. External stimuli include environmental factors such as light, noise and temperature as well as disruptions by others. 437
Early Morning Awakening: Early morning awakening occurs frequently among older clients. Sensitivity to environmental disturbances increases toward morning in people of all ages but even more so in older adults. Clients who are disturbed by early more awakening should be screened for depression. This transient cognitive disorder may e associated with acute illness, infection or admission to the hospital. Sleep is grossly disturbed with frightening dreams, disorientation and restlessness. Sleep Deprivation: Sleep deprivation is of particular concern for clients in critical care units. Multiple factors contribute to sleep deprivation including noise level, 24-hour lighting and frequency of caregiver interruptions. Studies have shown noise levels in general surgical wards to be above the World Health Organization‘s guidelines for both day and night shifts. REM Rebound: REM sleep occurs later in the sleep cycle and therefore can be missed when sleep time is reduced or interrupted. In order to compensate for missing sleep a greater proportion of REM-deprived clients‘ sleep will be REM. Withdrawal of medications that suppress REM sleep can lead to an REM rebound effect that is accompanied by nightmares. Normal physiologic occurrences during REM sleep, such as irregular, elevated heart rate and elevated blood pressure may place the REM rebound client at regular risk because of longer amount of time spent in REM. Sleep Assessment: Many people blame inadequate sleep for daytime fatigue or they underestimate the actual time they sleep. Nurses can obtain a more accurate sleep pattern assessment through sleep questionnaires, sleep diaries, polysomnographic evaluation and a multiple latency sleep test. Questionnaires: Several questionnaires have been developed to help to identify sleep patterns. They are either designed to obtain specific information or are unstructured to give the person more freedom to respond. Examples of questions for the client include: When you think about your sleep, what kinds of impressions come to mind? Do you fall asleep at inappropriate times? How long does it take you to fall asleep? Have you been told that you stop breathing while asleep? Do you fall asleep during physical activities? Questions for the members of the client‟s house-hold are: Dose the client snore or gasp for air when sleeping? Dose the client kick or thrash around while sleeping? Dose the client sleep-walk? Sleep Diary: A sleep diary is a daily account of sleeping and walking activities. The client or personnel compile the information in a sleep disorder clinic. The client notes the times he or she is sleep, describes daily activities, 24 hour log of consumed food and beverages and notes when he or she takes any medications. These self kept diaries generally cover a 2-week period. Nocturnal Polysomnography: Nocturnal Polysomnography is a diagnostic assessment technique in which a client is monitored for an entire night‘s sleep to obtain physiologic data. It generally takes place in 438
a sleep disorder clinic but it is now possible to conduct the study at the client‘s home; a technician monitors a computerized recording system up to 60 feet away. The sensors are attached to the head and body record: Brain waves. Eye movements. Muscle tone. Limb movement. Body position. Nasal and oral airflow. Chest and abdominal respiratory effort. Snoring sounds. Oxygen level in the blood. Multiple Sleep Latency Test: A multiple sleep latency test is another helpful study. The person undergoing this test is asked to take to a daytime nap at 2-hour intervals while attached to sensors similar to those used in polysomnography. The client is allowed to nap for about 20 minutes. The nap periods are repeated four or five times throughout the day. Clients who have certain sleep disorders causing day time sleepiness have a short latency period- that is they fall asleep in less than 5 minutes. Most well-rested persons take an average of 15 minutes before they experience the onset of daytime sleep. Management: Sleep is essential component of well-being. Planning and implementing client care especially in a health care facility, involves planning with the suitable measures to promote sleep. Usually sleep problems are not the primary reason for a client‘s interaction with the health care system. Fundamental to the success of any nursing measure to correct a sleep problem is the client‘s belief that the nurse cares and is readily available for extra help to promote sleep. Preparing a Restful Environment: Having a comfortable bed helps promote sleep. The bottom line should be tight and clean and upper linen should allow freedom of movement and should not exert pressure. A quiet and darkened room, with privacy is relaxing for nearly everyone. In a strange environment, unfamiliar noises such as people walking or entering and leaving the room bring complaints from most hospitalized clients. Although some of these sources are difficult for the nurse to control, every effort should be made toward reducing disturbances to promote sleep. The temperature of the room, the amount of ventilation and the quantity of bed covering are matters of individual choice. Promoting Bedtime Rituals: Most people have bedtime rituals to promote sleep. Reading, listening to the radio, watching television, talking to a family member and praying are common before-sleep activities. Children may search out a favorite doll, stuffed toy or blanket before going to bed; insist on a story. Snacks are important elements in the bedtime rituals of many children and adults. The nurse should be alert to the client‘s bedtime rituals and make every effort to observe them as far as possible to aid in promoting sleep. These rituals should appear in the client‘s plan of care so that all health personnel can observe them. 439
Offering Appropriate Bedtime Snacks and Beverages: Because carbohydrates seem to help promote sleep, there currently appears to be justification for offering a snack or beverages high in carbohydrates before bed-time. Beverages containing caffeine should be avoided for at least 4 to 5 hours before bedtime. It is best the client take fluids during the day and avoid excessive fluid intake before bedtime to prevent the necessity of using the bathroom during sleeping hours. Promoting Relaxation: One can relax without sleeping, but sleep rarely occurs until one is relaxed. Stress and anxiety-producing situations tend to interfere with a person‘s ability to relax and sleep. Effective means for dealing with worries include dealing with problems as they arise; conditioning oneself to worry only during preset times; teaching oneself that worrying never solve problems and giving the worries over to another e.g. a trusted family member, friend, caregiver or God. Back rubs, warm baths and face washing if the client is bedridden are typical nursing measures to help the client relax. Promoting Comfort: One of the greatest deterrents to rest and sleep is pain; it is not an uncommon experience when illness is present. Depending on the cause and severity of the discomfort or pain, appropriate nursing measures include remaining with a lonely and frightened child or adult, using the simple strategy of caring presence and touch, offering back massage, positioning, obtaining an extra blanket or administering an analgesic. Respecting Normal Sleep-Wake Patterns: Every effort should be made to observe the client‘s normal periods of sleep. It is recommended that a client‘s normal napping habits be followed when possible. It has been observed that REM sleep is common during morning naps where as NREM sleep is common during naps later in the day. With this knowledge, the nurse can help the client plan napping periods that best fit individual needs and that interfere least with nighttime sleeping. Scheduling Nursing Care to Avoid Unnecessary Disturbance: Common client complaints are that they are awakened to take sleeping pills and are aroused at early morning hours to prepare for breakfast long before it is served. These common observations should be considered when planning care. Every effort should be made to time care during periods when the client is normally awake. When this cannot be done, it is preferable to avoid awakening the client during REM sleep, when the rapid eye movements can be observed. Using Medications to Produce Sleep: Medications for sleep are often ordered for clients. Sedative-hypnotics induce sleep; anti anxiety drugs reduce anxiety and tension. The sleep produced by sedative-hypnotics is an unnatural sleep. All these drugs disturb either REM or NREM sleep to some degree. Although most sedative-hypnotics provide several nights of excellent sleep, the medication often loses its effect after a week or two. Nurses also need to be alert to the dangers of withdrawal symptoms that can accompany the abrupt cessation of barbiturate sedative-hypnotics. Medications used to induce sleep may produce day-time drowsiness. The nurse should administer these medications only when indicated and always with full knowledge of their limitations. Thorough client teaching should accompany their use. 440
Teaching About Rest and Sleep: A well-informed person is better able to cope with distressing situations. Helping clients and their families understand the nature of rest and sleep and their importance to well being through teaching is an important nursing function. Teaching should include aspects of normal variations in sleep patterns and common measures to promote relaxation and sleep. Also the plan of care should be discussed with the client for acceptability.
441
BIBLIOGRAPHY: Black Joyce M., Hawks Jane Hokanson; Medical-Surgical Nursing: Clinical Management for Positives Outcomes; Edition 8th, Vol 1; Saunders 2009; Pp 403-417. Timby Barbara K.; Fundamental Nursing Skills and Concepts; Edition 8th; Lippincott 2005; Pp 339-350. Taylor Carol, Lillis Carol, LeMone Priscilla; Fundamentals of Nursing: The Art and science of Nursing Care; Edition 3rd; Lippincott 1997; Pp 1072-1093.
442
CARDIO PULMONARY RESUSCITATION
Cardiopulmonary resuscitation (CPR): it is an emergency medical procedure for a victim of cardiac arrest or, in some circumstances, respiratory arrest. CPR is performed in hospitals or in the community by laypersons or by emergency response professionals. Cardiac or respiratory arrest can occur at any time to individuals of all ages. It is a crisis event that can be the result of an accident or a disease process. CPR is the basic life saving skill that is utilized in the event of cardiac, respiratory or cardiopulmonary arrest to maintain tissue oxygenation. Once the heart ceases to function, a healthy human brain may survive without oxygen for up to 4 minutes without suffering any permanent damage. Unfortunately, a typical emergency medical system {EMS} response may take 6, 8 or even 10 minutes. It is during those critical minutes that CPR can provide oxygenated blood to the victim's brain and the heart, dramatically increasing his chance of survival. And if properly instructed, almost anyone can learn and perform CPR. Historical Review: 5000 - First artificial mouth to mouth. 3000 BC - ventilation. 1780 – First attempt of newborn resuscitation by blowing. 1874 – First experimental direct cardiac massage. 1901 – First successful direct cardiac massage in man. 1946 – First experimental indirect cardiac massage and defibrillation. 1960 – Indirect cardiac massage. 1980 – Development of cardiopulmonary resuscitation due to the works of Peter Safar. Cpr Time Line: 0-4 minutes. Brain damage unlikely. 4-6 minutes. Brain damage possible. 6-10 minutes. Brain damage probable. Over 10 minutes. Probable brain death. How CPR Works: The air we breathe in travels to our lungs where oxygen is picked up by our blood and then pumped by the heart to our tissue and organs. When a person experiences cardiac arrest - whether due to heart failure in adults and the elderly or an injury such as near drowning, or severe trauma in a child - the heart goes from a normal beat to an arrhythmic pattern called ventricular fibrillation, and eventually ceases to beat altogether. This prevents oxygen from circulating throughout the body, rapidly killing cells and tissue. In essence, Cardio (heart) Pulmonary (lung) Resuscitation (revive, revitalize) serves as an artificial heartbeat and an artificial respirator. CPR may not save the victim even when performed properly, but if started within 4 minutes of cardiac arrest and defibrillation is provided within 10 minutes, a person has a 40% chance of survival. Invented in 1960, CPR is a simple but effective procedure that allows almost anyone to sustain life in the first critical minutes of cardiac arrest. CPR provides oxygenated blood to the brain and the heart long enough to keep vital organs alive until emergency equipment arrives. The medical term for the condition in which a person's heart has stopped is cardiac arrest (also referred to as cardiorespiratory arrest). 443
For 50 years CPR has consisted of the combination of artificial blood circulation with artificial respiration i.e., chest compressions and lung ventilation. However, in March 2008 the American Heart Association and the European Resuscitation Council, in a reversal of policy, endorsed the effectiveness of chest compressions alone--without artificial respiration--for adult victims who collapse suddenly in cardiac arrest (Cardiocerebral Resuscitation). If the patient still has a pulse, but is not breathing, this is called respiratory arrest and artificial respiration is more appropriate. However, since people often have difficulty detecting a pulse, CPR may be used in both cases, especially when taught as first aid. CPR is generally continued, usually in the presence of advanced life support, until the patient regains a heart beat (called "return of spontaneous circulation" or "ROSC") or is declared dead. CPR is unlikely to restart the heart, but rather its purpose is to maintain a flow of oxygenated blood to the brain and the heart, thereby delaying tissue death and extending the brief window of opportunity for a successful resuscitation without permanent brain damage. Defibrillation and advanced life support are usually needed to restart the heart. Main Stages of Resuscitation: A (Airway) – ensure open airway by preventing the falling back of tongue, tracheal intubation if possible. B (Breathing) – start artificial ventilation of lungs. C (Circulation) – restore the circulation by external cardiac massage. D (Differentiation, Drugs, Defibrillation) – quickly perform differential diagnosis of cardiac arrest; use different medication and electric defibrillation in case of ventricular fibrillation. Guidelines: In 2005, new CPR guidelines were published by the International Liaison Committee on Resuscitation (ILCOR), agreed at the 2005 International Consensus Conference on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science. The primary goal of these changes was to simplify CPR for lay rescuers and healthcare providers alike, to maximize the potential for early resuscitation. The important changes for 2005 were; A universal compression-ventilation ratio (30:2) recommended for all single rescuers of infant (less than one year old), child (1 year old to puberty), and adult (puberty and above) victims (excluding newborns). The primary difference between the age groups is that with adults the rescuer uses two hands for the chest compressions, while with children it is only one, and with infant‘s only two fingers (index and middle fingers). While this simplification has been introduced, it has not been universally accepted, and especially amongst healthcare professionals, protocols may still vary. The removal of the emphasis on lay rescuers assessing for pulse or signs of circulation for an unresponsive adult victim, instead taking the absence of normal breathing as the key indicator for commencing CPR. The removal of the protocol in which lay rescuers provide rescue breathing without chest compressions for an adult victim, with all cases such as these being subject to CPR. Research has shown that lay personnel cannot accurately detect a pulse in about 40% of cases and cannot accurately discern the absence of pulse in about 10%. The pulse check 444
step has been removed from the CPR procedure completely for lay persons and deemphasized for healthcare professionals. Contraindications: Do not resuscitate when a decision not to resuscitate has been noted in the chart. This order is often abbreviated to ―DNR‖ (do not resuscitate), is sometimes referred to as ―no code‖, and is now discussed with the client on admission and is referred to as ―an advanced directive.‖ CPR In Adults: American Heart Association's guidelines dictate that Adult CPR is performed on any person over the age of 8. Procedure: Purpose: 1. Restore cardiopulmonary functioning. 2. Prevent irreversible brain damage from anoxia. Assessment: 1. Determine that the client is unconscious. Shake the client and shout at him or her to confirm unconsciousness rather than being asleep, intoxicated or hearing impaired. 2. Assess for presence of respirations. 3. Assess carotid artery for pulse. Equipment: A hard, flat surface. No additional equipment is necessary but in hospital setting, an emergency (crash) cart with defibrillator and cardiac monitoring should be brought to the bedside. A crash cart usually contains: Airway equipment. Suction equipment. Intravenous equipment. Laboratory tubes and syringes. Pre packed medications for advanced life support. Procedure: ACTION RATIONALE One Rescuer – Adult, Adolescent client 1. Assess responsiveness by tapping or gently shaking client while shouting, ―Are you OK?‖ 2. Call for help or activate the emergency medical system.
Prevents injury to a client who is not experiencing cardiac or respiratory arrest. Also assists in assessing level of consciousness. The majority of the adults with sudden cardiac arrest are in ventricular fibrillation so survived is linked to early access to defibrillation from emergency medical systems.
445
3. Turn client on to the back while supporting head and neck. Place a cardiac board under the back or place client on the floor. 4. Position self. Face the client on your knees parallel to the client, next to the head, to begin to assess the airway and breathing status. 5. AIRWAY: a) "A" is for AIRWAY. If the client is unconscious and is unresponsive, you need to make sure that his airway is clear of any obstructions. Open the airway. b) The most commonly used method is the head tilt/ chin lift method. With the client lying flat on his back, place your hand on his forehead and your other hand under the tip of the chin. Gently tilt the client's head backward. c) Use the modified jaw thrust if a neck injury is suspected. Place hands at the angles of the lower jaw and lift, displacing the mandible forward while tilting the head backward. d) Assess for respirations. Place your ear over the client‘s mouth and observe the chest for rising with respiration. The breaths may be faint and shallow - look, listen and feel for any signs of breathing for 3 to 5 seconds. e) If respirations are absent 6. BREATHING: a) "B" is for BREATHING. With the client's airway clear of any obstructions, gently support his chin so as to keep it lifted up and the head tilted back. Pinch his nose with your fingertips to prevent air from escaping once you begin to ventilate.
A firm surface is needed for adequate compression of the heart beneath the sternum. Proper positioning prevents rescuer fatigue and facilitates CPR with minimal movement of the rescuer.
A patent airway is essential for successful artificial respirations. In this position the weight of the tongue will force it to shift away from the back of the throat, opening the airway.
Tilt head It prevents extension of the neck and decreases the potential for further injury.
CPR should not be administered to a client with spontaneous respirations or pulse due to potential risk of injury.
Occluding the nostrils and forming a seal will prevent air leakage and provide full inflation of lungs.
446
b) Form a seal over the client‘s mouth using either your mouth or the appropriate respiratory assist device (ambu bag and mask). c) Take a deep breath and place your mouth over the client's, creating a tight seal. As you assist the person in breathing, keep an eye on his chest. Try not to over-inflate the client's lungs. b) Give two full breaths of 0.5 to 2 seconds. Between each breath allow the client's lungs to relax - place your ear near his mouth and listen for air to escape and watch the chest fall as the client exhales.
Overinflation may force air into the stomach, resulting in gastric distension and causing him to vomit. If this happens, turn the person's head to the side and sweep any obstructions out of the mouth before proceeding.
Let client
Give two breaths c) In the event of serious mouth or jaw injury that prevents mouth to mouth ventilation, mouth to nose ventilation may be used by tilting the head with one hand and using the other hand to lift the jaw and close the mouth. d) If the client is breathing but still unresponsive, turn on to side (recovery position). e) Check the circulation. 7. CIRCULATION a) "C" is for CIRCULATION. In order to determine if the client's heart is beating, place two fingertips on his carotid pulse, located in the depression between the windpipe and the neck muscles, and apply slight pressure for 5 to 10 seconds on the side next to which you are kneeling.
exhale
Modified lateral position maintains airway and spine alignment while allowing rescuer to observe breathing.
Serious medical complications may occur if chest compressions are performed on a person who has a pulse.
447
b) If there is no pulse then the client's heart is not beating, and you will have to perform chest compressions COMPRESSIONS c) Maintain position on knees parallel to sternum. d) Position the hands for compressions: When performing chest compressions, proper hand placement is very important. Using the hand nearest to the legs place middle and index finger on the lower ridge or near ribs and move fingers up along ribs to the costalsternal notch (in centre of lower chest). e) Place middle finger on this notch and the index finger next to the middle finger on the lower end of the notch. f) Place the heel of other hand along the lower half of the sternum, next to the index finger. g) Remove first hand from the notch and place heel of that hand parallel over the hand on the chest and interlock the fingers, keeping them off client‘s chest. h) Keeping the hands on the sternum, extent the elbows, locking the elbows, with your shoulders directly over the client‘s chest. i) Using your body's weight, compress the client‘s chest. j) The depth of compressions should be approximately 1½ to 2 inches at the rate of 80 to 100 compressions per minute. Remember: 2 hands, 2 inches. If you feel or hear slight cracking sound, you may be pressing too hard. Do not become alarmed and do not stop your rescue efforts! Damaged cartilage or cracked ribs are far less serious than a lost life. Simply apply less pressure as you continue compressions.
Careful attention to hand placement during cardiac compression prevents fractured ribs and organ trauma.
Proper hand placement
This prevents trauma from pressure on the ribs.
Weight of your upper body and strength of both arms are needed for adequate cardiac compression. Placing your shoulders over the client‘s chest provides additional muscle power and prevents hands from slipping off sternum and breaking ribs. This depth is needed to compress the heart between sternum and vertebrae to pump blood out of the heart.
448
Two hands, two inches
k) The heal of the hand must completely release pressure between compressions, but it should remain in constant contact with the client‘s skin. l) Use the mnemonic ―one and, two and, three and …..‖ to keep rhythm and timing. m) Finish the cycle by giving the client 2 breaths. This process should be performed four times -30 compressions and 2 breaths after which remember to check the client's carotid artery for pulse and any signs of consciousness. If there is no pulse, continue performing 30 compressions/2 breaths, checking for pulse after every 4 cycles until help arrives. Two Rescuers – Adult, Adolescent 1. When the second rescuer arrives, the first rescuer stops CPR after completing two ventilations and assesses for carotid pulse for 5 seconds. 2. The second rescuer moves into the chest compression position. 3. If pulse less ness continues, the first rescuer states ―no pulse‖ and delivers one ventilation. 4. The second rescue begins chest compression while counting out loud. The compression rate is 100 per minute. 5. The first rescuer gives two slow ventilations after 30 cardiac compressions. The first rescuer also assesses carotid pulse during chest compressions to evaluate effectiveness. 6. If the second rescuer wishes to change the position, he or she states, ―change, one and two and three and four and five and‖ 7. The first rescuer delivers the ventilation then moves into the chest compression position. 8. The second rescuer moves to the ventilator position and assesses for carotid pulse for 5 seconds. If pulse less resume CPR.
To allow the heart to fill with blood.
CPR can be tiring, and fatigue decreases effectiveness.
Providing chest compressions is very fatiguing. Switching positions help to ensure effective CPR efforts.
449
Child CPR: According to the American Heart Association's guidelines Child CPR is administered to any victim under the age of 8. There are crucial distinctions that apply to children's rescue efforts. The first thing to remember about Child CPR is this: in children cardiac arrest is rarely caused by heart failure but rather by an injury such as poisoning, smoke inhalation, or head trauma, which causes the breathing to stop first. And since children are more resilient than adults‘ statistics have shown that they tend to respond to CPR much better if administered as soon as possible. If the child is unresponsive and you are alone with him, start rescue efforts immediately and perform CPR for at least 1 to 2 minutes before dialing 9-1-1. Before you call an ambulance, immediately check the victim for responsiveness by gently shaking the child and shouting, "Are you okay?" DO NOT shakes the child if you suspect he may have suffered a spinal injury. If the child is clearly unconscious, remember your A-B-C and check the child's airway Airway: "A" is for AIRWAY. A child's breaths may be extremely faint and shallow - look, listen and feel for any signs of breathing. If there are none, the tongue may be obstructing the airway and preventing the child from breathing on his own. Exercise extra caution when you open the victim's air passage using the head tilt/chin lift technique. This will shift the tongue away from the airway. Look, listen, and feel for If the child is still not breathing after his airway has been breaths cleared, you will have to assist him in breathing Breathing: "B" is for BREATHING. If the child remains unresponsive and still not breathing on his own, pinch his nose with your fingertips or cover his mouth and nose with your mouth creating a tight seal, and give two breaths Keep in mind that children's lungs have much smaller capacity than those of adults. When ventilating a child, be sure to use shallower breaths and keep an eye on the victim's chest to prevent stomach distention. If this happens and the child vomits, turn his head sideways and sweep all obstructions out of the mouth before proceeding. After you've administered the child two breaths and he remains unresponsive (no breathing, coughing or moving), check his circulation Circulation: "C" is for CIRCULATION. Check the child's carotid artery for pulse by placing two fingertips and applying slight pressure on his carotid artery for 5 to 10 seconds. 450
If don't feel a pulse then the victim's heart is not beating, and you will have to perform chest compression Compressions: When performing chest compressions on a child proper hand placement is even more crucial than with adults. Place two fingers at the sternum (the bottom of the rib cage where the lower ribs meet) and then put the heel of your other hand directly on top of your fingers. A child's smaller and more fragile body requires less pressure when performing compressions. The rule to remember is 1 hand, 1 inch. If you feel or hear slight 1. Proper hand cracking sound, you may be pressing too hard. Apply less placement pressure as you continue. Count aloud as you compress 30 times, followed by 2 breaths. Perform 5 cycles of 30 compressions and 2 breaths before checking the child for breathing and pulse. Victim‘s carotid artery for pulse as well as any signs of consciousness. Infant CPR: According to generally accepted guidelines, Infant CPR is administered to any victim under the age of 12 months. Infants, just as children, have a much better chance of survival if CPR is performed immediately. If you are alone with the infant, do not dial 9-1-1 until after you have made an attempt to resuscitate the victim. Check the infant for responsiveness by patting his feet and gently tapping his chest or shoulders. If he does not react (stirring, crying, etc.), immediately check his airway Airway: "A" is for AIRWAY. It is normal for an infant to take shallow and rapid breaths, so carefully look, listen and feel for breathing. If you cannot detect any signs of breathing, the tongue may be obstructing the infant's airway. Although the head tilt/chin lift technique is similar to adults and children, when clearing an infant's airway it's important not to tilt the head too far back. An infant's airway is extremely narrow and . "Sniffer's position" overextending the neck may actually close off the air passage. Tilt the head back into what is called the "sniffer's position" - far enough to make the infant look as if he is sniffing.
451
Breathing: "B" is for BREATHING. Cover the infant's mouth and nose with your mouth creating a seal, and give a quick, gentle puff from your cheeks. Let the victim exhale on his own - watch his chest and listen and feel for breathing. If he does not breathe on his own, again place your mouth over his mouth and nose and give another small puff (Figure 1). If the infant remains unresponsive (no crying or moving), Puff from the cheeks immediately check his circulation
Cirulation: "C" is for CIRCULATION. An infant's pulse is checked at the brachial artery, which is located inside of the upper arm, between the elbow and the shoulder (Figure 1). Place two fingers on the brachial artery applying slight pressure for 3 to 5 seconds. If you do not feel a pulse within that time, then the infant's heart is not beating, and you will need to perform chest compressions Brachial artery Compressions: An infant's delicate ribcage is especially susceptible to damage if chest compressions are improperly performed; therefore it is important to use caution when rescuing an infant. Place three fingers in the center of the infant's chest with the top finger on an imaginary line between the infant's nipples. Raise the top finger up and compress with the bottom two fingers. The compression should be approximately ⅓ to ½ the depth of the Infant hand placement infant's chest. Count aloud as you perform 5 cycles of 30 compressions and 2 breaths before checking the infant for breathing and pulse. If there is no pulse, continue administering 30 compressions/2 breaths until an ambulance arrives. If at any point the infant regains a pulse but still does not breathe on his own, give him one rescue breath every three seconds. Five Key Aspects To Great CPR: Rate. Depth. Release. Ventilation. Uninterrupted. Defibrillation: General concept 452
Immediate defibrillation if witnessed arrest and AED available Compressions before defibrillation if unwitnessed or arrival at the scene >4-5 minutes. One shock followed by immediate CPR (beginning with chest compressions) Importance early defibrillation: Most frequent arrest rhythm VF / VT. Treatment is defibrillation. Successful conversion diminishes over time. VF tends to deteriorate to Asystole. Not Used For: Sinus rhythm. Bradycardia. A systole. PEA. Drugs Used In CPR: Sno • Drugs • Indication • Dosage 1. • 2. • 3. •
4 5 6. 7. 8.
Inj Epinephrine•
Asystole •Or 1mg Dose Repeated Every Pulseless Electrical 3-5 Mt Interval Activity Inj Atropine • Symptomatic • 0.5-2.5 Mg Every 3-5 Mts Sulfate Bradycardia If Necessary Inj Lidocaine • Persisting VT •Or Give As Iv Bolus 1.0-1.5 VF After Mg/Kg Defibrillation And • Maint. Dose 2-4 Mg/Mt Epinephrine Inj Sodium Bi Metabolic Acidosis Iv Bolus Carbonate 1 Meq/Kg Inj Magnesium VT,VF 1-2g Iv Administered Over 1-2 Sulphate Mts Inj Calcium Chloride Ventricular Standstill 5-10 Ml Iv Slow 10% Inj Dopamine Shock Hypotension 5-10 G /Kg/Mt Inj Dobutamine Refractory Pump 5-10 G /Kg/Mt Failure
453
Adult Bls Algorithm:
454
Termination Of Basic Life Support: CPR is stopped as a result of a number of circumstances; these are typically restoration of spontaneous respiration and circulation, complete rescuer exhaustion, or medical decision. Signs of restored ventilation and circulation include 1) struggling movements, 2) improved color, 3) return of or stronger pulse, and 4) return of systemic blood pressure. Struggling however, does not necessarily mean the person has recovered. When the rescuer is alone, although people are seldom alone in health care facilities, the rescuer may not be able to continue because of exhaustion. Rescuers who become exhausted often feel very guilty and may need support to deal with their feelings and to realize that they did the best they could. It may help them to know, even under the best circumstances, individuals suffering cardiopulmonary arrest do not always recover after CPR. On occasion, a medical decision is made to stop CPR without going on to advanced life support techniques. This decision is usually related to the person‘s underlying disease or condition. Sometimes these decisions are made in advance by the person and significant others in consultation with the physician. In these cases, CPR is not initiated. Special Considerations: Although AIDS isn‘t known to be transmitted in saliva, some health care professionals may hesitate to give rescue breaths, especially if the victim has AIDS. For this reason, it is recommended that all health professionals should how to use disposable airway equipments. Always remember to exercise solid common sense! When faced with an emergency situation we may act impulsively and place ourselves in harm's way. Although time should not be wasted, only approach the victim after determining that the scene is safe: always check for any potential hazards before attempting to perform CPR Potential Hazards Of Cpr: HAZARD CAUSES ASSESSMENT PREVENTIVE FINDINGS MEASURES Sternal and• rib Osteoporosis • Paradoxical chest While performing CPR, fractures • Malnutrition movement Don‘t rest your hands or • Improper hand • Chest pain or fingers on the patient‘s ribs. placement tenderness Interlock your fingers. • Crepitus Keep your bottom hand in • Palpation of contact with the chest, but movable bony release pressure after each fragments over the compression. sternum. Compress the sternum at the recommended depth for the patient‘s age. Pneumothorax, • Lung punctures • Chest pain hemothorax or from fractured dyspnea both rib. • Decreased or 455
and Follow the measures listed for sternal or rib fractures
• • •
absent breath sounds over the affected lung. Tracheal deviation from midline Hypotension Hyperresonance to percussion over the affected area along with shoulder pain Jugular vein Perform chest compressions distension properly Muffled heart sounds Pulsus paradoxus Narrowed pulse pressure Adventitious heart sounds Hypotension ECG changes
Injury to the • Improperly • heart and great performed chest vessels compressions • • Transvenous or transthoracic • pacing attempts • • Central line placement • during resuscitation • • Intracardiac • drug administration Organ • Forceful • Persistent right laceration compression upper quadrant (primarily liver • Sharp edge of a tenderness (liver and spleen) fractured rib or injury) xiphoid process • Persistent left upper quadrant tenderness (splenic injury) • Increasing abdominal girth Aspiration of • Gastric • Fever, hypoxia, stomach distension and and dyspnea contents an elevated • Auscultation of diaphragm from wheezes and high ventilatory crackles pressures • Increased WBC count • Changes in colour and odor of lung secretions
456
Follow same measures as for rib fracture
• Intubate early • Insert a nasogastric tube and apply suction if gastric distension is marked.
Nursing Responsibilities: • Preliminary assessment. • Preparation of the equipment. • Preparation of patient and environment. • Continuous monitoring and documentation. Documentation: Whenever you perform CPR, document why you initiated it, whether the victim suffered from cardiac or respiratory arrest, when you find the victim and stated CPR, and how long the victim received CPR. Note his response and any complications. Also any interventions taken to correct complications. If the victim also received advanced cardiac life support, document which interventions were performed, who performed them, when they were performed, and what equipment was used.
457
END OF LIFE 1. Introduction: Life and death is the two main stages in a human beings life, where we come across many challenges, diseases, and other problems. Olden days persons with chronic diseases, terminal illness and dying is viewed as taboo topics, due to which few new concept developed for the care of person who is at their end stage, one of those topics is end of life. 2. Definition: End of life: It is the concluding phase of normal lifespan although life can end at any age 3. Goals: Provide comfort and supportive care during process Improve the quality of remaining life Help to ensure dignified death 4. Terminologies: Advance directives: Advanced care directives are specific instructions, prepared in advance, intended to direct a person's medical care in the event that he/she is unable to do so in the future. Bereavement: it is an individual‘s response to the loss of a significant person. Cheyne-stoke respiration: a striking form of breathing in which there is a cyclical variation in the rate. This becomes slower until breathing stops for several seconds before speeding up to a peak and then slowing again. Death: Legal definition of death, in most states, requires "irreversible cessation of all functions of the entire brain, including the brain stem." Death rattle: inability to cough or clear secretions resulting in grunting. Hospice: A special concept of care designed to provide comfort and support to patients and their families when a life-limiting illness no longer responds to cure-oriented treatments. Palliative: a medicine that gives temporary relief from the symptoms of diseases but actually does not cure the disease Durable power of attorney : A legal document that allows an individual to appoint someone else (proxy) to make medical or health care decisions, in the event the individual becomes unable to make and/or communicate such decisions personally. Medical power of attorney: it‘s a term which describes a document used for listing the person to make health care decisions when the patient is unable to make decisions for self. Directive to physicians: A written document specifying the patients wish to be allowed to die without heroic or extraordinary measures. 5. Physical changes at end of life: Sensory changes: its mainly due to decrease oxygenation and circulatory changes Hearing & touch: decreased perception of pain, touch & sensation Taste & smell: Decreases with disease progression, blurring of vision, blinking reflex absent.
458
Integumentary system: cold, clammy skin. Wax like skin due to loss of muscle tone, cyanosis on nose, nail beds, knees due to decrease oxygenation and circulatory changes. Cardiovascular system: pulse rate increases and slows down later& becomes weak, blood-pressure decreases, elevation in the body temperature due to changes in hypothalamic function, and delayed absorption of drugs. Respiratory system: increased respiratory rate, Cheyne stroke respiration, death rattle irregular breathing. Urinary system: urinary output decreases due to loss of ability to form urine, incontinence of urine & unable to urinate. Gastrointestinal system: slowing of digestive tract, accumulation of gas due to decrease gastric motility and peristalsis which lead to constipation. Musculoskeletal system: gradual loss of ability to move, difficulty in speaking & swallowing, maintaining body posture, due to weakening of muscular system because of metabolic changes. 6. Psychological changes at the end of life: A variety of feelings and emotions affect the dying patient and family at the end of life. most patients and family struggle with a terminal diagnosis and the realization that there is no cure Grief: it is a emotional and behavioral changes to loss , it is a positive coping mechanism which also helps in individual wellbeing Stages of grief Denial: Denial is usually only a temporary defense for the individual. This feeling is generally replaced with heightened awareness of situations and individuals that will be left behind after death. [1] Example - "I feel fine."; "This can't be happening, not to me." Anger: Once in the second stage, the individual recognizes that denial cannot continue. Because of anger, the person is very difficult to care for due to misplaced feelings of rage and envy. Any individual that symbolizes life or energy is subject to projected resentment and jealousy. [1] Example - "Why me? It's not fair!"; "How can this happen to me?"; "Who is to blame?" Bargaining: The third stage involves the hope that the individual can somehow postpone or delay death. Usually, the negotiation for an extended life is made with a higher power in exchange for a reformed lifestyle. Psychologically, the person is saying, "I understand I will die, but if I could just have more time..." [1] Example - "Just let me live to see my children graduate."; "I'll do anything for a few more years."; "I will give my life savings if. Depression: During the fourth stage, the dying person begins to understand the certainty of death. Because of this, the individual may become silent, refuse visitors and spend much of the time crying and grieving. This process allows the dying person to disconnect themselves 459
from things of love and affection. It is not recommended to attempt to cheer an individual up that is in this stage. It is an important time for grieving that must be processed. [1] Example - "I'm so sad, why bother with anything?"; "I'm going to die . . . What's the point?"; "I miss my loved one, why go on?" Acceptance: This final stage comes with peace and understanding of the death that is approaching. Generally, the person in the fifth stage will want to be left alone. Additionally, feelings and physical pain may be non-existent. This stage has also been described as the end of the dying struggle. [1] Example - "It's going to be okay."; "I can't fight it, I may as well prepare for it." 7. Ethical, legal and communication issues at end of life: Assessing decision making capacity: the physician must assess the patient's decision making capacity before concluding that a given individual cannot speak for himself or herself. An assessment of decision making capacity can and should be performed by the primary physician; determining decision capacity for a specific medical intervention requires neither legal intervention nor psychiatric expertise. On the other hand, decisions about competence are judicial determinations that involve ruling on the patient's global decision making ability. Competency determinations are necessary when evaluating the capacity of a person to make non-medical decisions, such as financial matters. Patients and families struggle with many decisions during the terminal illness and dying experience. Many people decide that the outcomes related to their care should be based on their own wishes. The decisions may involve the choice for Legal documents used in end of life care: Advance directives: Advanced care directives are specific instructions, prepared in advance, intended to direct a person's medical care in the event that he/she is unable to do so in the future. Durable power of attorney : A legal document that allows an individual to appoint someone else (proxy) to make medical or health care decisions, in the event the individual becomes unable to make and/or communicate such decisions personally. Medical power of attorney: it‘s a term which describes a document used for listing the person to make health care decisions when the patient is unable to make decisions for self. Directive to physicians: A written document specifying the patients wish to be allowed to die without heroic or extraordinary measures. Under this acts patient can tell the physician that what treatment is or is not desired. Verbal directives are given to physicians with specific instructions in the presence of two witnesses in case if person is not able to communicate his wishes, the family and physician will decide what to be and what not to be done and the decision taken by the family should be recorded by physician. Organ and tissue donation: persons who are legally competent may choose organ donation. Any body part or the entire body may be donated. The decisions to donate organs or to provide anatomic gifts may be made by a person before death .and family permission must be obtained at time of donation. These peoples will have the ID card 460
given by the agencies. The physicians must be notified immediately when organ donation is intended because some tissues must be used within hours after death Euthanasia: Refers to the practice of ending a life in a painless manner. Many different forms of euthanasia can be distinguished, including animal euthanasia and human euthanasia, and within the latter, voluntary and involuntary euthanasia. Voluntary euthanasia and physician-assisted suicide have been the focus of great controversy in recent years. Euthanasia by consent: Euthanasia may be conducted with consent (voluntary euthanasia) or without consent (involuntary euthanasia). Involuntary euthanasia is conducted where an individual makes a decision for another person incapable of doing so. The decision can be made based on what the incapacitated individual would have wanted, or it could be made on substituted judgment of what the decision maker would want were he or she in the incapacitated person's place, or finally, the decision could be made by assessing objectively whether euthanasia is the most beneficial course of treatment. In any case, euthanasia by proxy consent is highly controversial, especially because multiple proxies may claim the authority to decide for the patient and may or may not have explicit consent from the patient to make that decision. Euthanasia by means: Euthanasia may be conducted passively, non-actively, and actively. Passive euthanasia entails the withholding of common treatments (such as antibiotics, chemotherapy in cancer, or surgery) or the distribution of a medication (such as morphine) to relieve pain, knowing that it may also result in death (principle of double effect). Passive euthanasia is the most accepted form, and it is a common practice in most hospitals. Non-active euthanasia entails the withdrawing of life support and is more controversial. Active euthanasia entails the use of lethal substances or forces to kill and is the most controversial means. An individual may use a euthanasia machine to perform euthanasia on him / her. Assisted suicide: Assisted suicide is a form of euthanasia where the patient actively takes the last step in their death. The term "assisted suicide" is contrasted with "active euthanasia" when the difference between providing the means and actively administering lethal medicine is considered important. For example, Swiss law on assisted suicide allows assisted suicide, while all forms of active euthanasia (like lethal injection) remain prohibited. Resuscitation: in recent days it‘s the right of the patient and the family to Decide whether resuscitation to be done. For every patient physician order is compulsory for the use of CPR Types of CPR decisions: Full code: which allows CPR drugs and mechanical ventilation? Chemical code: allows use of chemical drugs but no CPR. No code or DNR: which allows the person to die comfortably without interference of the technology? Advanced directives, organ donor information and Dr. Orders should be recorded in both medical and nursing record. 461
8. Palliative, hospice and spiritual care at the end of life: Hospice: Hospice is a concept of care that provides compassion, concern, and support for the dying. It exists to provide support and care for the persons in last phases of incurable diseases so that they can lead their life comfortably. Hospice care is given by a medically supervised interdisciplinary team of professionals and volunteers. As a nurse it‘s our responsibility to co-ordinate the team. Hospice nurse work with hospice physicians, pharmacists, dietitians, social workers, and volunteers to provide care and support to patient and family members. Hospice is a philosophy of care. The hospice philosophy or viewpoint accepts death as the final stage of life. The goal of hospice is to enable patients to continue an alert, painfree life and to manage other symptoms so that their last days may be spent with dignity and quality, surrounded by their loved ones. Hospice affirms life and does not hasten or postpone death. Hospice care treats the person rather than the disease; it focuses on quality rather than length of life. Hospice care is family-centered care -- it involves the patient and the family in making decisions. Care is provided for the patient and family 24 hours a day, 7 days a week. Hospice care can be given in the patient's home, a hospital, nursing home, or private hospice facility. Most hospice care in the United States is given in the home, with a family member or members serving as the main hands-on caregiver. Hospice care is meant for the time when cancer treatment can no longer help you, and you are expected to live 6 months or less. Hospice gives you palliative care, which is treatment to help relieve disease-related symptoms, but not cure the disease; its main purpose is to improve your quality of life. You, your family, and your doctor decide together when hospice cares should begin. One of the problems with hospice is that it is often not started soon enough. Sometimes ``the doctor, patient, or family member will resist hospice because he or she thinks it ``means you're giving up, or that there's no hope. This is not true. If you get better or the ``cancer goes into remission, you can be taken out of the hospice program and go into active cancer treatment. You can go back to hospice care at a later time, if needed. The hope that hospice brings is the hope of a quality life, making the best of each day during the last stages of advanced illness. Hospice care services: There are many things about hospice care that set it apart from other types of health care. A team of professionals In most cases, an interdisciplinary health care team manages hospice care. This means that many interacting disciplines work together to care for the patient. Doctors, nurses, social workers, counselors, home health aides, clergy, therapists, and trained volunteers care for you. Each of these people offers support based on their special areas of expertise. Together, they then give you and your loved ones complete palliative care aimed at relieving symptoms and giving social, emotional, and spiritual support. Pain and symptom control: The goal of pain and symptom control is to help you be comfortable while allowing you to stay in control of and enjoy your life. This means that side effects are managed to make sure that you are as free of pain and symptoms as possible, yet still alert enough to 462
enjoy the people around you and make important decisions. To learn more on this topic, please see our document, Spiritual care Hospice care also tends to your spiritual needs. Since people differ in their spiritual needs and religious beliefs, spiritual care is set up to meet your specific needs. It may include helping you to look at what death means to you, helping you say good-bye, or helping with a certain religious ceremony. People may think that they are not forgiven by god for their mistakes, as a nurse it‘s our responsibility to assess their spiritual needs and help them to meet their spiritual needs to improve the harmony of the patient and family. Home care and inpatient care Although hospice care can be centered in the home, you may need to be admitted to a hospital, extended-care facility, or a hospice inpatient facility. The hospice can arrange for inpatient care and will stay involved in your care and with your family. You can go back to in-home care when you and your family are ready. Respite care: While you are in hospice, your family and caregivers may need some time away.. Hospice service may offer them a break through respite care, which is often offered in up to 5-day periods. During this time you will be cared for either in the hospice facility or in beds that are set aside for this in nursing homes or hospitals. Families can plan a minivacation, go to special events, or simply get much-needed rest at home while you are cared for in an inpatient setting. Family conferences: Through regularly scheduled family conferences, often led by the hospice nurse or social worker, family members can stay informed about your condition and what to expect. Family conferences also give you all a chance to share feelings, talk about expectations, and learn about death and the process of dying. Family members can find great support and stress relief through family conferences. Conferences may also be done informally on a daily basis as the nurse or nursing assistant talks with you and your caregivers during their routine visits. Bereavement care: Bereavement is the time of mourning after a loss. The hospice care team works with surviving loved ones to help them through the grieving process. A trained volunteer, clergy member, or professional counselor provides support to survivors through visits, phone calls, and/or letter contact, as well as through support groups. The hospice team can refer family members and care-giving friends to other medical or professional care if needed. Bereavement services are often provided for about a year after the patient's death. Volunteers: Hospice volunteers play an important role in planning and giving hospice care in the United States. Volunteers may be health professionals or lay people who provide services that range from hands-on care to working in the hospice office or fundraising. Staffs support: Hospice care staff members are kind and caring. They communicate well, are good listeners, and are interested in working with families who are coping with a lifethreatening illness. They are usually specially trained in the unique issues surrounding death and dying. Yet, because the work can be emotionally draining, it is very important 463
that support is available to help the staff with their own grief and stress. Ongoing education about the dying process is also an important part of staff support. Coordination of care: The interdisciplinary team coordinates and supervises all care 7 days a week, 24 hours a day. This team is responsible for making sure that all involved services share information. This may include the inpatient facility, the home care agency, the doctor, and other community professionals, such as pharmacists, clergy, and funeral directors. You and your caregivers are encouraged to contact your hospice team if you are having a problem, any time of the day or night. There is always someone on call to help you with whatever may arise. Hospice care assures you and your family that you are not alone and help can be reached at any time. Hospice care settings: Hospice care is defined not only by the services and care provided, but also by the setting in which these services are delivered. Hospice care may be provided in your home or in a special facility. Most cancer patients choose to get hospice care at home. In fact, more than 90% of the hospice services provided in this country is based in patients' homes. Before making a decision about the type of program that is best for you and your family, it is important to know all your options and what each requires. Your doctor, hospital social worker, or discharge planner can be very helpful in deciding which program is best for you and your family. Home hospice care: Many, if not all, of the home health agencies in your community, as well as independently owned hospice programs, will offer home hospice services. Although a nurse, doctor, and other professionals staff the home hospice program, the primary caregiver is the key team member. The primary caregiver is usually a family member or friend who is responsible for around-the-clock supervision of the patient. This person is with the patient most of the time and is trained by the nurse to provide much of the hands-on care. It is important to know that home hospice may require that someone be home with you at all times. This may be a problem if you live alone, or if your partner or adult children have full-time jobs. But creative scheduling and good team work among your friends and loved ones can overcome this problem. Members of the hospice staff will visit regularly to check on you and your family and give needed care and services. Care begins when you are admitted to the program, which generally means that a hospice team member visits the home to learn about your situation and needs. Return visits are set up so that your needs can be re-evaluated regularly. To handle around-the-clock patient needs or crises, home hospice programs have an on-call nurse who answers phone calls day and night, makes home visits, or sends the team member you may need between scheduled visits. Medicare-certified hospices must provide nursing, pharmacy, and doctor services around the clock. Hospital-based hospices: Hospitals that treat seriously ill patients often have a hospice program. This arrangement allows patients and their families‘ easy access to support services and health care professionals. Some hospitals have a special hospice unit, while others use a hospice 464
team of caregivers who visit patients with advanced disease on any nursing unit. In other hospitals, the staff on the patient's unit will act as the hospice team. Independently owned hospices: Many communities have free-standing, independently owned hospices that feature inpatient care buildings as well as home care hospice services. As with long-term care facility hospice programs, the free-standing hospice can benefit patients who do not have primary caregivers available at home. Palliative: definition given by whom. Palliative care is an approach that improves the quality of patients and their families facing the problem associated with life threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychological, and spiritual. Goals of Palliative Care: To prevent or treat as early as possible the symptoms of the disease, side effects caused by treatment of the disease To prevent or treat psychological, social, and spiritual problems related to the disease or its treatment. To help people with life-threatening disease to live more comfortably. Palliative care emphasizes management of psychological, social, and spiritual problems in addition to control of pain and other physical symptoms. As the definition suggests, palliative. Care is not care that begins when cure-focused treatment ends. The goal of palliative care is to improve the patient‘s and families. Quality of life and many aspects of this type of comprehensive, comfort-focused approach to care are applicable earlier in the process of life-threatening disease in conjunction with cure focused treatment. In addition to a focus on the multiple dimensions of the illness experience for Both patients and their families, palliative care emphasizes the interdisciplinary collaboration that is necessary to bring about the desired outcomes for patients and their families. Interdisciplinary collaboration: it is distinguished from multidisciplinary practice in that the former is based on communication and cooperation among the various disciplines; each member of the team contributes to a single care plan that addresses the needs of the patient and family. Palliative philosophy identified from the last acts palliative care task force and the national hospice and palliative care organization includes the following. Palliative care provides support and care for persons facing life limited illness across all care settings. Palliative care identifies death as normal and natural. The dying process is profoundly individualized and occurs within the dynamics of family. Palliative care enhances the quality of life and integrates the physical, psychological, social, and spiritual aspects of care. The interdisciplinary team addresses the multidimensional needs of the dying clients and his or her family. 465
Palliative interventions affirm life and neither hastens nor postpones death. Appropriate palliative care and a supportive environment promote of life and health closure for the client and family. 9. Physical manifestations as death approaches and the nursing management: Certain signs and symptoms can help a caregiver anticipate when death is near. They are described below, along with suggestions for managing them. It is important to remember that not every patient experiences each of the signs and symptoms. In addition, the presence of one or more of these symptoms does not necessarily indicate that the patient is close to death. A member of the patient's health care team can give family members and caregivers more information about what to expect. Drowsiness, increased sleep, and/or unresponsiveness (caused by changes in the patient's metabolism). The caregiver and family members can plan visits and activities for times when the patient is alert. It is important to speak directly to the patient and talk as if the person can hear, even if there is no response. Most patients are still able to hear after they are no longer able to speak. Patients should not be shaken if they do not respond. Decreased socialization and withdrawal (caused by decreased oxygen to the brain, decreased blood flow, and mental preparation for dying). Speak to the patient directly. Let the patient know you are there for them. The patient may be aware and able to hear, but unable to respond. Professionals advise that giving the patient permission to ―let go‖ can be helpful. Decreased need for food and fluids, and loss of appetite (caused by the body's need to conserve energy and its decreasing ability to use food and fluids properly). Allow the patient to choose if and when to eat or drink. Ice chips, water, or juice may be refreshing if the patient can swallow. Keep the patient's mouth and lips moist with products such as glycerin swabs and lip balm. Loss of bladder or bowel control (caused by the relaxing of muscles in the pelvic area). Keep the patient as clean, dry, and comfortable as possible. Place disposable pads on the bed beneath the patient and remove them when they become soiled. Darkened urine or decreased amount of urine (caused by slowing of kidney function and/or decreased fluid intake). Caregivers can consult a member of the patient's health care team about the need to insert a catheter to avoid blockage. A member of the health care team can teach the caregiver how to take care of the catheter if one is needed. Skin becomes cool to the touch, particularly the hands and feet; skin may become bluish in color, especially on the underside of the body (caused by decreased circulation to the extremities). Blankets can be used to warm the patient. Although the skin may be cool, patients are usually not aware of feeling cold. Caregivers should avoid warming the patient with electric blankets or heating pads, which can cause burns. Rattling or gurgling sounds while breathing, which may be loud; breathing that is irregular and shallow; decreased number of breaths per minute; breathing that alternates
466
between rapid and slow (caused by congestion from decreased fluid consumption, a buildup of waste products in the body, and/or a decrease in circulation to the organs). Breathing may be easier if the patient's body is turned to the side and pillows are placed beneath the head and behind the back. Although labored breathing can sound very distressing to the caregiver, gurgling and rattling sounds do not cause discomfort to the patient. An external source of oxygen may benefit some patients. If the patient is able to swallow, ice chips also may help. In addition, a cool mist humidifier may help make the patient's breathing more comfortable. Increased difficulty controlling pain (caused by progression of the disease). It is important to provide pain medications as the patient's doctor has prescribed. The caregiver should contact the doctor if the prescribed dose does not seem adequate. With the help of the health care team, caregivers can also explore methods such as massage and relaxation techniques to help with pain. 10. Management of psychological changes at the end of life: Withdrawl:patient near death may seem to be withdrawn from the physical environment maintaining the ability to hear while not able to respond Converse as if the patient is alert, using a soft voice and gentle touch Unusual communication: patient may become restless and agitated or perform repetitive tasks; unusual communication may indicate that an unresolved issue is preventing the dying person from litting go encourage the family to tell the dying person , its ok to go to be fine Saying goodbyes : it is important for the patient and family members acknowledge their sadness , mutually forgive one another ,and say goodbye Encourage the dying person and family members to verbalize their feelings to of sadness, loss, forgiveness, to touch, hug cry. Allow the patient and family privacy to express their feelings and comfort one another. A. management of grief: Express patient to describe loss and their perception of the experience. Avoid confronting. Give opportunities to share feelings. Acknowledge patient perception and feelings. Encourage to express feeling in constructive way. Acknowledge anger as a legitimate feeling in grief. Redirect inappropriate expression of anger towards self or others. Provide privacy when they cry. 11. after death care: Signs of death: There is no breathing or pulse. The eyes do not move or blink, and the pupils are dilated (enlarged). The eyelids may be slightly open. The jaw is relaxed and the mouth is slightly open. The body releases the bowel and bladder contents. The patient does not respond to being touched or spoken to.
467
After the patient has passed away, there is no need to hurry with arrangements. Family members and caregivers may wish to sit with the patient, talk, or pray. When the family is ready, the following steps can be taken. Place the body on its back with one pillow under the head. If necessary, caregivers or family members may wish to put the patient's dentures or other artificial parts in place. If the patient is in a hospice program, follow the guidelines provided by the program. A caregiver or family member can request a hospice nurse to verify the patient's death. Contact the appropriate authorities in accordance with local regulations. If the patient has requested not to be resuscitated through a Do-Not-Resuscitate (DNR) order or other mechanism. Contact the patient's doctor and funeral home. When the patient's family is ready, call other family members, friends, and clergy. Provide or obtain emotional support for family members and friends to cope with their loss. 12. Care of care gives: Being present during a family members dying process can be highly stressful, our main role is to Recognizing signs and behaviors among family members who may be at risk for abnormal grief reaction , which includes dependency and negative feelings about the dying person ,inability to express feelings , concurrent life crisis, a history of depression, difficult reaction to previous losses , low self-esteem ,alcoholism , substance abuse . Family caregivers & other family members need encouragement to continue their usual activities as much as possible. They need to discuss their activities & maintain some control over their lives .health care providers need to be sensitive to the importance of significant others who are not necessarily relatives,. Resources such as community counseling & local support may assist some people in working through their grief Family caregivers need to be encouraged to take care of themselves. Keeping a journal can help the care giver express feelings that may be difficult to express verbally. Humor is important , and its use from time to time in some situation can provide distraction and relieve stress filled situation 13. Nursing process: Pain, chronic related to progress of disease. Nausea, vomiting related to complication of drugs and diseases. Fluid volume deficit, dehydration related to fewer intakes of food and fluids. Nutrition status imbalanced, related to dysphasia, loss of meal time companion. Bowel elimination problem, constipation related to immobility, poor intake of fluid. Skin integrity impaired related to immobility, incontinence of urine. Sleeping pattern disturbed, related to anxiety, agitation. Anxiety related to loneliness, social isolation. Self care deficit related to depression. Spiritual distress related to sense of abandonment by god and loss of significant others.
468
Assessment
Nursing diagnosis Subjective data: Pain, chronic patient says that related to he has pain progress of Objective data: disease. On observation patient is restless
Subjective data Patient verbalizes that , he is feeling vomiting sensation Objective data On observation patient is vomiting
Objective
Intervention
Evaluation
Asses pain thoroughly and regularly to Patient said that his determine the quality, intensity, and pain is reduced. location. Minimize irritants such as pressures, wetness. Provide divertional therapy such as music. Administer drug as per order. Evaluate effectiveness of pain relief measures frequently. Patient said that his Nausea, Patient vomiting is stopped vomiting verbalizes Asses the patient for complaints for and he is not having related to that he is not vomiting and possible causes. nausea sensation complication having Discuss modification to the drug of drugs and vomiting regimen with health care provider diseases sensation Provide frequent mouth care. Offer frequent meals. Administer anti emetics before meal as per order Patient verbalizes that his pain is relived
469
Assessment Subjective data: Patient says that he is feeling thirsty and fatigue. Objective data : On observation patient has sunken eyes and cracked lips. Subjective data: Patient says that he is having difficulty in swallowing food. Objective data: On observation patient is not having food regularly
Nursing diagnosis Fluid volume deficit, dehydration related to fewer intakes of food and fluids
Nutrition status imbalanced, related to dysphasia, loss of meal time companion.
objective
intervention
evaluation
To maintain patients fluid and electrolyte balance
Assess condition of mucous Patient is maintaining membrane to prevent excessive dryness. fluid and electrolytes Maintain regular mouth care, to balance. maintain hydration of mucous membrane Encourage the patients to have sips of water and ice chips Apply lubricants to lips and mucous membrane
To make Patient comfortable during his meal time
Patient said that, he can Arrange regular meal time have food much more Have the diet an favorable to patient Allow family members to be present easily than before. during meal time Suction the patient before meal time Provide medicines as per order
470
Assessment Subjective data : Patient says that he is not able to pass motion regularly. Objective data : On observation patient is not taking fluids and bed ridden. Subjective data : Patient says that he is having skin irritation Objective data : On observation patient is skin has become reddened and he is having incontinence of urine.
Nursing diagnosis Bowel elimination problem, constipation related to immobility and poor intake of fluid.
Objective
Intervention
Evaluation
Patient will be able to pass motion regularly.
Asses the bowel pattern of the patient. Encourage movement and exercises as tolerated. Encourage fiber rich diet. Encourage fluids. Use suppositories, laxatives or enema if ordered.
Patient verbalized that he is able to maintain normal bowel pattern.
To improve Asses for skin breakdown. the skin Prevent skin breakdown by mobilizing Skin integrity integrity of or keeping the skin clean from urine. impaired the patient. Use absorbent pads for urinary related to incontinence. immobility, Discuss about the condom catheter with incontinence consultant. of urine. Apply petroleum jellies at the area of skin irritation.
Patient says he is not having any irritation and he is comfortable on bed.
471
Assessment
Nursing diagnosis Subjective data : Sleeping Patient says that pattern he is not able to disturbed, sleep during related to night time. anxiety, Objective data : agitation. On observation patient eyes are sunken, anxious. Subjective data : Patient says that Anxiety he is feeling related to lonely. loneliness, Objective data : social On observation isolation. patient is alone and he is not able to go out along with his loved ones.
Objective
Intervention
Asses the patient sleeping pattern and level of anxiety. Allow patient attendees to talk with him. Talk to patient about his concerns. Provide calm environment during night time. Administer medicine to reduce anxiety as per order. Asses the anxious level of the patient. To relieve Advice the patient attendees to spend anxiety of the time with the patient. patient. Talk to patient and provide psychological support. Don‘t allow the patient to be alone, keep him engaged with some work. Provide medicine as per order. To bring back his normal sleeping pattern.
472
Evaluation Patient said that he is able to sleep normally in the night.
Patient verbalizes that he is not feeling lonely.
Assessment
Nursing Objective diagnosis Subjective data: Self care To resolve Patient says that deficit related patient he doesn‘t want to depression. depression food, take bath and he want to be alone. Objective data: On observation patient is not talking to anyone and not doing his routine things. Subjective data: Patient says that Coping To bring back he is not able to ineffective, normal cope up with his related to coping life situations. depression, mechanism. Objective data: lack of family On observation support. patient is alone and he is confused.
Intervention
Evaluation
Asses the psychological status of the patient. Advice the patient attendees to spend time with the patient. Talk to patient and provide psychological support. Don‘t allow the patient to be alone, keep him engaged with some work. Advice patient to do his daily routine regularly. Talk with consultant and arrange for counseling. Provide antidepressants as per order. Asses the psychological status of the patient. Advice the patient attendees to spend time with the patient. Talk to patient and provide psychological support. Talk with consultant and arrange for counseling. Provide antidepressants as order.
Patient is doing his daily routines and mingling with all.
473
Patient is able to cope up with his daily life situations.
Assessment Subjective data: Patient says that he is punished by the god for his sins. Objective data: On observation patient is always thinking about the god.
Nursing diagnosis Spiritual distress related to sense of abandonment by god and loss of significant others.
Objective To make patient comfortable in his stay.
Intervention
Evaluation
Asses the psychological status of the Patient says that he much more relaxed patient. Allow patient to do spiritual activities than before. without any disturbance. Talk to patient and provide psychological support. Talk with consultant and arrange for counseling.
474
14. Conclusion: In the recent years end of life care concept is increasing in the society because of various reasons, and it‘s also necessary that some one near by death should spend his life peacefully with the help of all medical and nursing group, and the family. 15. BIBLIOGRAPHY: Lewis, heitkemper, Dirksen, editors. Medical surgical nursing: assessment and management of clinical problem.6th ED.mosby; 2004.p.160-73. Joyce.m.black, jone hakason hawks, editors. Clinical management for positive outcomes.7th ED.saunders; 2005.p. 488-503. Wj Phipps,jk sandsy, jf marek, editors. Medical surgical nursing: concepts and clinical practice .6th ED.mosby; 1999.p.163-92. Suzannec smeltzer, brendabare, editors. Medical surgical nursing; 10th ED.lww; 2004.p.369-391. Joyce.v.zerewekh, editor.nursingcare at the end of life: palliative care for patients and families. af davis;p3-21,179-213. End of life care, national cancer institute. March 7th 2009. Available at; url:www.cancer.gov/cancer topics/end of life care. End of life care issues. Available at: url:www.apa.org/pi/col/homepage.html.
475
INFLAMATION 1.) Meaning: It is the protective response by the body or reaction of the living tissues of the body to injury, infection or irritation. 2.) Definition: I. ―Inflammation is the local response of living mammalian tissues to injury due to any agent. It is a body defense reaction in order to eliminate or limit the spread of injurious agent as well as to remove consequent necroses cells and tissues‖ -Harsh Mohan II. ―Inflammation is a defensive reaction, the intent of which is to neutralize, control or to eliminate the offending agent and to prepare the site for repair‖. -Suzanne.C.Smeltzer IV. The Nature Of Body Defense Mechanism: For the immune system to function properly, the cells must be able to distinguish self from oneself cells. All cells of the body have specific markers, usually proteins that identify them as belonging to self. If the markers are not present or the immune system does not recognize them, the cells are identified ad oneself, and reactions are elicited to destroy them. Any substance in the body that is interpreted as oneself and triggers an immune reaction is called an antigen. The leukocytes or the white blood cells, provide the immune system with an army that protects the body against foreign invasion. The total number of leukocytes is 4000 to 10,000 cells are cubic millimeters of blood. The human body is continually exposed to disease producing organism called pathogens, if these enter the body, they may disrupt homeostasis and cause disease. The body‘s ability to counteract the effect of pathogens and other harmful agent is called resistance and is dependent on a variety of defense mechanism. Types of immune response: Defense mechanism or immune response is mainly classified in to two types. 1. Nonspecific defense mechanism. 2. Specific defense mechanism. 1.) Nonspecific Defense Mechanism: Some defense mechanisms called nonspecific mechanism as it acts against all harmful agents and provide no specific resistance. Non-specific mechanisms are directed against all pathogens and foreign substances, regardless of the nature they are present the initial barriers against invading organisms. The first line of the defense is the barrier against invasion provided by: Intact skin. Mucous membrane. Flow of the fluid such as tears, saliva and urine. Chemicals those are present in the tears and other fluids. If a foreign agent penetrates the first line barriers, it meets a second line of defense that includes, Chemical action of complements: It promotes phagocytosis and inflammation and cause bacterial cells to rupture. 476
Chemical action of interferon: Protects cells from viral infection. When a cell becomes infected with the virus, the cell usually stops its normal functions. The virus uses the cells metabolic machinery or organelles for one goal viral replication or reproduction, when the cell is full of virus it ruptured and releases many viruses to infect the new cell. This is how the viral infection is Established. Interferon stimulates the uninfected cells to produce a protein that blocks viral the natures they are present the initial barriers against invading organisms. The first line of the defense is the barrier against invasion provided by: Intact skin. Mucous membrane. Flow of the fluid such as tears, saliva and urine. Chemicals those are present in the tears and other fluids. If a foreign agent penetrates the first line barriers, it meets a second line of defense that includes, Chemical action of complements: It promotes phagocytosis and inflammation and cause bacterial cells to rupture. Chemical action of interferon: Protects cells from viral infection. When a cell becomes infected with the virus, the cell usually stops its normal functions. The virus uses the cells metabolic machinery or organelles for one goal viral replication or reproduction, when the cell is full of virus it ruptured and releases many viruses to infect the new cell. This is how the viral infection is Established. Interferon stimulates the uninfected cells to produce a protein that blocks viral replication. In this way the uninfected cells are protected from the virus. Phagocytosis: Phagocytosis is the ingestion and destruction of the solid particles by certain cells. The cells are called phagocytes, and the particles may be microorganism or their parts, foreign articles, an individual‘s own damaged or dead cells or cell fragments. Inflammation: Inflammation is a non-specific defense mechanism that occurs in response to tissue damage from microorganisms or trauma. It is evidenced by redness, warmth, swelling and pain. Specific Defence Mechanisam: Some defense mechanisms only act against certain agents and are called specific defense mechanisms these provide specific resistance or immunity. To maintain a state of health, all the body defense mechanism must act together to provide protection against invading pathogens, foreign cells that are transplanted into the body, and body‘s own cells that have become cancerous. Specific defense mechanisms or immune responses provide the third line of defense against microbial invasion the primary cells involved in immune responses are: - Lymphocytes. - Macrophages. Two characteristics of these responses are: Specificity: when an antigen (foreign substance) enters the body a series of cellular changes occurs. These changes result in the formation of a specific antibody or sensitized lymphocytes that attaches to the surface of the antigen.
477
Memory: once the system has been exposed to a particular invading agent, components of the specific defense mechanism ―remember‖ that agents and launch a quicker attack if it enter the body again Development of lymphocytes: Like all other blood cells lymphocytes develop from stem cells in the bone marrow during fetal development, the bone marrow releases immature and undifferentiated lymphocytes in to the blood, some of these go the thymus gland where they acquire the ability to distinguish between self and non self molecules. The lymphocytes differentiate to become T lymphocytes or T cells in the thymus gland. For several months afterward thymus gland continues to process the T cells for specific activity in immune reactions then differentiate T cells lives the thymus Others go elsewhere, probably the fetal lever and differentiated intro b lymphocytes or B cells. Then both T cells and B cells are migrated to the spleen, lyphnodes and lymph nodules where they are found after birth. When activated during an immune response, some B cells will become plasma cell that produces anti bodies to a specific foreign agent Cell mediated immunity: T- Cells are responsible for cell mediated immunity, in which t cells directly attack and destroy foreign agents, cell mediate immunity is most effective against virus infected cells, cancer cell, foreign tissue cells (transplant rejection), fungi and protozoan parasites These activated T cells, which are antigen specific divides into four major sub groups: 1) killer T cells : able to chemically destroy foreign antigen by disrupting the cell membranes 2) Helper T cell: secrete substance that stimulate T cells and promote the immune response. Interleukin –2 is one of the substances secreted by helper T cells , researches are using interlukin-2 produced by genetic engineering to stimulate the immune system 3) Suppressor T cells: will control bar stock the immune response once the foreign antigen has been destroyed. 4) Memory T cell: will remember the specific foreign antigen and become active if it enters the body again. Antibody mediated immunity: B - Cells are responsible for antibody mediated immunity, also called humeral immunity in which the b- cells are responsible for the production of antibodies that react with the antigen or with substances produced by the antigen. Antibody mediated immunity is most effective against bacteria, viruses, that are outside body cells and toxins produced by antigens. It is also involved in allergic reaction. When antigen enters the body, macrophages engulf and process them, then present them to T- cells and helper T-cells .the activated T-cells secrete substances that stimulates bcells to divide and form a clone of cells consisting of memory B-cells and plasma cells. Plasma cells produce large quantities of anti bodies that inactivate the invading antigens. Memory B-cells remember the antigen, and subsequent exposure to the same antigen changes memory B-cells to plasma cells for a rapid production of anti bodies The production of anti bodies after the first exposure to an antigen is different that following a second or subsequent exposure. The primary response normally takes three to 478
fourteen days to produce enough antibodies to be effective against the antigen. In the mean time the individual usually Develops disease symptoms because the antigen has had enough time to cause tissue damage. The second response provides better protection than the primary response for two reasons The time required to produce antibodies is less from a few hours to a few days and more antibodies are produced consequently The antigen is quickly destroyed and no disease symptoms develop and the person is immune. If memories T-cells are not stimulated, or if memory cells produced are short lived, it is possible to have repeated infections of the same disease Ex: - cold viruses causes cold more time. Immunoglobulin: Antibodies belong to a class of proteins called globulins, which because they are involved in immune reactions, are also called immunoglobulin There are five main classes of anti bodies or immunoglobulin, each with a specific role in immunity Sl Class % of location Functions no total 1 IgG 75 - Blood, plasma Nature antibody in primary and secondary 85 responses, inactivates antigen, neutralizes toxins, crosses placenta to provide immunity to new born , responsible Rh reaction 2 IgA 5 - 15 saliva, mucus, tears, Protect mucus membranes on body breast milk surfaces, provides immunity for new born. 3 IgM 5 - 10 Attached to B-cells , Causes antigens to clamp together released in to plasma responsible for transfusion reactions in the during immune ABO blood typing system response 4 IgD 0.2 Attached to B-cells Receptor sites for antigen on B-cells, binding with antigen results in b-cell activation 5 IgE 0.5 Produced by plasma Binds to mast cells and basophiles causing cell in mucus release of histamine, responsible for membrane and allergic reactions V. Factors affecting body defense mechanism: 1. Age: persons at the extreme of the life span are more likely to develop problems related to immune system functioning than are those in there middle years 2. Gender: auto immune diseases are more common in females than males 3. Nutrition: nutrition is of vital importance to the immune system. appropriate proteins are necessary for the proliferation of leukocytes and are the synthesis of immunoglobulin , high calorie diet appear to b involved in the development of auto immune disease
479
4. Genetics: genetics provides the foundation for one‘s immune system, influences the expression of allergy and auto immune diseases and certain form of cancer to developer within families 5. Other organ diseases: conditions such as burns or other forms of injury, infection and cancer may contribute to alter immune system function. Chronic illness like renal failure, recurrent respiratory tract infection, COPD etc. 6. Medication: certain medication can cause both desirable and undesirable alteration in immune system functioning. Four major classification of medicine are i) antibiotics ex: penicillin ii) corticosteroids ex: prednisone iii) NSAIDS ex: aspirin, Ibuprofen iv) Cytotoxic agent ex: cyclosporine, alkyltic agent 7. Radiation: radiation destroys lymphocytes and decreases the population of cells required to replace them, whole body radiation may leave the individual totally immuno suppressed 8. Stress: stress have been linked to suppression of the immune system for decades . Physical stress such as trauma and burns, emotional stress such as grief are known to depress immune cell function. A number of hormones associated with stress also decrease immune activity.
480
UNIT-VII
481
SYLLABUS Unit Hours VIII
10
Content Nursing process approach: �Health Assessment- illness status of patients/clients (Individuals, family, community), Identification of healthillnes problems, health behaviors, signs and symptoms of Clients. �Methods of collection, analysis and utilization of data Relevant to nursing process. �Formulation of nursing care plans, health goals, Implementation, modification and evaluation of care.
482
HEALTH ASSESSMENT Nursing Process Overview: Introduction: A systematic problem-solving approach used to identify, prevent and treat actual or potential health problems and promote wellness. A systematic way to plan, implement and evaluate care for individuals, families, groups and communities. Components of nursing process: The nursing process consists of five dynamic and interrelated phases:1. Assessment. Evaluation 2. Diagnosis. Assessment 3. Planning. 4. Implementation. 5. Evaluation. Implementa tion
Diagnosis
Planning
HEALTH ASSESSMENT Introduction: It is systematic and continuous collection, validation and communication of client data as compared to what is standard/norm. It includes the client‘s perceived needs, health problems, related experiences, health practices, values and lifestyles. Purpose: To establish a data base (all the information about the client): Nursing health history. Physical assessment. The physician‘s history & physical examination. Results of laboratory & diagnostic tests. Material from other health personnel. Types of Assessment: a. Initial comprehensive assessment: An initial assessment, also called an admission assessment, is performed when the client enters a health care from a health care agency. The purposes are to evaluate the client‘s health status, to identify functional health patterns that are problematic, and to provide an in-depth, comprehensive database, which is critical for evaluating changes in the client‘s health status in subsequent assessments. b. Problem-focused assessment: A problem focus assessment collects data about a problem that has already been identified. This type of assessment has a narrower scope and a shorter time frame than the initial assessment. In focus assessments, nurse determine whether the problems still exists and whether the status of the problem has changed (i.e. improved, worsened, or resolved). This assessment also includes the appraisal of any new, overlooked, or misdiagnosed problems. In intensive care units, may perform focus assessment every few minute. c.Emergency assessment: Emergency assessment takes place in life-threatening situations in which the preservation of life is the top priority. Time is of the essence rapid 483
identification of and intervention for the client‘s health problems. Often the client‘s difficulties involve airway, breathing and circulatory problems (the ABCs). Abrupt changes in self-concept (suicidal thoughts) or roles or relationships (social conflict leading to violent acts) can also initiate an emergency. Emergency assessment focuses on few essential health patterns and is not comprehensive. d. Time-lapsed assessment or Ongoing assessment: Time lapsed reassessment, another type of assessment, takes place after the initial assessment to evaluate any changes in the clients functional health. Nurses perform time-lapsed reassessment when substantial periods of time have elapsed between assessments (e.g., periodic output patient clinic visits, home health visits, and health and development screenings). Steps of Assessment: 1. Collection of data. Subjective data collection. Objective data collection. 2. Validation of data. 3. Organization of data. 4. Recording/documentation of data. Assessment = Observation of the patient + Interview of patient, family & SO + examination of the patient + Review of medical record I. Collection of data: Gathering of information about the client. Includes physical, psychological, emotion, socio-cultural, spiritual factors that may affect client‘s health status. Includes past health history of client (allergies, past surgeries, chronic diseases, use of folk healing methods). Includes current/present problems of client (pain, nausea, sleep pattern, religious practices, medication or treatment the client is taking now). Types of Data: a. Subjective data: Also referred to as Symptom or sensations. Information from the client‘s point of view or are described by the person experiencing it. Information supplied by family members, significant others; other health professionals are considered subjective data. Example: pain, dizziness, ringing of ears/Tinnitus b. Objective data: Also referred to as Sign. Those that can be detected observed or measured/tested using accepted standard or norm. Mainly collected by general observation and by using the four physical examination techniques: inspection, percussion, palpation, and auscultation. Example: pallor, diaphoresis, BP=150/100, yellow discoloration of skin.
484
Methods of Data Collection: Interview: A planned, purposeful conversation/communication with the client to get information, identify problems, evaluate change, to teach, or to provide support or counseling. Interviewing, an essential skill for obtaining information for the nursing history, consist of asking question designed to elicit subjective data from the client or family members. The nursing history focuses on client‘s account of the actual or potential health problems and their impact on his her health status. Observation: use to gather data by using the 5 senses and instruments. Examination: Systematic data collection to detect health problems using unit of measurements, physical examination techniques, interpretation of laboratory results. Assessment Sequencing. a. Cephalocaudal approach – head-to-toe assessment: Physical Assessment using head toe approach General: Chest: General health status. Inspect and palpate breast. Vital signs and weight. Inspect and auscultation lungs. Nutrional status. Auscultator heart. Mobility and self care: Abdomen: Observe posture. Inspect, auscultation, and palpate four Assess gait and balance. quadrants. Evaluate mobility. Palpate and peruses liver, stomach, and Activities of daily living. bladder. Bowel elimination. Head face and neck: Evaluate cognition. Urinary elimination LOC. Genitalia: Orientation. Inspect female client. Mood. Inspect male client. Language and memory. Extremities: Sensory function. Palpate arterial pulses. Test vision. Observe capillary refill. Inspect and examine ears. Evaluate edema. Test hearing. Assess joint mobility. Cranial nerves. Measure strength. Inspect lymph nodes. Assess sensory function. Inspect neck veins. Assess circulation, movement, & sensation. Deep tendon reflexes. Skin, hair and nails: Inspect scalp, hair & nails. Inspect skin and nails. Evaluate skin turgid. Observe skin lesion. Assess wounds.
485
b. Body System approach – examine all the body system: Review Of Systems: General presentation of symptoms: Fever, chills, malaise, pain, sleep patterns, fatigability Diet: Appetite, likes and dislikes, restrictions, written dairy of food intake Skin, hair, and nails: rash or eruption, itching, color or texture change, excessive sweating, abnormal nail or hair growth Musculoskeletal: Joint stiffness, pain, restricted motion, swelling, redness, heat, deformity Head and neck: I Eyes: visual acuity, blurring, diplopia, photophobia, pain, recent change in vision Ears: Hearing loss, pain, discharge, tinnitus, vertigo Nose: Sense of smell, frequency of colds, obstruction, epistaxis, sinus pain, or postnasal discharge Throat and mouth: Hoarseness or change in voice, frequent sore throat, bleeding o swelling, of gums, recent tooth abscesses or extractions, soreness of tongue or mucosa. Endocrine and genital reproductive: Thyroid enlargement or tenderness, heat or cold intolerance, unexplained weight change, polyuria, polydipsia, changes in distribution of facial hair; Males: Puberty onset, difficulty with erections, testicular pain, libido, infertility; Females:Menses{onset, regularity, duration and amount}, Dysmenorrhea, last menstrual period, frequency of intercourse, age at menopause, pregnancies{number, miscarriage, abortions} type of delivery, complications, use of contraceptives; breasts{pain, tenderness, discharge, lumps} Chest and lungs: Pain related to respiration, dyspnea, cyanosis, wheezing, cough, sputum {character, and quantity}, exposure to tuberculosis (TB), last chest X-ray Heart and blood vessels: Chest pain or distress, precipitating causes, timing and duration, relieving factors, dyspnea, orthopnea, edema, hypertension, exercise tolerance Gastrointestinal: Appetite, digestion, food intolerance, dysphagia, heartburn, nausea or vomiting, bowel regularity, change in stool color, or contents, constipation or diarrhea, flatulence or hemorrhoids Genitourinary: Dysuria, flank or suprapubic pain, urgency, frequency, nocturia, hematuria, polyuria, hesitancy, loss in force of stream, edema, sexually transmitted disease Neurological: Syncope, seizures, weakness or paralysis, abnormalities of sensation or coordination, tremors, loss of memory Psychiatric: Depression, mood changes, difficulty concentrating nervousness, tension, suicidal thoughts, irritability. Pediatrics: along with systemic approach in case of pediatrics, measure anthropometric measurement and neuromuscular assessment.
486
c. Review of System approach: examine only particular area affected d.Inspection: Inspection is the visual examination of the client. Guidelines for Effective Inspection: Be systematic Fully expose the area to be inspected; cover other body parts to respect the client's modesty. Use good light, preferably natural light. Maintain comfortable room temperature. Observe color, shape, size, symmetry, position, and movement Compare bilateral structures for similarities and differences. e Palpation: Palpation uses the sense of touch to assess various parts of the body and helps to confirm findings that are noted on inspection. The hands, especially the finger tips are used to assess skin temperature, check pulses, texture, moisture, masses, tenderness, or pain. Ask the Client for permission first and explain to your client what you intend to examine. Establish client trust with being professional. Please remember to use warm hands. Any tender areas should be palpated last. Types of Palpation: Light Palpation: To check muscle tone and assess for tenderness Deep Palpation: To identify abdominal organs and abdominal masses. f Percussion: Percussion is the striking of the body surface with short, sharp strokes in order to produce palpable vibrations and characteristic sounds. It is used to determine the location, size, shape, and density of underlying structures; to detect the presences of air or fluid in a body space; and to elicit tenderness Types of Percussion: 1. Direct Percussion: Percussion in which one hand is used and the striking finger of the examiner touches the surface being percussed. 2. Indirect Percussion: Percussion in which two hands are used and the plexor strikes the finger of the examiner's other hand, which is in contact with the body surface being percussed. 3. Blunt Percussion: Percussion which the ulnar surface of the hand or fist is used in place of the fingers to strike the body surface, either directly or indirectly. Percussion Sounds: Resonance: A hollow sound. Hyper resonance: A booming sound. Tympany: A musical sound or drum sound like that produced by the stomach. Dullness: Thud sound produced by dense structures such as the liver, and enlarged spleen, or a full bladder. Flatness: An extremely dull sound like that produced by very dense structures such as muscle or bone. g Auscultation: Auscultation is listening to sounds produced inside the body. These include breath sounds, heart sounds, vascular sounds, and bowel sounds. It is used to detect the presence 487
Of normal and abnormal sounds and to assess them in terms of loudness, pitch, quality, frequency and duration. Source of data: a. Primary source: data directly gathered from the client using interview and physical examination. b. Secondary source: data gathered from client‘s family members, significant others, client‘s medical records/chart, other members of health team, and related care literature/journals. In the Assessment Phase, obtain a Nursing Health History - a structured interview designed to collect specific data and to obtain a detailed health record of a client. Components of a Nursing Health History: Biographic data – name, address, age, sex, martial status, occupation, religion. Reason for visit/Chief complaint – primary reason why client seek consultation or hospitalization. History of present Illness – includes: usual health status, chronological story, family history, disability assessment. Past Health History – includes all previous immunizations, experiences with illness. Family History – reveals risk factors for certain disease diseases (Diabetes, hypertension, cancer, mental illness). Review of systems – review of all health problems by body systems Lifestyle – include personal habits, diets, sleep or rest patterns, activities of daily living, recreation or hobbies. Social data – include family relationships, ethnic and educational background, economic status, home and neighborhood conditions. Psychological data – information about the client‘s emotional state. Pattern of health care – includes all health care resources: hospitals, clinics, health centers, family doctors. II. Validation of Data: the act of ―double-checking‖ or verifying data to confirm that it is accurate and complete. Validation of data is the process if confirming or verifying that the subjective and objective data collected are reliable and accurate. The steps of validation include deciding whether the data require validation, determining ways to validate the data, and identifying areas where data are missing. Failure to validate data may result in premature closure of the assessment or collection of inaccurate data. Purposes of data validation: a. Ensure that data collection is complete. b. Ensure that objective and subjective data agree. c. Obtain additional data that may have been overlooked. d. Avoid jumping to conclusion. e. Differentiate cues and inferences. Data Requiring Validatio: Not every piece of data you collect must be verified. For example: you would not need to verify or repeat the client‘s pulse, temperature, or blood pressure unless certain conditions exist.
488
Conditions that require data to be rechecked and validated include: Discrepancies or gaps between the subjective and objective data. For example, a male client tells you that he is very happy despite learning that he has terminal cancer. Discrepancies or gaps between what the client says at one time and then another time. For example, your female patient says she has never had surgery, but later in the interview she mentions that her appendix was removed at a military hospital when she was in the navy. Findings those are very abnormal and inconsistent with other findings. For example, the client has a temperature of 104oF degree. The client is resting comfortably. The client‘s skin is warm to touch and not flushed. Methods of validation: There are several ways to validate your data: Recheck your own data through a repeat assessment. For example, take the client‘s temperature again with a different thermometer. Clarify data with the client by asking additional questions. For example: if a client is holding his abdomen the nurse may assume he is having abdominal pain, when actually the client is very upset about his diagnosis and is feeling Verify the data with another health care professional. For example, ask a more experienced nurse to listen to the abnormal heart sounds you think you have just heard. Compare you objective findings with your subjective findings to uncover discrepancies. For example, if the client state that she ―never gets any time in the sun‖ yet has dark, wrinkled, suntanned skin, you need to validate the client‘s perception of never getting any time in the sun. III.Organization of Data: uses a written or computerized format that organizes assessment data systematically. Maslow’s basic needs:
489
Body System Model: The Body systems model (also called the medical model or review of systems) focuses on the client‘s major anatomic systems. The framework allows nurses to collect data about past and present condition of each organ or body system and to examine thoroughly all body systems for actual and potential problems. Gordon’s Functional Health Patterns: The client‘s strengths, talents and functional health patterns are an integral part of the assessment data. An assessment of functional health focuses on client‘s normal function and his or her altered function or risk for altered function. 1. Health perception-health management pattern. 2. Nutritional-metabolic pattern. 3. Elimination pattern. 4. Activity-exercise pattern. 5. Sleep-rest pattern. 6. Cognitive-perceptual pattern. 7. Self-perception-concept pattern. 8. Role-relationship pattern. 9. Sexuality-reproductive pattern. 10. Coping-stress tolerance pattern. 11. Value-belief pattern. IV. Communicate/Record/Document Data : Nurse records all data collected about the client‘s health status. Data are recorded in a factual manner not as interpreted by the nurse. Record subjective data in client‘s word; restating in other words what client says might change its original meaning. Purposes of documentation: 1. Provides a chronological source of client assessment data and a progressive record of assessment findings that outline the client‘s course of care. 2. Ensures that information about the client and family is easily accessible to members of the health care team; provides a vehicle for communication; and prevents fragmentation, repetition, and delays in carrying out the plan of care. 3. Establishes a basis for screening or validation proposed diagnoses. 4. Acts as a source of information to help diagnose new problems. 5. Offers a basis for determining the educational needs of the client, family, and significant others. 6. Provides a basis for determining eligibility for care and reimbursement. Careful recording of data can support financial reimbursement or gain additional reimbursement for transitional or skilled care needed by the client. 7. Constitutes a permanent legal record of the care that was or was not given to the client. 8. Provides access to significant epidemiologic data for future investigations and research and educational endeavors.
490
Guidelines for documentation: Document legibly or print neatly in unerasable ink Use correct grammar and spelling Avoid wordiness that creates redundancy Use phrases instead of sentences to record data Record data findings, not how they were obtained Write entries objectively without making premature judgments or diagnosis Record the client‘s understanding and perception of problems Avoid recording the word ―normal‖ for normal findings Record complete information and details for all client symptoms or experiences Include additional assessment content when applicable Support objective data with specific observations obtained during the physical examination. Stage one of the nursing process: Assessment is the first stage of the nursing process in which the nurse should carry out a complete and holistic nursing assessment of every patient's needs, regardless of the reason for the encounter. Usually, an assessment framework, based on a nursing model is used. The purpose of this stage is to identify the patient's nursing problems. These problems are expressed as either actual or potential. For example, a patient who has been rendered immobile by a road traffic accident may be assessed as having the "potential for impaired skin integrity related to immobility". Components of a nursing assessment: Nursing history: Taking a nursing history prior to the physical examination allows a nurse to establish a rapport with the patient and family. Elements of the history include: Health status. Course of present illness including symptoms. Current management of illness. Past medical history including family's medical history. Social history. Perception of illness. Psychological and social examination: The psychological examination may include: Client‘s perception (why they think they have been referred/are being assessed; what they hope to gain from the meeting). Emotional health (mental health state, coping styles etc). Social health (accommodation, finances, relationships, genogram, employment status, ethnic back ground, support networks etc). Physical health (general health, illnesses, previous history, appetite, weight, sleep pattern, diurinal variations, alcohol, tobacco, street drugs; list any prescribed medication with comments on effectiveness).
491
Spiritual health (is religion important? If so, in what way? What/who provides a sense of purpose?). Intellectual health (cognitive functioning, hallucinations, delusions, concentration, interests, hobbies etc). Physical examination: A nursing assessment includes a physical examination: the observation or measurement of signs, which can be observed or measured, or symptoms such as nausea or vertigo, which can be felt by the patient. The techniques used may include Inspection, Palpation, Auscultation and Percussion in addition to the "vital signs" of temperature, blood pressure, pulse and respiratory rate, and further examination of the body systems such as the cardiovascular or musculoskeletal systems. Documentation of the assessment: The assessment is documented in the patient's medical or nursing records, which may be on paper or as part of the electronic medical record which can be accessed by all members of the healthcare team. Assessment tools: A range of instruments has been developed to assist nurses in their assessment role. These include. The index of independence in activities of daily living: Activities of daily living (ADLs) are "the things we normally do in daily living including any daily activity we perform for self-care (such as feeding ourselves, bathing, dressing, grooming), work, homemaking, and leisure." The Barthel index: The Barthel Index consists of 10 items that measure a person's daily functioning specifically the activities of daily living and mobility. The items include feeding, moving from wheelchair to bed and return, grooming, transferring to and from a toilet, bathing, walking on level surface, going up and down stairs, dressing, continence of bowels and bladder. Example form: Patient Name: __________________ Rater: ____________________ Date: / / : Activity Feeding: 0 = unable 5 = needs help cutting, spreading butter, etc., or requires modified diet 10 = independent Bathing: 0 = dependent 5 = independent (or in shower)
Score 0
0
492
5 10
5
Grooming: 0 = needs to help with personal care 5 = independent face/hair/teeth/shaving (implements provided) Dressing: 0 = dependent 5 = needs help but can do about half unaided 10 = independent (including buttons, zips, laces, etc.) Bowels: 0 = incontinent (or needs to be given enemas) 5 = occasional accident 10 = continent Bladder: 0 = incontinent, or catheterized and unable to manage alone 5 = occasional accident 10 = continent Toilet Use: 0 = dependent 5 = needs some help, but can do something alone 10 = independent (on and off, dressing, wiping)
0
5
0
5 10
0
5 10
0
5 10
0
5 10
Transfers (bed to chair and back): 0 = unable, no sitting balance 5 = major help (one or two people, physical), can sit 10 = minor help (verbal or physical) 15 = independent
0 5 10 15
Mobility (on level surfaces): 0 = immobile or < 50 yards 5 = wheelchair independent, including corners, > 50 yards 10 = walks with help of one person (verbal or physical) > 50 yards 15 = independent (but may use any aid; for example, stick) > 50 yards
0 5 10 15
Stairs: 0 = unable 5 = needs help (verbal, physical, carrying aid) 10 = independent TOTAL (0 - 100)
0
5 10
________
493
The general health questionnaire. Mental health status examination. The Mental Status Exam (MSE) is a series of questions and observations that provide a snapshot of a client's current mental, cognitive, and behavioural condition. Other assessment tools may focus on a specific aspect of the patient's care. For example, the Waterlow score deals with a patient's risk of developing a Bedsore (decubitus ulcer) the Glasgow Coma Scale measures the conscious state of a person,
494
BIBLIOGRAPHY: 1. Weber J. & Kelley ― Health Assessment in Nursing‖ 2nd ed; Lippincott Williams; 2003 2. Craven R.F. ―Fundamentals of Nursing‖ 4th Ed. Lippincott; 2003; 139-140, 149-161, 394-453. 3. Perry & Potter ―Fundamentals of Nursing‖ 6th Ed. Elsevier; 2006;424-445
495
NURSUNG DIAGNOSIS AND ANALYSIS OF DATA Introduction to Nursing Process: The practice of nursing involves the provision of comprehensive nursing care to clients based on knowledge from biological, physical and social sciences. Integral to the practice of nursing is the nursing process, an activity that facilitates the nurse‘s interaction with clients in an effort to assist the clients to maintain and restore health. Definition of Nursing Process: Nursing process primarily refers to the independent responsibility of the nurse in providing client care. It has been derived from the scientific method and adapted as an organized. systematic method for identifying clients concern and problems ,choosing expected client outcomes ,determining interventions to resolve these problems and evaluating achievement of expected outcomes following provision of nursing care. Nursing Assessment: Every health care professional performs assessments to make professional judgements related to his or her clients.However, the purpose of nursing history and physical examination differs greatly from that of medical or other type of health examination. The purpose of nursing assessment is to collect subjective and objective data to determine the client‘s overall level of functioning in order to make a professional clinical judgement. The nurse collects physiologic, psychological, sociocultural, developmental and spiritual data about the client. The end result of a nursing assessment is the formulation of nursing diagnosis that require nursing care ,the identification of collaborative problems that require interdisciplinary care and the identification of problems that require immediate referral. Phases of Nursing Process: There are five phases of nursing process: Phase Title Description 1. Assessment Collecting subjective and Objective data. 2. Diagnosis Analysis subjective and objective data to make nursing diagnosis. 3. Planning Determining outcome criteria and developing a plan. 4. Implementati Carrying out a plan. on 5. Evaluation Assessing wheather outcome criteria have been met and revising the plan as necessary. Historical Development O Nursing Diagnosis: As early as 1926, Harmer suggested that nurse should include problem statements when documenting client care. In 1947, Lesnich and Anderson argued that diagnosis was within the scope of nursing practice. Fry (1953) is generally credited with the first use of the term nursing diagnosis in the nursing literature. During the 1960s, a series of research studies focused on the nurse‘s ability to make clinical judgements using client cues. These studies reveal that knowledge and interpretation varied widely and that the terms used to describe the client‘s problem were not standardized.
496
In 1972, Gordon completed her dissertation on diagnostic reasoning in nursing. The formal development of the identification and classification of nursing diagnosis began with the first National Conference on the Classification of Nursing Diagnosis, conveyed by Gebbie and Levin in 1973. Although implied in the assessment phase of nursing process, nursing diagnosis emerged as a separate phase in early 1970s. the act of diagnosing was recognized by the American Nurses Association(ANA) in standards of nursing practice (A NA 1973) and reaffirmed by the publication of revised standards in 1991(ANA 1991). It gained further support when the ANA included diagnosis as a separate activity in nursing. Since that time most state nurse practice acts have included diagnosis as part of the domain of nursing practice for which the nurse is held accountable. Standards developed by the Joint Commission on the Accreditation of Health Care Organization (JCAHO) mandate that each client‘s nursing care be based on identified nursing diagnosis or client care needs (1996) Nurse continue to develop new nursing diagnosis, refine the existing diagnosisand organize them into a classification system useful to practicing nurses. NANDA has been the leader in nursing diagnosis classification and has been endorsed by the ANA as having the responsibility to do so. To date 14 conferences have been held to refine the classification system for nursing diagnosis. Nursing Diagnosis Taxonomy Development: Definition Of Taxonomy: Taxonomy is a method for ordering complex information. Each classification system is based on a single principle or set of principles that establish the ground rules for selecting and placing the individual elements in the system. NANDA’s goal has been to develop nursing diagnosis taxonomy. At the first conference in 1973, 86 nursing diagnosis were listed alphabetically and published for use and development by all registered nurses. There was no claim as to validity of the diagnosis, nor was the list considered final. No classification system was selected. Through first six conferences, the listing of the nursing diagnosis remained alphabetical, but attention was focusing on selecting a classification system. As of 2000, NANDA has accepted 155 nursing diagnosis for clinical use and testing. NANDA is receiving and staging additional diagnosis. Psychiatric nurses requested inclusion of their nursing diagnosis at the 11th biennial conference and their labels were accepted for development. Definition: A nursing diagnosis is a statement that describes the client‘s actual or potential responses to a health problem that the nurse is licensed and competent to treat.e.g Impaired skin integrity related to decreased mobility and risk for infection related to poor nutritional intake. Nursing diagnosis provide the basis for selection of nursing intervention to achieve outcome for which the nurse is accountable. Outcomes and interventions are selected in relationship to particular nursing diagnosis. The reason for formulating a nursing diagnosis after analyzing assessment data are to identify the health problems involving the client and family and to provide direction for nursing care. 497
What Is Not A Nursing Diagnosis? The nursing diagnosis statement is written in terms of a client problem, alteration in health state for which the nursing provides the primary therapy. The following are not nursing diagnosis: Medical diagnosis. Medical pathology. Diagnostic tests. Treatments. Equipments. Types of Diagnostic Statements: TYPE CONSTRUCTION EXAMPLE Actual nursing diagnosis Three part statement includes Acute pain related to diagnostic lable,related surgical trauma and factors, defining inflammation, as characteristics evidenced by grimacing and verbal reports of pain Risk nursing diagnosis Two part statement includes Risk for infection related diagnostic label, risk factors to surgery and immunosupperession Possible nursing diagnosis Two part statement includes Possible self esteem diagnostic lable,related disturbance related to factors (unknown) unknown etiology Wellness diagnosis One part statement includes Readiness for enhanced diagnostic label spiritual wellbeing Analysis and Intrepretation Of Data: Analysis of subjective and objective data to make nursing diagnosis: After completing the nursing assessment, the nurse proceeds to the process of forming appropriate nursing diagnosis. A nursing diagnosis is a clinical judgement about individual, family or community responses to actual health problem or life processes. {NANDA} In the assessment phase, data are initially collected from a variety of source and validated. The nurse then applies reasoning and begins to look for patterns in the assessment data. To arrive at nursing diagnosis we must go through the steps of data analysis. This process requires diagnostic reasoning skills, often called critical thinking. Steps of Data Analysis: 1. Identify abnormal data and strengths. 2. Cluster the data. 3. Draw inferences and identify the problem. 4. Propose possible nursing diagnosis. 5. Check defining characteristics. 6. Confirm or rule out. 7. Document conclusion. Identify Abnormal Data And Strengths: Identifying abnormal findings and strengths requires the nurse to have and use a knowledge base of anatomy and physiology, psychology and sociology. In addition the 498
collected data should be compared with findings in reliable charts and reference sources that provide standards and values for physical and psychological norms (i.e.height, nutritional requirement, growth and development) additionally the nurse should have a basic knowledge of risk factors for the client. Risk factors are based on client data such as gender, age, cultural background, and occupation. The nurse‘s knowledge of anatomy and physiology, psychology and sociology, use of reference materials and attention to risk factors help to identify strengths, risks and abnormal findings. Identified strengths are used to in formulating wellness diagnosis. Identified potential weaknesses are used in formulating risk diagnosis and abnormal findings are used in formulating actual nursing diagnosis. Cluster The Data: In this step the nurse looks at the identified abnormal findings and strengths for cues that are related. Both abnormal cues and strength cues should be clustered and a particular nursing framework should be used as a guide when possible. The following is the example of how to cluster the data after assessing a client who reports the subjective information defined below and whose physical examination discloses the objective findings listed below: Identified abnormal data and strengths: Subjective Hair falling out in chunks. Red rash on face and chest. So ugly. Identified abnormal data and strengths: Objective Anxious appearing. Patchy alopecia. Red raised plaques on face, neck, shoulders, back and chest. While clustering the data, we may find that certain cues are pointing towards a problem but that more data are needed to support the problem. Draw Inferences: This step requires writing down the hunches about each cue cluster. You will write what you think the data is saying and determine what you can treat independently.i.e something that nurse would intervene and treat independently. Another purpose of this step is the referral of identified problems for which the nurse cannot prescribe the definitive treatment. Referring can be defined as connecting the clients with other professionals and resources. E.g. diabetic client who is having trouble with understanding the exchange diet. Although the nurse has knowledge in this area, referral to a dietician can provide the client with updated material and allow the nurse more time to deal with client problems within the nursing domain. Propose Possible Nursing Diagnosis: If the situation requires primarily nursing intervention then the nursing diagnosis may be wellness diagnosis, risk diagnosis or actual diagnosis. A wellness diagnosis indicates that the client has the opportunity for enhancement of a health state. A risk diagnose indicate the client does not currently have the problem but is at high risk for developing it. An Actual nursing diagnosis indicates the client is currently experiencing the stated problem or has a dysfunctional pattern. 499
Comparison of Wellness, Risk and Actual Nursing Diagnosis: Wellness diagnosis Risk diagnosis Client status State of harmony and State of risk for balance identified diagnosis Format for stating Opportunity to Risk for enhance Examples Opportunity Risk for to enhance body altered body image image Risk for altered family Opportunity to enhance effective process breast feeding Risk for ineffective breast Opportunity to enhance skin feeding integrity Risk for impaired skin integrity
Actual diagnosis State of health problems Nursing diagnosis Altered body image related to hand wound that is not healing Altered family process related to hospitalization Ineffective breast feeding related to poor mother –infant attachment Impaired skin integrity related to immobility
Check For Defining Characteristics: At this point the nurse must check for defining characteristics for the data clusters in order to choose the most accurate diagnosis and delete that diagnosis which are not valid for the client. This step is difficult because diagnostic labels overlap, making it hard to identify the most appropriate diagnose.e.g the diagnostic categories of impaired gas exchange, ineffective airway clearance and ineffective breathing pattern, all reflect respiratory problems but each is used to describe a very different human response pattern and set of defining characteristics. Confirm Or Rule Out: If the cue cluster data do not match the defining characterstics, you can rule out that particular diagnosis with the other health care professionals who are caring for the client. Tell the client what you perceive his or her diagnosis to be. Often nursing diagnosis terminology is difficult for the client to understand.e.g you would not tell the client that you believe that he has impaired nutrition: less than body requirement. Instead, that you might say that you believe that current nutritional intake is not adequate to promote healing of body tissues. Then you ask the client if this seems to be an adequate statement of the problem. It is essential that client understand the problem so that treatment can be properly implemented. If the client is not in the coherent state of mind, to help validate the problem you can consult with family members. Document Conclusions: Be sure to document all your professional judgements and the data that supports those judgements. Nursing diagnosis can be documented and worded in different formats like wellness diagnosis, risk diagnosis, and actual nursing diagnosis.
500
Sources Of Diagnostic Errors: A diagnosis or judgement is considered to be highly accurate if the diagnosis is consistent with all of the cues, supported with highly relevant cues. Developing expertise with making professional judgements comes with accumulation of both knowledge and experience. One does not become an expert diagnostician overnight. It is the process that develops with time and practice. Errors In Data Collection: This type of error occurs in assessment process. The nurse must be knowledgeable and skilled in physical examination. If data are incomplete, omitted or inaccurate, nursing diagnosis may be missed. If data collection is disorganized, the diagnostic process is scattered. The following practices are essential during assessment to avoid data collection errors:1. Nurse critically reviews his or her level of comfort and competence with interview and physical assessment skills. 2. Nurse must determine the accuracy of data collected. 3. Nurse must check the completeness of assessment data. 4. An organized approach must be used for assessment. Prior to assessment the nurse must have appropriate forms and examination equipment. Errors in Interpretation And Analysis Of Data: Following assessment the nurse reviews the database. During this review the nurse determines if the data is accurate and complete. The nurse reviews the data to validate that subjective data are supported by measurable objective physical findings when necessary. Errors in Data Collection: Errors in data clustering occur when data are clustered prematurely and incorrectly. Premature closure of clustering occurs when the nurse makes the nursing diagnosis before all the data has been grouped. Incorrect clustering occurs when the nurse tries to make the nursing diagnosis fit the signs and symptoms obtained. Errors in Diagnostic Statement: This type of error occurs, the manner in which the nursing diagnosis is stated. The statement should be worded in appropriate concise and precise language which involves using correct terminology reflecting the client‘s response to the illness. A diagnostic statement such as ―unhappy and worried about health‖ can lead to errors. The language needs to be more precise and appropriate, such as ineffective individual coping related to fear of medical diagnosis. Avoiding and Correcting Errors: Nursing diagnosis are easy to write if the nurse remembers that the problem portion of the statement is concerned with the client‘s response to the illness and that the etiology portion must be within the scope of nursing to diagnose and treat. The following suggestions may help in avoiding the errors:1. Identify the client‘s response, not the medical diagnosis requires medical interventions, it is legally inadvisable to include it in the nursing diagnosis. The diagnosis, pain related to myocardial infarction should be changed to pain related to physical exertion. 501
2. Identify a NANDA diagnostic statement rather than the symptom. E.g cough related to excessive mucus production should be written as “ineffective breathing pattern related to increased airway secretions”. 3. Identify a treatable etiology rather than a clinical sign or chronic problem. Nursing interventions are directed toward correcting the etiology of the problem. A diagnostic test or a chronic dysfunction is not an etiology or nursing intervention. Altered respiratory function related to abnormal arterial blood gas levels can be correctly stated as “altered tissue perfusion related to inadequate oxygen intake”. 4. Identify the problem caused by the treatment or diagnostic study rather than the treatment or study it. Clients experience much response to diagnostic tests and medical treatment. These responses are area of nursing concern. The diagnosis, cardiac catheterization related to angina, should be restated to read anxiety related to lack of knowledge about cardiac catheterization. 5. Identify the client‘s response to equipment rather than the equipment itself. Clients are often unfamilial to medical technology. The diagnosis, anxiety related to cardiac monitor can be changed to knowledge deficit regarding the need for cardiac monitoring. 6. Identify the client‘s problem rather than the nurse‘s problem. Nursing diagnosis are always client centered. Potential complications related to poor vascular access indicates a nursing problem in initiating and maintaining intravenous therapy. The diagnosis potential for infection related to presence of invasive lines properly centers attention on clients need. 7. Identify the client problem rather than the nursing intervention. Nursing interventions are planned to alleviate client problems. The statement offer bedpan frequently because of altered elimination patterns should be changed to identify the problem and etiology. Diarrhea related to food intolrence corrects the misstatement and allows proper implementation of the nursing process. 8. Identify the client‘s problem rather than the goal. Goals are established in terms of client‘s problems. Client need high protein diet related to potential alteration in nutrition should be changed to potential altered nutrition: less than body requirement related to inadequate nutritional intake to allow for planning to correct the etiology. 9. Identify the problem and etiology. Be careful to avoid a circular statement. Such statements are vague and give no directions to nursing care. Alteration in comfort related to pain can be caused to identify the client problem and the cause: ineffective breathing pattern related to incisional pain. Nursing Diagnosis Application To Care Planning The use of nursing diagnosis is a mechanism for identifying the domain of nursing: The formulated nursing diagnosis provides direction for the planning process and the selection of nursing interventions to achieve the desired outcome. The care plan is a mechanism for demonstarating accountability. In addition, the nursing diagnosis and subsequent care plan assist in communicating to other professionals the client centered problems through the nursing care plan, consultations, and discharge planning and client care conferences. Making accurate nursing diagnosis helps to ensure that clients receive quality nursing care. 502
Nursing diagnosis help to increase the specificity of nursing interventions for each client. Coding of nursing diagnosis in computerized systems allows direct reimbursement for nurses. Studies of specific nursing diagnosis improve understanding of nursing diagnostic process and contribute to examination of nurse‘s role in health care. The development of taxonomy of nursing diagnosis should significantly affect practice, education, research, legislation, and nursing as a profession. A nursing diagnosis will help to bridge a gap between knowledge and practice and will articulate the scope of nursing practice, essential to developing nursing‘s professional role in healthcare. Advantages Of Nursing Diagnosis: Nursing diagnosis is advantageous for both nurses and clients:1. They facilitate communication among nurse about the client‘s level of wellness and assist in discharge planning. 2. Nursing diagnosis helps in prioritizing the client‘s needs. 3. nursing diagnosis are also used for charting in the progress notes,writing referrals and providing effective transition of care from one unit to another, from one clinic to another or from the hospital to community. 4. Nursing diagnosis can also serve as focus for quality improvement. When focusing the nursing diagnosis the reviewer can determine wheather nursing care was correct and delivered according to standards of practice. 5. Nursing diagnosis is beneficial for the client and family. Limitations of Nursing Diagnosis: Nursing diagnosis has limitations and the beginning practitioner should be aware of their existence. Because of the continuous evolution of the terms and use of nursing diagnosis, the language can occasionally be verbose and contain jargon. This may limit the use of nursing diagnosis to only nursing professionals and result is confusion among other members of health team. CONCLUSION: Thus it is concluded from the topic that making nursing diagnosis is utmost important and analysis of collected data is also important to make correct nursing diagnosis so that the patient can get nursing care according to the need or problem.
503
BIBLIOGRAPHY: 1. Carol Tylor,Lillis,Priscilla Lemone, Fundamentals of nursing, 3rd edition, Published by Lippincott pp.275 2. Janet Weber and Jane Kelley, Health Assessment in Nursing,2nd edition, Published by Lippincott,pp.74-78 3. Potter Parry, Fundamentals of Nursing,vlo-1,5th edition, Published by Harcourt ,pp314-322 4. Ruth,Constance, Fundamentals of nursing,4th edition, Published by Lippincott, pp178-179
504
PLANNING Planning, the fourth phase of nursing process refers to the development of nursing strategies designed to ameliorate client problems. A plan of care is developed to direct nursing care activities related to the person for whom the goals and outcome criteria were developed. A written plan of care directs of the activities of the nursing staff in the provision of client care. Purposes of Planning: Direct client care activities. Promote continuity of care. Focus charting Requirements. Allow for delegation of specific activities. The Planning Process: The planning process includes the following activities: Selecting priorities. Establishing client goals/expected outcomes. Selecting nursing strategies. Developing nursing care plans. Selecting Priorities: Priority setting is a process of establishing a preference order for nursing strategies. The nurse and the client begin planning by deciding which nursing diagnosis requires attention first, which second, and so on. Instead of rank ordering diagnoses, nurses can group them as having high, medium and low priority. Life threatening problems such as loss of respiratory and cardiac functioning, are designated as high priority, for example high risk for aspiration.. Health threatening problems, such as acute illness and decreased coping ability, may result in delayed development or cause destructive physical or emotional changes; thus, they are usually assigned medium priority, e.g. impaired physical mobility. A low priority problem is one that arises from normal developmental needs or that requires only minimal nursing support. Using a framework makes priority setting easier. Although it is not, a nursing framework, nurses frequently use Maslow‘s hierarchy of needs when setting priority. In Maslow‘s hierarchy, physiological needs such as air, food and water, are basic to life and receive higher priority than the need for security and activity. Growth needs, such as self esteem, are not perceived as ―basic‖ in this framework. Thus, when the nurse plans care for a client with unmet physiological needs and unmet growth needs, the physiological needs receive first priority. Priority setting does not require that all the high priority diagnoses be resolved before the nurse addresses any others. The nurse may partially address a high priority diagnosis and then deal with a diagnosis of lesser priority. The priorities assigned to problems do not remain fixed; rather, they change as the client responses, problems and therapies change. The nurse assigns priorities on the basis of nursing judgement and, insofar as possible, client preference. The nurse must consider a variety of factors, for example, the client‘s values and priorities and the available resources. Nursing diagnoses provide the framework for establishing outcomes for care. 505
Establishing Client Goals/Expected Outcomes: After establishing priorities, the nurse sets goals for each nursing diagnosis. A goal is a desired outcome or change in client behavior. Goal attainment is the resolution of the problem specified in the nursing diagnosis. On a care plan, the goals describe, in terms of observable client responses, what the nurse hopes to achieve by implementing the nursing orders. A distinction is made between the goals and expected outcomes, Goals are the broad statements about what the client‘s state will be after the nursing intervention is carried out e.g. nutritional status will improve. Expected outcomes are the more specific, measurable, realistic statements of goal attainment e.g. Will gain 5 lb by the end of the week. They may restate the goal, but they also present information that will guide the evaluation phase of the nursing process. Some sources also use the terms outcome criteria, objective and predicted outcome. When goals are defined broadly, the client‘s care plan must include both goals and expected outcomes. In fact, they are sometimes combined into one statement linked by the words ―as evidenced by‖, for e.g. Nutritional status will improve, as evidenced by weight gain of 5 lb by end of the week. Writing the broad goals first may help to think of the specific outcomes that are needed but even though broad goals can be a starting point for planning, it is the specific, measurable outcome that must be written on the care plan. For example, Goal is ―Improved mobility‖; expected outcome is ―Client will ambulate with crutches by the end of the week‖. Criteria for Expected Outcome: According to ANA:The nurse identifies expected outcomes individualized to the client. 1. Outcomes are derived from the diagnoses. 2. Outcomes are documented as measurable goals. 3. Outcomes are mutually formulated with the client and health care providers, when possible. 4. Outcomes are attainable in relation to resources available to the client. 5. Outcomes are realistic in relation to the client‘s present and potential capabilities. 6. Outcomes include a time estimate for attainment. Outcomes provide direction for continuity of care. Purpose of Goals/ Expected Outcomes: Provide direction for planning nursing interventions that will achieve the desired changes in the client. Ideas for interventions come more easily if the goals state clearly and specifically what the nurse hopes to achieve. Provide a time span for planned activities. Serve as criteria for evaluation of client progress. Although developed in the planning step of the nursing process, the expected outcomes serve as criteria for judging nursing interventions and client progress in the evaluation step. Enable the client and nurse to determine when the problem has been resolved. Help motivate the client and nurse by providing a sense of achievement. Long-Term and Short-Term Goals: Goals may be short term or long term. A short term goal can be met in a relatively short period (with in days or less than 1 week). A long term goal requires more time, perhaps 506
several weeks or months. A short term goal might be ―client will raise right arm to shoulder height by Friday.‖ In the same context, a long term goal might be ―client will regain full use of right arm in 6 weeks.‖ In the acute care setting, much of nurse‘s time is spent on the client‘s immediate needs, so most goals are short term. Short term goals also enable the nurse to evaluate client progress more accurately. Long term goals are often used for clients who live at homes and have chronic health problems and for clients in nursing homes, extended care facilities, and rehabilitation centers. Short term goals are useful a) for clients who require health care for short time and b) for those who are frustrated by long term goals that seem difficult to attain and who need the satisfaction to achieving a short term goal. Relationship of Goals/ Expected Outcomes To Nursing Diagnoses: Goals/ expected outcomes are derived from and relate to the client‘s nursing diagnosesprimarily from the first clause (problem). The problem clause contains the unhealthy response; it states what should change. Therefore, the essential client goals are derived from the problem clause. For example, if the nursing diagnosis is High risk for fluid volume deficit related to diarrhea and inadequate intake secondary to nausea, the essential goal statement might be ―client‘s fluid balance will be maintained, as evidenced by urinary and stool output in balance with fluid intake, normal skin turgor, and moist mucus membranes.‖ In this, a general goal (fluid balance) is stated as the opposite of the problem (Fluid volume deficit) and then followed by list of measurable expected outcomes. If achieved, the expected outcomes would be evidence that the problem has been prevented. Goals may occasionally be derived from second cause (etiology of the diagnosis), but they are different from those derived from the problem. Their achievement may help to resolve the problem, but they might also be achieved without resolving the problem. In the above example, the following expected outcome can be derived from the etiology: ―Client will have daily fluid intake of 1500ml‖. Note that drinking 1500ml of fluid would help the client achieve fluid balance; however, if the nurse discontinued the care plan on the basis of achieving this outcome, then the client‘s needs would not be met. The fact that the client intake was 1500ml does not ―prove‖ that the problem was prevented. For e.g. continued diarrhea or a high fever that cause the client to lose more than 1500ml of fluid could still create a problem of Fluid volume deficit. For every nursing diagnosis, the nurse must write at least one outcome criterion that, when achieved, directly demonstrates resolution of the problem clause. When developing outcome criteria, ask the following questions: What is the problem clause? What is the opposite, healthy response? How will the client look or behave if the healthy response is achieved? What must the client do and how well must the client do it to demonstrate problem resolution or to demonstrate the capability of resolving the problem? Components Of Goal/ Expected Outcome Statements: Goal/ expected outcome statements generally have the following four components:-
507
1) Subject: The subject, a noun, is the client, or some attribute of the client, such as client‘s pulse or urinary output. Often the subject is omitted in nursing care plan goals; it is assumed that the subject is the client unless indicated otherwise. 2) Verb: The verb denotes an action the client is to perform, for e.g. what the client is to do, learn, or experience. Verbs that denote directly observable behaviors, such as administer, demonstrate, show, walk, and and so on are used. Examples of Verb Actions: Apply Arrange Assemble Breathe Choose Communicate Compare Construct Calculate Classify Define Demonstrate Describe Design Differentiate
Discuss Draw Drink Explain Express Help Identify Inject List Maintain Move Name Prepare Perform Practice
Report Recall Recite Share Stand Sleep State Show Talk Take Transfer Turn Use Verbalize Walk
3) Conditions Or Modifiers: Conditions or modifiers may be added to the verb to explain the circumstances under which the behavior is to be performed. They explain what, where, when, or how. For e.g. Walks with the help of walker (how). After attending two group diabetes classes, list sign and symptoms of diabetes (when). When at home maintains weight at existing level (where). Discusses four food groups and recommended daily servings (what). Conditions need not be included if the criterion of performance clearly indicates what is expected. 4) Criterion Of Desired Performance: The criterion indicates the standard by which a performance is evaluated or the level at which the client will perform the specified behavior. These criteria may specify time or speed, accuracy, distance, and quality. To establish a time achievement criterion, the nurse needs to ask, ―How long?‖ To establish an accuracy criterion, the nurse asks, ―How well?‖ Similarly, the nurse asks, ―How far?‖ and ―What is the expected standard?‖ to establish distance and quality criteria, respectively. For e.g. Weighs 75kg by April (time). Lists five out of six signs of diabetes (accuracy). 508
Walks one block per day (time and distance). Administers insulin using aseptic technique (quality). Guidelines for Writing Goals/ Expected Outcomes: Write goals or outcome criteria in terms of client behavior. Begin each goal and outcome criteria with ―the client‖. Outcome criteria should focus on what the client will accomplish, not what the nurse will do. Avoid statements that start with enable, facilitate, allow, let, permit, or similar verbs followed by the work client. These words indicate what the nurse hopes to accomplish not what the client will do. Make sure that the goal statement is appropriate the nursing diagnosis. Validate the outcomes. If the outcomes are accomplished, will the client‘s nursing diagnosis be resolved? Be sure that the outcomes are realistic for the client‘s capabilities, limitations, and designated life span, if it is indicated. Limitations refer to finances, equipment, family support, social services, physical and mental condition, and time. Make sure that the client considers the goals/ outcomes important and values them. Some outcomes such as those for problems related to self-esteem, parenting, and communication, involve choices that are best made by the client or in collaboration with the client. Ensure that the goals and outcomes are compatible with the work and therapies of other professionals. Make sure that each goal is derived from only one nursing diagnosis. When writing expected outcomes, use observable, measurable terms; avoid words that are vague and require interpretation or judgement by the observer. Characteristics Of Well Stated Goals/ Expected Outcomes: A well stated expected outcome is: Derived primarily from the first clause of the nursing diagnosis. Possible to achieve. Stated in terms of client responses rather than nursing activities. Statement of one specific client behavior. Specific and concrete. Appraisable or measurable. Valued by the client and family. Compatible with the therapies of other professionals. Selecting Nursing Strategies: This involves selecting action that enables the person to achieve the outcomes and to resolve the related factors in the nursing diagnosis. These selected actions or strategies are called nursing interventions. The specific strategies chosen should focus on eliminating or reducing the etiology of the nursing diagnosis, which is the second clause of the diagnostic statement. Correct identification of the etiology during the diagnostic phase provides the framework for choosing successful nursing interventions. Often the nurse and the client can establish a number of nursing strategies for each problem statement. Two many alternatives can be confusing. Usually three to five alternative nursing strategies for each health problem are satisfactory. 509
Considering the consequences of each strategy: Once the nurse identifies a number of possible strategies to implement, the next step is to consider the risks and benefits of each action. Often, an action will have more than one consequence. Determining the consequences of each strategy requires nursing knowledge and experience. Criteria for choosing nursing strategies: The following criteria can help the nurse choose the best nursing strategy. The planned action must be:1) Safe and appropriate for the individual‘s age, health, and so on. 2) Achievable with the resources available. 3) Congruent with the client‘s values and beliefs. 4) Congruent with other therapies. 5) Based on nursing knowledge and experience or knowledge from relevant sciences (based on rationale). 6) With in established standards of care as determined by state laws, professional associations, and the policies of the institution. Types Of Nursing Strategies: Nursing strategies are identified and written during the planning step of the nursing process; however, they are actually performed during the implementing step. A nursing intervention is any direct care treatment that a nurse performs on the behalf of a client, whether nurse initiated or physician initiated. Independent Interventions: are those activities that nurses are licensed to initiate on the basis of their knowledge and skills. They include physical care, ongoing assessment, emotional support and comfort, teaching, counseling, environmental management, and making referrals to other health care professionals. McCloskey and Bulechek refer to these as nurse initiated treatments. Mundinger prefers the term autonomous nursing practice. She states, ―Knowing why, when, and how to position clients and doing it skillfully makes the function an autonomous therapy‖. Dependent Interventions: are those activities carried out under the physician‘s order or supervision, or according to specific routines. McCloskey and Bulechek call these physician initiated treatments. Medical orders commonly include orders for medications, intravenous therapy, diagnostic tests, treatments, diet and activity. The nurse is responsible for explaining, assessing the need for, and administering the medical orders. Dependent interventions are usually directly related to the client‘s disease, and their importance should not be minimized. Collaborative Interventions: are actions the nurse carries out in collaboration with other health team members, such as physical therapists, social workers, dietitians, and physicians. Collaborative nursing activities reflect the overlapping responsibilities of, and collegial relationships between, health personnel. To achieve collaborative nursing practice, nurses must be clinically competent, feel confident in their knowledge and skills, and assume responsibility for their own actions. Writing Nursing Orders: After choosing the appropriate nursing interventions, the nurse writes them on the care plan as nursing orders. Nursing orders are instructions for the specific activities the nurse 510
performs to help the client meet established health care goals. The term order connotes a sense of accountability for nurse who gives the order and for the nurse who carries it out. Carnevali and Thomas use the term nursing directives. A complete well-written nursing order is composed of five components: Date: Nursing orders are dated when they are written and reviewed regularly at intervals that depend on the individual‘s needs. Specific action verb, such as instruct, place, supervise, and observe. Sometimes a modifier, such as actively, softly, firmly helps clarify the verb. Content area: The content is the where and what of the order. Time element: The time element answers when, how long, or how often the nursing action is to occur. Signature: the signature of the nurse prescribing the order show‘s the nurses accountability and has legal significance. Developing Nursing Plans: The nursing care plan is a written guide that organizes information about a client‘s care into a meaningful whole. It includes the actions nurses must take to address the client‘s nursing diagnoses and meet the stated goals. The nurse starts the care plan as soon as the client is admitted to the health care agency and constantly updates it throughout the client‘s stay, in response to changes in the client‘s condition and evaluations of goal achievement. Purposes of a Written Care Plan: To provide direction for individualized care of the client. To provide for continuity of care. To provide direction about what needs to be documented on the client‘s progress notes. To serve as a guide for assigning staff to care for the client. To serve as a guide for reimbursement from medical insurance companies, often called third party reimbursement. To provide for individual and family participation in the nursing care plan. To outline a program for health education of individuals and significant others. To encourage adequate discharge planning. To provide a source of information for quality improvement and research. Writing a Nursing Plan Of Care: A nursing plan of care documents the problem-solving process. The ability to create the nursing plan of care has become a standard expected of every nurse. The plan is a critical element in focusing nursing activity. To serve as evaluation criteria and meet the standards of the Joint Commission for Accreditation of Healthcare Organizations (JACHO; 1996), the plan must be developed by a registered nurse, it must be documented in the client‘s health record, and it must reflect the standards of care established by the institution and the profession. Two important concepts guide a nursing plan of care: The plan of care is nursing centered. The plan of care is a step by step process.
511
Keeping the plan of care nursing centered is essential to identify the scope and depth of nursing practice. By focusing on the treatment of human resources to actual or potential health problems, the nurse remains in the nursing practice domains. A step-by-step process is evidenced by the following:Sufficient data are collected to substantiate nursing diagnoses. At least one goal must be stated for each nursing diagnosis. Outcome criteria must be identified for each goal. Nursing interventions must be specifically designed to meet the identified goal. Each intervention should be supported by a scientific rationale. Evaluation must address whether each goal was completely met, partially met, or completely met. Guidelines for Writing Nursing Care Plans: 1) Date and sign the plan. 2) Use the category headings ―Nursing Diagnosis,‖ ―Goals/ outcome criteria,‖ ―Nursing orders‖and―Evaluation‖ and include a date for the evaluation of each goal. 3) Use standardized medical or English symbols and key words rather than complete sentences to communicate your ideas. 4) Refer to procedure books or other sources of information rather than including all the steps on a written plan. 5) Tailor the plan to the unique characteristics of the client by ensuring that the client‘s choices, such as preferences about the time of care and the methods used, are included. This reinforces the client‘s individuality and sense of control. 6) Ensure that the nursing plan incorporates preventive and health maintenance aspects as well as restorative. 7) Ensure that the plan contains orders for ongoing assessment of the client. 8) Include collaborative and coordination activities in the plan. 9) Include plans for the client‘s discharge and home care needs. Types of Nursing Care Plans: As you care people in various health care facilities, you will discover a variety of nursing care plan formats. The documentation of the plan of care is also changing as federal, state, and accrediting agencies examine and modify their standards. It can be written in various ways. The most common formats for care plans include student nursing care plan, individually developed nursing care plan, practice guidelines, critical path or case management plans, and computerized nursing care plans. Student Nursing Care Plans: Each school of nursing has a care plan format adopted by or developed by the faculty for student use. Because student plans are used as learning tools, they are usually more comprehensive and detailed than the care plans utilized by graduate staff nurses. Student care plans focus heavily on documenting signs and symptoms and proving the rationale for specific nursing interventions. This information is no less important to the graduate nurse. However, the experienced nurse is capable of high level assessment and synthesis of data, which are still step-by-step for the student. The components usually include Nursing diagnoses, client goals, outcome criteria, nursing interventions, scientific rationale, and evaluation. 512
Individually Developed Nursing Care Plans: The Individually developed nursing care plan is the most traditional and oldest method of documenting the plan of care. It typically consists of three columns, which are labeled, according to the setting, as nursing diagnoses or problems, outcomes or goals, and nursing interventions or orders. Additional columns may be added to the format to include a spot for the date and initials of the nurse who developed the plan, the date for the outcome achievement, and the date the nursing diagnosis was resolved. Individual care plans are intended to focus on the specific needs of the person and are to be updated as the person’s condition changes. The Individually developed nursing care plan, like the other formats for the plan of care, is usually combined with a Kardex. A Kardex is an abbreviated form that contains 1) basic demographic information about the person, such as name, age, sex, medical diagnoses, surgical procedures, and physician‘s name, and 2) basic care information, such as type of bath, frequency of vital signs, allowable activity, ordered treatments and so on. Advantages: The advantages of individually developed nursing care plans include their specificity to a particular person. They contain only the pertinent nursing diagnoses, outcomes and interventions. Disadvantages: The primary disadvantage of this is the time-consuming aspect of the development process. Also, as is true with other formats for care plans, the individually developed nursing care plan may not accurately reflect the person‘s current problems if it has not been updated. Standardized Nursing Care Plans: Printed care plans, known as standardized care plans, are developed commercially or by an individual health care facility. They direct nursing care for people with specific medical diagnoses (e.g. myocardial infarction) with certain nursing diagnoses such as pain or anxiety, or who are undergoing special procedures such as cardiac catheterization. These care plans are typed, preprinted, duplicated, and made available to the appropriate units in the health care facility. The format is designed to leave space for the nurse to individualize the care plan by filling in specific related factors associated with nursing diagnosis, adding deadlines to the outcomes, and clarifying the interventions with additional details. For example, the interventions could be individualized by adding frequencies, amounts, times, and the client‘s preferences. Advantages: Reduced amount of writing needed to record routine nursing interventions and help to the staff by highlighting necessary interventions These are usually developed by a group of nurses who use their collective expertise and experience to produce a well researched tool. Particularly helpful to nurses who may be asked to work in an unfamiliar area. Disadvantages: Nurses may use these care plans without individualizing them for a particular person. Many of the nursing diagnoses, outcomes, and interventions may not be applicable. These may tend to be long. 513
Frustrated by the amount of time it takes simply to read them, some nurses have not found them to be helpful. This problem can be reduced by developing concise standardized care plans that contain only the essential information. Teaching Plans: Teaching plans are a specialized form of nursing care plans. Individually developed teaching plans may be hand written or computer generated for individuals with complex teaching needs. An agency may have a variety of standardized teaching plans prepared for people with commonly seen teaching needs. The nurse modifies the standard teaching plan as needed and uses the form to document the outcome of the teaching. Practice Guidelines: Practice Guidelines also called protocols; specify nursing management of broad clinical issues like maintenance of skin integrity, phases of hospitalization such as postoperative care, or interdependent clinical issues- for e.g. management of a person receiving a certain type of potent medication, such as cardiac medication given intravenously in ICUs. Whereas the standardized care plan or individually developed care plan contains information about a variety of nursing diagnoses, the practice guidelines typically addresses one issue, problem, or nursing diagnosis. Practice guidelines are usually developed by experts and reviewed by a group of nurses for validity. When a practice guideline addresses an interdependent clinical issue that includes both medical and nursing management of a particular concern, physician committee review of the medical orders is usually needed. These plans illustrate the manner in which health care professionals collaborately manage treatment. Practice guidelines are used commonly in short stay areas of a hospital, such as Emergency departments and Post-Anesthesia care units. Certain commonalities exist among people in these areas, making it possible to manage their care according to practice guidelines. Advantages: They clearly specify well-researched and agreed-upon management of certain problems. Once the initial work of developing the practice guideline is completed, their use saves much time by quickly transmitting information that does not need to be documented for each person for whom it is applicable. Practice guidelines are not considered standards. Disadvantages: The temptation to follow uncritically the interventions without individualizing them for a particular person. No prepared plan of care, no matter what its format, replaces the judgement and critical thinking of the nurse. Case Management Care Plans: Case management is a method of delivering care that has evolved from the emphasis on decreasing the length of stay in hospitals and the focus on achieving timely client outcomes. Case management is designed to organize care to achieve certain specific outcomes with in a time frame permitted by the reimbursement system. 514
The Case management plan is a standardized care plan that consists of nursing diagnoses, outcomes, deadlines, nursing interventions, and physician interventions. The plan is developed collaboratively by nurses, physicians and other health care professionals and is reviewed and individualized for a particular person. The comprehensive case management plan is often summarized in the form of a critical path or patient outcome timeline. Critical paths can improve quality of care by: Allowing health care professionals to share knowledge with each other. Educating clients by thoroughly explaining the treatment plan. Permitting comparison of outcomes or results of various treatment methods. Identifying and reinforcing steps critical to the desired outcome. Advantages: Easy to identify appropriate steps in achieving the outcomes. Resources of the nursing staff and hospital are used more effectively as they become directed at moving the person through the hospitalization. The person is actively involved in reviewing the plan of care. Nurses are given more authority to make changes in the system to facilitate the achievement of outcomes. Disadvantages: A great deal of planning needed to implement this method of delivering care. It may be difficult in some instances to gain the cooperation of physicians in defining how to manage certain types of clients and to collaborate with nurses on a professional level. Certain people will have preexisting conditions or complications that will prevent the achievement of outcomes at specified time periods. Computerized Nursing Care Plans: Many software vendors have developed computerized nursing care plans and critical paths. Computerized plans of care are generated from assessment data entered into a computer about a specific client. The plan is written by experts in the area and the content is similar to that of standardized plan of care. Once the plan is on the computer screen, the nurse has opportunity to customize it for the client. Advantages: Legibility. Reduction in the amount of time needed to develop and update the plan. Access to plans developed by expert clinicians. Ability to collect information about groups of patients for research. Disadvantages: It requires a critical analysis of a preexisting plan to ensure that it is appropriate and current. It is critical that all pertinent information be collected and entered into the system.
515
IMPLEMENTATION Interoduction: The nursing process is a deliberative, problem- solving approach to meeting the health care and nursing needs of patients. It involves assessment, diagnosis, outcome identification, planning, implementation and evaluation, with subsequent modifications used as feedback mechanisms that promote the resolution of the nursing diagnoses. The process as whole is cyclical, the steps being interrelated, interdependent, and recurrent. The nursing process is action oriented, client centered, and goal directed. After developing a plan of care based on the assessing and diagnosing phases, the nurse puts the plan into effect and evaluates the results. Based on this evaluation, the plan of care is continued, modified, or terminated. As in all phases of the nursing process, clients and support persons are encouraged to participate as much as possible. The degree of participation depends on the client‘s health status. After the nurse and client identify problems and strengths, they plan together methods of helping the client maintain or return to healthy function. Out-come criteria are set for goals, and a plan of care is developed. Now they are ready for the implementation phase of the nursing process, the activity that provides planned care, and the evaluation phase, in which the client‘s status is measured in response to the nursing care provided. Definition: Implementation refers to the action phase of the nursing process in which nursing care is provided. It is the actual initiation of the plan and recording of nursing actions. Its purpose is to provide technical and therapeutic nursing care required to help the client achieve an optimal level of health. Bulechek define nursing interventions as ―any direct care treatment that a nurse performs on behalf of a client. These treatments include nurse- initiated treatments resulting from medical diagnoses and performance of the daily essential functions for the client who that cannot do these.‖ Implementation Skills: The implementation phase of the nursing process draws heavily on the intellectual, interpersonal, and technical skills of the nurse. These are also known as cognitive, affective and conative skills. Decision-making, observation, and communication are significant skills, enhancing the success of action. These skills are utilized with the client, the nurse, nursing team members, and health team members. Competence in intellectual, interpersonal and technical skills is required to carry out the implementation phase. Intellectual/ Cognitive Skills: The intellectual skills used in implementation include problem solving, decision making, critical thinking and teaching. To solve problems, nurses ask clients pertinent questions, discuss alternatives, and are open new ideas. To enrich the decision making abilities of clients, nurses give them opportunities to choose which treatments are performed, when and in what sequence. Teaching requires knowledge about teaching-learning principles and information to convey. Interpersonal/ Affective Skills: The ability to work with others to accomplish goals is critical to nursing. Nurses use communication skills to carry out planned nursing interventions. Verbal and non-verbal 516
communication skills are utilized when you interact with the health care team. These skills are often crucial in the successful implementation of nursing care. People often judge nurses not by their technical skills alone but by whether they are kind, concerned and caring. The ability to use effective interpersonal skills when communicating with physicians, social workers, and other personnel will also affect the success of the implementation phase. It is essential that the nurses be able to use cognitive skills to solve problems and make decisions and use interpersonal skills to implement those decisions. Technical / Conative Skills: Psychomotor or technical skills are the third major category of skills used during implementation of nursing care. These skills are used to carry out treatments and procedures. Nurses learn the specific skills through clinical practice. Technical competence means being able to use equipment machines and supplies in particular specialty. For example, nurses working in delivery rooms must be familiar with fetal monitoring, positioning on delivery- room table, and neonatal resuscitation devices. On the other hand, nurses working on medical units may need technical competence in using hypothermia blankets, therapeutic beds or feeding pumps. Nurses often find that when technical skills are unfamiliar, it is difficult to incorporate the cognitive and interpersonal components. Implementation Activities: The activities of implementation include the following: Reassessing. Setting priorities. Performing nursing intervention. Recording nursing actions. Reassess: Assessing is carried out throughout the nursing process, whenever the nurse has contact with the client. Just before implementing, the nurse must reassess whether the intervention is still needed because a client‘s condition can change quickly and dramatically. For example, the client who experiencing pain may become quite and withdraw from external stimuli. Recognizing such a change, nurses can intervene, validate, and assist the client to become more comfortable. As they initiate the nursing plan of care, nurses must ensure that the planned interventions are still relevant. Set Priorities: Because a person‘s condition changes, priorities also may change. Priorities are based on information collected during reassessment. When setting priorities, nurses rank nursing problems in order of importance based on several factor. The client‘s condition. New information from reassessment. Time and resources available for nursing interventions. Feedback from the client, family and health staff. The nurse‘s experience in assessing situations and setting priorities. Priorities can be set every few minutes, hourly, daily, weekly or for longer periods. For example, in the critical care unit, priorities may need to be set every few minutes for an unstable client with multiple traumas. 517
Perform Nursing Interventions: Nurse carry out the nursing interventions listed on the nursing plan of care. If a nurse is caring for several clients, he or she develops a schedule so that all clients are cared for in a timely fashion. Intervention for collaborative problems: Nurses manage collaborative problems using both nurse and physician prescribed interventions to reduce risk of complications. Both types of interventions involve nursing judgment, because both require legal mandates. Record Actions: After carrying out nursing interventions, nurses record them in the client‘s health record. Each institution determines the specific requirements for documentation and should prepare written guidelines for the use of all forms. Types of Nursing Interventions: Nursing intervention fall within three major categories: those using cognitive skills, those using interpersonal skills and those using technical. Selection of the type of nursing intervention to be used in client situations depends on the client‘s dysfunction and functional requirements. Cognitive Interventions: Educational interventions: Nurses carry out educational nursing interventions by applying general principles about the teaching and learning process. They develop teaching plans and provide instruction about health Promotion or specific healthcare problems and their management. The ability to teach clients requires knowledge of normal anatomy and physiology, usual patterns of client response to health changes and pathophysiology of the disease process. Once a nurse is aware of the client‘s readiness for learning, he or she can implement outcome-based teaching plans, using instruction methods that optimize successful outcomes. Supervisory interventions: The term supervisory interventions are applied in the context of overseeing a client‘s overall care. Supervisory nursing interventions include ensuring that other members of the nursing team carry out specified aspects of the plan of care, and that those involved with the client or family show return demonstration of skills. Supervising the client or family in skill performance is essential, to provide encouragement, give feedback about correct and incorrect performance and facilitate introduction of new skills to be learned. Nurses include clients and family members in planning and implementing initial care. They help clients and families begin to assume responsibility for self-management. Interpersonal Interventions: Coordinating interventions: coordinating client activities serves many purposes. Coordination involves acting as a client advocate, making referrals for follow-up care, collaborating with other health care team members and ensuring that the client‘s schedule is therapeutic. In the advocacy role, the nurse presents the client‘s point of view and suggests ways in which the client‘s requests can be met. Nurses are in a position to know what type of nursing follow-up clients need. They make referrals to home health agencies, visiting nurse associations or other healthcare providers to facilitate return to optimal function. 518
Supportive interventions: supportive nursing interventions emphasize use of communication skills, relief of spiritual distress and caring behaviors. A combination of good communication and caring provides comfort and promotes a healthy response to health problems. Nurses provide spiritual support by giving clients time to carry out religious practices, meditate or read. Respecting the client‘s privacy during these times conveys acceptance and understanding. Psychosocial interventions: psychosocial nursing interventions focus on resolving emotional, psychological or social problems. Humor, individual or group therapy, rolemodeling social skills and exploring feelings are all ways of carrying out psychosocial nursing interventions. Providing individual and group therapy is the nurse‘s responsibility in various setting. For example, individual therapy is used as a means of resolving psychological problems and group therapy is used to provide support and guidance for clients with similar needs or problems. Technical Interventions: Maintenance interventions: Maintenance nursing interventions help clients retain a certain state of health, preventing deterioration of physical or psychological functioning and preserving independence. Maintenance interventions include basic hygiene, skin care and other routine nursing activities. Surveillance interventions: Surveillance nursing interventions include detecting changes from baseline data and recognizing abnormal responses. This activity also can be categorized as observation, inspection or vigilance. Nurses rely on the senses to detect changes: observing the appearance and characteristics of client ; hearing by auscultation,; detecting odors and comparing them with past experiences and using touch to assess body temperature and skin condition. Nurses use all these surveillance activities to determine the status of clients and changes from previous states. Psychomotor interventions: Psychomotor nursing interventions-those requiring technical expertise-include inserting, removing, changing, applying, administering, cleansing or any other activity that requires a psychomotor action. The management and care of equipment, supplies, treatments and procedures also falls into this category of nursing interventions nurses gain technical competence through practice. Relationship of Implementing To Other Nursing Process Phases and Resource Available In the Unit: Successful implementing depends, in parts, on the quality of assessing, diagnosing and planning that has been done. These first nursing process phases provide the basis for the autonomous nursing actions performed during the implementing step. In turn, the implementing step provides the actual nursing activities and client responses that are evaluated in the final step (evaluating). The nursing process phases are interdependent and overlapping rather than separate and linear. Using data acquired during assessment, the nurse can individualize the care given in the implementing phase, tailoring the Interventions to fit a specific client rather than applying them routinely to categories of clients. Ongoing assessment occurs simultaneously with implementation. While implementing the nursing orders, the nurse continues to reassess the client at every contact, gathering 519
data about the client‘s responses to the nursing actions and about the new problems that may develop. Successful implementing also depends upon resources available in the unit. If all the resources are sufficient (manpower, time and material), the quality care is provided to clients and the organizational and client centered goals are achieved. Along with this, the nurses have skills to utilize those resources while implementing nursing care and use alternatives if resources are not appropriate to provide quality care. Responsibilities in Implementation Of Nursing Care: It is the professional responsibility to carry out the nursing care as the primary nurse, delegate certain interventions to appropriate nursing or allied health professionals and carry out physician orders, thereby integrating medical therapy into overall care plan. Nursing care is implemented to assist people in achieving the outcomes established in the plan of care, to prevent disease and illness by promoting wellness, to restore functioning and to facilitate coping with illness. The major responsibilities in implementing nursing care include: Reviewing the planned interventions for appropriateness. Scheduling and organizing the interventions. Collaborating with other team members. Supervising and delegating nursing care by other members of nursing team. Achievement of the organizational and client care goals. Providing direct nursing care. Providing counseling. Involving the client in health care. Teaching the client and family. Making referrals to other health care professionals. Documenting nursing care provided. Reviewing the planned interventions for appropriateness: The first phase of implementation involves reviewing the planned interventions. Cognitive skills are used to choose the appropriate nursing interventions. Developing a plan of action is a two-step process. 1. Develop interventions: Interventions are generated through processing information and using creativity. The consideration of numerous interventions results in a creative solution to the diagnosis. The specific ways in which interventions are developed: Recall ways in which you handled a similar nursing diagnosis in past. Consider the nursing diagnosis from various angles and in different ways. Imagine how you would ideally like to see the nursing diagnosis resolved. Discuss the interventions with the person and family to hear their ideas on solutions to resolving the nursing diagnosis. Talk with colleague, or meet with a group of colleagues, and ―brainstorm‖ possible solutions to the diagnosis. Obtain expert advice and recommendations. Review current literature. 2. Select the best intervention: The next step is to analyze the interventions and choose the one that seems best. In most nursing care situations, the best approach is the one promising the greatest benefit with the least risk. To select such an intervention, 520
systematically examine all the available options. Ask yourself the following questions and try to answer them objectively: Has this type of intervention been used before in a similar situation? If so, what were the results? Will this particular intervention enable the person to meet outcomes within proposed time limits? Dose this intervention take into consideration the person‘s, age, sex, lifestyle, attitudes, religious and cultural traditions, social resources, and coping abilities? Is this intervention acceptable to the individual and family? Is the intervention realistic? Are equipment, staff time, staff size and other resources adequate? What might be some undesirable consequences if this intervention is selected? Would this particular solution bring more problems in its wake? Scheduling and organizing the interventions: Specific coordinating activities include meeting with other health care team members to plan and organize care, scheduling the person‘s activities (scheduling appointment with dietitian, determining the best time for physical or occupational therapy), discussing the person‘s progress, consulting with the physician, arranging for discharge and long-term needs. Scheduling and coordinating nursing care require time management skills. You will be involved in balancing the requirements of several people, including several patients and health care practitioners. As you become more comfortable with providing nursing care, you will be better able to organize your day and address the needs of many people. Collaborating with other team members: One should not be the primary nurse for every person in your clinical area. Therefore, communication with and collaboration among team members are essential. These valuable resource people are nurses prepared at the master‘s level who possess expertise in specific clinical specialties. Staff nurses should also consult each other as professional colleagues, so that nursing as a profession is strengthened. Collaboration with other professional nurse also improves the quality of nursing care. Supervising and delegating nursing care by other members of the nursing team: As a professional, nurse will delegate appropriate responsibilities to the person, significant others and other team members. The delegation of nursing care is based on six elements, as defined by the Joint Commission of Accreditation of Healthcare Organizations. The complexity of the individual‘s condition and nursing care needs. The stability of the person‘s status. The complexity of the assessment required to care for the person properly, including the knowledge and skills needed by the nursing staff member in order to complete the assessment. The type of technology or equipment employed in providing nursing care. The degree of supervision required by the nursing staff member based on the nurse‘s level of competence. The availability of supervision. 521
Delegation of nursing care also depends on the job description and legal limitations of the scope of practice of other team members. For example, a registered nurse could not ask a nursing assistant to give a dose of intravenous medication. Achieving of the organizational and client care goals: The nursing team carries out the nursing orders detailed in the nursing plan of care. If the plan of care is well constructed, carrying out its orders is the most important task and should receive top priority. The nursing actions planned to promote client goal or outcome achievement and the resolution of health problems should be carefully executed. As the quality care provided to clients and achieve the client‘s goals, ultimately the organizational goals are achieved. Providing direct nursing care: The nursing interventions may be independent or interdependent. They may also be dependent which are carried out based on the physician‘s orders e.g. medication administration, providing IV fluids etc. In some instances, there are standing orders that direct the care of the client. Standing orders are typically developed when the facility is caring for a group of people with clearly identified and anticipated needs. Both dependent interventions and standing orders must be evaluated carefully to be sure they are appropriate for the person. Nurses are legally responsible for questioning physician‘s orders that are inappropriate or inaccurate. Providing counseling: Counseling helps individuals with long-term chronic illness and disabilities to come to terms with their condition. In this case, encourage people to verbalize fears or concerns by establishing a warm, nonthreatening atmosphere. Counseling also involves helping people cope successfully as they pass through the various developmental stages of a normal life. In this case, the counselor not only discusses the person‘s problems but also talks about many normal changes that occur during different developmental stages. Involving the client in health care: There is a strong trend toward offering the client choices to enhance the acceptability of the outcomes and interventions. The degree considered necessary or desirable by the client, family members have a right to be informed about and involved in the provision of nursing care. Teaching the client and family: Teaching is a vital part of implementing the care plan and promoting change. Nurses assume the role of teacher when clients have identifiable learning needs. It helps clients and family to develop the self-care abilities that enable them to maximize their functioning and quality of life. Making referrals to other health care professionals: Most health care agencies have a referral procedure to simplify the transfer of information from one health care facility or department to another. Referrals are written on special forms, made over the phone, or requested in person. Clients are typically referred to dietitians, social workers, psychiatrists, physical and occupational therapists, and various organizations.
522
Documenting nursing care provided: During and after implementation of care nurse will record information in the medical record. This information includes data, observations, interventions and evaluation of the effectiveness of care. Summary: The ultimate intent of the implementation phase is the use of strategies to help the person achieve the outcomes. By providing focused and planned care, you use your cognitive, interpersonal and technical skills to assist the person. The major responsibilities of nursing care involve reviewing the planned interventions, scheduling, organizing, collaborating, supervising, providing direct care, counseling, teaching, referring and documenting.
523
BIBLIOGRAPHY: Craven Ruth F, Hirnle Constances J, Fundamentals of Nursing: Human Health and Function, Fourth Edition, Lippincott, 202-206. Kozier, Erb Balis, Wilkinson, Fundamentals of Nursing: Concepts, Process and Practice, Fifth Edition, Addison-Wesley, 149-153. Sorensen and Luckman‘s, Basic Nursing: A Psychophysiological Approach, Third Edition, Saunders, 158-163. www.google.com
524
EVALUATION Introduction: As a part of professional accountability, nurses are answerable to themselves as practitioners, to individuals and significant others, to physicians and others who participate in giving care, to agencies in which they practice, and to the community. The use of evaluation helps fulfill the nurse‘s duty to act in a professionally responsible way. Definition: To evaluate is TO JUDGE or TO APPRAISE. Evaluation is a planned, ongoing, purposeful activity, in which client and health care professionals determine – 1) The client‘s progress toward goal achievement. 2) The effectiveness of nursing care plan. Evaluation is defined as the judgment of the effectiveness of nursing care to meet client goals based on the client‘s behavioral responses. This phase involves a thorough, systematic review of the effectiveness of nursing interventions and a determination of client goal achievement. Nurses use a variety of skills to judge the effectiveness of nursing care. These skills include knowledge of standards of care, normal client responses, and conceptual models and theories of nursing; ability to monitor the effectiveness of nursing interventions; and awareness of clinical research. Critical appraisal of goal attainment is determined jointly by the nurse and the client. Difference between Assessment and Evaluation: Assessment involves data gathering for the purposes of deriving a nursing diagnosis and forming a plan. Therefore, the assessment phase consists of gathering information about the existing problems and strengths of the person. The evaluation step of nursing process uses your knowledge and skills to make a clinical judgment about the achievement of outcomes. During Evaluation, you compare the current status of the person with the expected outcomes. When you evaluate the person, you make a decision about how well the person achieved the outcomes and whether the plan of care should be continued, modified, or discontinued. Purposes: To collect the objective and subjective data to make judgments about nursing care delivered. To examine the client‘s behavioral responses to nursing interventions. To compare the client‘s behavioral responses with predetermined outcome criteria. To appraise the extent to which client goals were attained or problems resolved. To appraise involvement and collaboration of the client, family members, nurses, and healthcare team members in healthcare decisions. To provide a basis for the revision of the nursing plan of the care evaluation. To monitor the quality of nursing care and its effect on the client‘s health status. Types: There are three types of evaluation:i. Structure Evaluation: Structure evaluation focuses on the attributes of the setting or surroundings where healthcare is provided. It deals with the environmental 525
aspects that directly or indirectly influence the quality of care provided. Availability of equipment, layout of physical facilities, nurse- client ratios, administrative support, and maintenance of nursing staff competence are some areas of concern for structure evaluation. ii. Process Evaluation: Process evaluation focuses on the nurse‘s performance and whether the nursing care provided was appropriate and competent. The phases of the nursing process are used as the framework for the evaluation of nursing care. Areas of concern for this type of evaluation include the type of information obtained by interview and physical assessment, the validity of the nursing diagnostic statements, and the nurse‘s technical competence. iii. Outcome Evaluation: Outcome evaluation, which focuses on the client and the client‘s function. Outcome evaluation determines the extent to which the client‘s behavioral response to nursing intervention reflects the desired client goal and outcome criteria. Outcome evaluation can take place only after standards have been developed. An example of an outcome evaluation is to establish standards of care for a specific diagnosis and then compare actual client outcome with that standard. Evaluation may also be Ongoing, Intermittent, or Terminal: I. Ongoing Evaluation: Ongoing evaluation is done while or immediately after implementing a nursing order; it enables the nurse to make on the spot modifications in an intervention. II. Intermittent Evaluation: It is performed at specified intervals (e.g. Once a week), shows the extent of progress toward goal achievement and enables the nurse to correct any deficiencies and modify the care plan as needed. Evaluation continues (either ongoing or intermittently) until the client achieve the health goals or is discharged from nursing care. III. Terminal Evaluation: It indicates the client‘s condition at the time of discharge. It includes the status of goal achievement and an evaluation of the client‘s self care abilities with regard to follow-up care. Most agencies have a special discharge record for the terminal evaluation. Relationship of Evaluation to Other Nursing Process Phases: Evaluation depends on the effectiveness of the steps that precede it. Assessment data must be accurate and complete so that the nurse can formulate appropriate expected outcomes in the planning step. The expected outcomes must be stated concretely in behavioral terms if they are to be useful for evaluating client responses. And finally, without the implementing phase, in which the plan is put into action, there would be nothing to evaluate. Evaluation: The final phase of the nursing process, in which the nurse determines the client‘s progress toward goal/outcome achievement and the effectiveness of the nursing care plan.
526
ASSESSMENT
DIAGNOSING
PLANNING
IMPLEMENTATION EVALUATION
Steps of Evaluation: Review Client Goals and Outcome Criteria: Measuring goal attainment starts by reviewing the client goals and outcome criteria, written in measurable terms that were developed from each nursing diagnosis. Nurses‘ review expected client behavior by examining the time frames and methods of measurement of goal fulfillment. They evaluate client goals and outcome criteria in a variety of ways, including observing client behaviors, using documentation of the client‘s responses to interventions, and receiving feedback from the client, family members, and other healthcare providers, if appropriate. This review helps nurses focus on data they need to assess the accuracy and realistic nature of goals and outcome criteria. Collect Data: Systematic data collection is required to determine goal achievement. Subjective data are collected from any sources: the client, family members or significant others, nursing staff, and other healthcare team members. Objective data from observation (e.g. posture, skin, color, and behavior), health records (e.g. laboratory results, reports from other health care team members), physical assessment (e.g. breath 527
sounds, strength of extremities) and measurement devices (e.g. blood pressure, temperature) are collected to judge the client‘s behavioral responses to nursing interventions. Nurses also use subjective data to evaluate the effectiveness of nursing care provided. E.g. a client with a nursing diagnosis of Acute Pain related to a recent surgical procedure may have as a goal, ―Client will state that pain is relieved within 10 minutes after repositioning.‖ The client‘s subjective statement would be needed to judge whether this goal has been achieved. Measure Goal/Outcome Achievement: After collecting data, nurses form a comprehensive picture of the client‘s behavioral responses to nursing interventions. The next activity is to make a judgment about goal attainment by comparing the client‘s actual behavioral responses to the predicted responses or predetermined outcome criteria developed in the planning phase. When possible, the client is involved. The four possible judgments that may be made are as following: The goal was completely met. The goal was partially met. The goal was completely unmet. New problems or nursing diagnosis have developed. The fourth judgment can exist simultaneously with any of first three. Once the judgment about the attainment or lack of attainment of outcome criteria is made, the plan of care is revised. Assess Facilitators of Goal Attainment: Clients, family members, significant others and other healthcare team members are invaluable in facilitating or helping with goal attainment. Occasionally, only those closest to the client can identify the subtle or elusive factors that helped or hindered goal achievement. Examples of facilitators include audiovisual materials, written handouts, repetition of material, and easily assessable and interested nursing staff. Assess Barriers to Goal Attainment: Several barriers to goal attainment have been identified. Barriers may involve the client, family members or significant others, and the nurse or other healthcare team members. Examples of how goal attainment may be blocked include providing incorrect information, withholding information, having an unexpected reaction to treatment (e.g. allergic response to therapy), possessing inadequate coping ability, and experiencing a worsened underlying pathologic condition. Family members also may act as barriers to goal achievement in many ways. E.g. their lack of understanding the plan of care, lack of interest in the client etc. Nurses may unwittingly block goal achievement. E.g. by neglecting to collect pertinent assessment data, delegating nursing care to inappropriate nursing staff members. Other healthcare team members also may be barriers. They may lack communication among themselves, be unable to work together as a team. The evaluation phase identifies the barriers that are interfering with the client‘s advancement towards goal achievement. Record Judgment or Measurement of Goal Attainment: Written documentation of the subjective and objective data gathered and the judgment made about goal attainment is required on the client‘s health record. Judgment about goal attainment is written clearly and concisely. 528
Revise or Modify the Nursing Care Plan: Revision or modification of the nursing plan of care is part of evaluation phase. It provides a feedback mechanism that starts the entire chain of events again. Nursing diagnoses that are resolved require no further nursing intervention and may be removed from the nursing plan of care. To maintain the client‘s Problem- free status, a nursing plan of care is developed that incorporates potential for wellness and other health promoting nursing diagnosis and focuses nursing actions towards maximal functioning. The levels of functioning and health status changes are periodically reassessed to determine whether new problems or nursing diagnosis have developed.
529
BIBLIOGRAPHY: Craven Ruth F., Hirnle Constance J., Fundamentals of Nursing: Human Health and Function, Fourth Edition, Lippincott, 895-901. Kozier, Erb Blais, Wilkinson, Fundamentals of Nursing: Concepts, Process, and Practice, Fifth Edition, Addison-Wesley, 1171. Sorensen and Luckman‘s, Basic Nursing: A Psychophysiological Approach, Third Edition, Saunders, 555-581. Nursing Procedures, Third Edition, Springhouse, 388-395. Altman Gaylene Bouska, Patricia Buchsel, Valerie Coxon, Fundamental and Advanced Nursing Skills, 195-208. www.google.com
530
MODIFICATION
Some client goals are partially met or completely unmet. Modification begins with a complete client reassessment. Changes in client goals, client outcome criteria, and nursing interventions are required. If new problems have arisen, new nursing diagnosis must be identified and a nursing plan of care written.
531
Functional Approach to Evaluation: Evaluation using the functional health approach requires a specific perspective. In addition to measuring attainment of client goals, the client‘s functional status for each health pattern is established. After implementing the nursing plan of care, the nurse ascertains the client‘s functional status based on data from the evaluation phase. Subjective and Objective data are used to determine the client‘s movement toward improved function. Evaluation using the functional health approach provides a framework for organizing and evaluating data for revision or modification of the nursing plan of care. Quality Improvement Programs: Evaluation can also focus on the quality of nursing care provided to groups of clients with similar problems or nursing diagnoses. Quality improvement programs are mechanisms for healthcare organizations to assess and improve care. Formerly called quality assurance monitors, total quality management (TQM), or continuous quality improvement (CQI), these programs ensure that quality client care is provided and standards are upheld. They provide input for the development and refinement of standards of care for groups of similar clients. Standards provide the basis for quality monitors ―because they are statements of accountability and define requirements for quality nursing care.‖ Quality improvement involves measuring the extent to which standards have been achieved. Focus on quality improvement is the combined result of consumers‘ demands for high- caliber health services and soaring healthcare costs. Also, governmental agencies, accreditation groups, and regulatory bodies have pressured the nursing profession to respond to quality improvement issues. Standards of care have been proposed by ANA, JCAHO, specialty nursing organizations (e.g. Associations of Rehabilitation Nurses, American Association of Spinal Cord Injury Nurses), and individual healthcare institutions. American Nurses Association: The ANA first established the Standards of Nursing Practice in 1973; these were updated in 1998 with the second edition of Standards of Clinical Nursing Practice, which include ―standards of care‖ and ―standards of professional performance‖. Based on a nursing process framework, ―standards of care‖ are composed of seven nursing standards for providing nursing care to all clients. The behaviors and role of professional nurses are described in eight ―standards of professional performance.‖ Both sets of standards include measurement criteria for evaluating nursing care and performance. Joint Commission on Accreditation of Healthcare Organizations: The JCAHO (1996) is an external review board that establishes standards for institutions to ensure that the institution functions within the specific guidelines. The hospital standards for nursing care are applicable to all clients in every setting where nursing care is provided. Recent changes in the JCAHO guidelines require the continuous monitoring and evaluation of the quality of nursing care provided by the department of nursing. Peer Review: Peer review is the evaluation and judgment of a nurse‘s performance by other nurses. It is another mechanism for evaluating and monitoring the nursing care that is provided. 532
There are two types of peer review: Nursing Monitors: the nursing monitor, previously called a nursing audit, is ―a review, by a nurse, of the client‘s care or records to determine the extent to which the care or records meet establishing standards‖. Nursing monitoring committees usually establish the ―standards against which their observation will be measured‖. Although nursing departments develop their own standards for particular nursing care settings, the ANA‘s Standards of Clinical Nursing Practice is often used as a model in generating unique standards for a particular setting or institution. Individual Peer Review: The second type of peer review is individual peer review, which focuses on the nurse. An individual nurse‘s performance is evaluated and judged by other nurses with similar education and experience. This type of review also is based on preestablished standards. Individual peer review adds to nurse monitoring data.
533
BIBLIOGRAPHY: Craven Ruth F., Hirnle Constance J., Fundamentals of Nursing: Human Health and Function, Fourth Edition, Lippincott, 206-213. Kozier, Erb Blais, Wilkinson, Fundamentals of Nursing: Concepts, Process, and Practice, Fifth Edition, Addison-Wesley, 153-161. Sorensen and Luckman‘s, Basic Nursing: A Psychophysiological Approach, Third Edition, Saunders, 166-173. www.google.com
534
UNIT-VIII
535
SYLLABUS Unit
Hours
Content
VIII
30
Psychological aspects and Human relations: �Human behavior, Life processes & growth and development, personality development, defense mechanisms, �Communication, interpersonal relationships, individual and group, group dynamics, and organizational behavior, �Basic human needs, Growth and development, (Conception through preschool, School age through adolescence, Young & middle adult, and Older adult) �Sexuality and sexual health. �Stress and adaptation, crisis and its intervention, �Coping with loss, death and grieving, �Principles and techniques of Counseling.
536
WHAT IS LIFE PROCESS OR WHAT IS BEING ALIVE 78 Rate or flag this page By simplyglobal How do we differentiate between living and non living beings: LIFE PROCESSES: Various functions are going inside our body and inside the body of all living organisms. These functions are necessary to maintain the living being. The maintenance functions of living organisms must go on even when they are not doing anything particular. Even when we are just sitting in front of computer, even if we are just asleep, this maintenance job has to go on. The processes which together perform this maintenance job are life processes. Following functions comprise the life processes: 1. Nutrition 2. Respiration 3. Excretion 4. Growth & Repair 5. Reproduction Nutrition: Nutrition is the process of getting energy from outside sources. Next process of nutrition is to break down these sources to release energy. Process of getting nutrition can vary from organism to organism and is affected by the external environment. Based on Mode of getting food organisms can be classified as follows: 1. Autotrophs 2. Heterotrophs Autotrophs make their own food. All green plants are autotrophs. You must be aware that green leaves contain a pigment called chlorophyll, which makes them green. Apart from colouring purpose, chlorophyll plays a more important role of converting the Sun's photo energy to chemical energy. The process of food preparation in plant is called Photosynthesis. It involves making of Glucose with the help of Carbon Dioxide and Water in the presence of sunlight. Photosynthesis can be expressed by following chemical reaction: 6CO2 + 6H2O ---------- C6H12O6 + 6O2 Carbon Dioxide + Water==Glucose + Oxygen Glucose thus formed is used by the plant to satisfy its energy needs. The excess amount is stored as starch in various parts of the plant. Experiment to show presence of starch in a plant leaf: Take a potted plant with variegated leaves – for example, money plant or crotons. Keep the plant in a dark room for three days so that all the starch gets used up. Now keep the plant in sunlight for about six hours. Pluck a leaf from the plant. Mark the green areas in it and trace them on a sheet of paper. Dip the leaf in boiling water for a few minutes. After this, immerse it in a beaker containing alcohol. 537
Carefully place the above beaker in a water-bath and heat till the alcohol begins to boil. What happens to the colour of the leaf? What is the colour of the solution? Now dip the leaf in a dilute solution of iodine for a few minutes. Take out the leaf and rinse off the iodine solution. Observe the colour of the leaf and compare this with the tracing of the leaf done in the beginning What can you conclude about the presence of starch in various areas of the leaf? Iodine after reacting with starch turns its colour to blue. Carbon Dioxide Uptake in Plants: Leaves have small pores called stomata. These pores open to allow entry of CO2 inside leaves. Water flows into guard cells to swell them, which helps in opening of stomatal opening. Heterotrophs: Those organisms which are dependent on other organisms for their food are called heterotrophs. Some animals, like humans have complex digestive system to break the food into basic constituents to make them fit for oxidation. Certain organisms break the food into basic molecules outside their body then absorb them. Fungi use some enzymes to break the food outside their body. Some organisms take food from other organisms without killing them. Most of the parasites take nutrition in this way. Human Digestive System: Human Digestive System is a complex and elaborate system. The digestive system carries out following functions: 1)Intake of Food 2)Digestion of Food 3)Assimilation of Food and 4)expulsion of waste products. Movement of Food in the Alimentary Canal: Alimentary Canal constricts and expands in rhythmic fashion. This pushes food particles forward through the alimentary canal. At every junction there is valve like structure which prevents the back-flow of food. Sometimes these valves or sphincters malfunction, which results in regurgitation of food, resulting in burning sensation in mouth and throat. Respiration: Breaking down of nutrients to release energy is called respiration. The way cooking gas is burnt to produce energy for kitchen the living organism burns food to release energy. A complex series of oxidation-reduction goes inside the cell to burn food to produce energy. This energy is used to carry out different activity inside a living organism. The Chemical Reaction During Respiration can be written as follows: C6H12O6 + 6O2 6CO2 + 6H2O + 674 Kcal Oxygen is required for oxidation of Glucose during cellular respiration. In plants and smaller animals this oxygen get inside the organism by simple mechanical way like osmosis or by difference in air pressure. But in larger organisms complex system is needed to carry out transportation of oxygen inside the body and that of carbon dioxide out of the body. This process is called external respiration and is different from cellular respiration.
538
Haemoglobin: Red Blood Cells in the blood contain haemoglobin which carries oxygen to the cell and carbon dioxide away from the cells. Arteries: Arteries carry oxygenated blood from heart to different parts of the body. Veins: Veins carry deoxygenated blood from different parts of the body to heart. Heart: Heart functions like a pump and helps in pumping in the deoxygenated blood to lungs for Oxygenation. Thereafter, heart pumps oxygenated blood to different parts of the body. Lungs: Lungs helps in sucking in oxygen from air and pumping out carbon dioxide in the air. Excretion: As you may have noticed that burning petrol or diesel causes release of obnoxious fumes out of a car, our body also produces such obnoxious things. They are harmful and need to be expelled out of our body. Expulsion of harmful substances, which are byproducts of life processes is called excretion. In human body, many organs help in excreting harmful substances out of the body. For example Lungs expel carbon dioxide, skin expels some waste products through sweating, mouth expels some waste through spit, and rectum expels waste through faeces. But the main excretory organ in the human body is kidney. Kidney filters harmful substances from blood and expels them through urine. After all the metabolic activities, blood collects byproducts from different parts of the body and passes through kidney to filter out harmful products. Then only it goes to the heart for oxygenation. This is the reason a malfunctioning kidney is a life threatening condition. People with bad kidney need to undergo dialysis. In this process blood is filtered using artificial kidneys or dialysis machine. Transportation of Water in Plant: Plants have special tube like structure made of special tissues called xylem and phloem. They create capillary effect and the water rises from ground to the top of the tree. Apart from this evaporation of water through leaves creates low pressure. This low pressure creates a pull effect. Both factors combine resulting in transportation of water and minerals from roots to the top of the tree. I biological terms this is called Ascent of Sap.
539
Human digestive system
540
PERSONALITY DEVELOPMENT 1. Introduction 2. Personality a. Definition 3. Theories of personality a. Type and Trait theories of personality b. Dynamic personality theories c. Learning and behavior theories of personality d. Humanistic theories 4. Influences of personality 5. Development of personality in infancy a. Personality development b. Physical hazards c. Psychological hazards 6. Development of personality in babyhood a. Personality development b. Physical hazards c. Psychological hazards 7. Development of personality in early childhood a. Personality development b. Physical hazards c. Psychological hazards 8. Development of personality in late childhood a. Personality development b. Physical hazards &Psychological hazards 9. Puberty 10. Development of personality in adolescence a. Personality development b. Physical hazards & Psychological hazards 11. Development of personality in early adulthood a. Personality development b. Physical hazards & Psychological hazards 12. Development of personality in middle adulthood a. Personality development b. Physical hazards & Psychological hazards 13. Development of personality in old age a. Personality development b. Physical hazards &Psychological hazards 14. Nurses responsibilities for the development of a healthy personality 15. Conclusion 16. Bibliography
541
Introduction: An individual's personality is the complex of mental characteristics that makes them unique from other people. It includes all of the patterns of thought and emotions that cause us to do and say things in particular ways. At a basic level, personality is expressed through our temperament or emotional tone. However, personality also colors our values, beliefs, and expectations. There are many potential factors that are involved in shaping a personality. These factors are usually seen as coming from heredity and the environment. Research by psychologists over the last several decades has increasingly pointed to hereditary factors being more important, especially for basic personality traits such as emotional tone. However, the acquisition of values, beliefs, and expectations seem to be due more to socialization and unique experiences, especially during childhood. The concept of personality refers to the profile of stable beliefs, moods, and behaviors that differentiate among children (and adults) who live in a particular society. The profiles that differentiate children across cultures of different historical times will not be the same because the most adaptive profiles vary with the values of the society and the historical era. An essay on personality development written 300 years ago by a New England Puritan would have listed piety as a major psychological trait but that would not be regarded as an important personality trait in contemporary America. Definition of personality: There where many people who tried to define personality, of which the most accepted version is the one that Gordan Allport had mentioned. ―Personality is the dynamic organization within the individual of psychophysical systems that determine his characteristics, behavior and thought. ― Five Perspectives on Personality Development Perspective Assumed Processes Primary Outcomes Temperament
Ease of arousal, ability to regulate emotions Inherent physiological and impulses, energy, reaction to unfamiliar mechanisms people and events, dominant mood
Psychoanalytic
Conflict over sexual and hostile motives
Defenses, phobias, depressed mood
Attachment
Relation to the caretaker in the infant years
Control of impulse, social habits, security, anger, frustration tolerance, trust in others, capacity for love
Self
Interpretations of experience, identification
Guilt, shame, anxiety, self-confidence
Observed Sociability, aggressive behavior, impulsivity, Acquired habits behavior shyness, obedience Theories Of Personality Development: I) Psychosexual theory: According to Sigmund Freud, personality is mostly established by the age of five. Early experiences play a large role in personality development and continue to influence behavior later in life. 542
Freud's theory of personality development is one of the best known, but also one of the most controversial. Freud believed that personality develops through a series of childhood stages during which the pleasure-seeking energies of the id become focused on certain erogenous areas. This psychosexual energy, or libido, was described as the driving force behind behavior. If the stages are completed successfully, the result is a healthy personality. If certain issues are not resolved at the appropriate stage, fixation can occur. A fixation is a persistent focus on an earlier psychosexual stage. Until this conflict is resolved, the individual will remain "stuck" in this stage. For example, a person who is fixated at the oral stage may be over-dependent on others and may seek oral stimulation through smoking, drinking, or eating. The Oedipus complex describes these feelings of wanting to possess the mother and the desire to replace the father. However, the child also fears that he will be punished by the father for these feelings, a fear Freud termed castration anxiety. The term Electra complex has been used to described a similar set of feelings experienced by young girls. Freud, however, believed that girls instead experience penis envy. Eventually, the child realizes begins to identify with the same-sex parent as a means of vicariously possessing the other parent. For girls, however, Freud believed that penis envy was never fully resolved and that all women remain somewhat fixated on this stage. Psychologists such as Karen Horney disputed this theory, calling it both inaccurate and demeaning to women. Instead, Horney proposed that men experience feelings of inferiority because they cannot give birth to children. If the other stages have been completed successfully, the individual should now be wellbalanced, warm, and caring. The goal of each stage is to establish a balance between the various life areas. Stages (age) According to S. Freud According to E Erickson 1.)Infancy (birth to 18 Oral stage, Trust vs. Mistrust The infant's primary source of Feeding Children months): interaction occurs through the develop a sense of trust mouth, so the rooting and when caregivers sucking reflex is especially provide reliability, care, important. The mouth is vital and affection. A lack of for eating, and the infant this will lead to derives pleasure from oral mistrust. stimulation through gratifying activities such as tasting and sucking.
543
2.)Early Childhood (2 to 3 Anal stage, years): Primary focus of the libido was on controlling bladder and bowel movements. The major conflict at this stage is toilet training--the child has to learn to control his or her bodily needs. Developing this control leads to a sense of accomplishment and independence.
Autonomy vs. Shame and Doubt Toilet Training Children need to develop a sense of personal control over physical skills and a sense of independence. Success leads to feelings of autonomy, failure results in feelings of shame and doubt.
Phallic stage, The primary focus of the libido is on the genitals. Children also discover the differences between males and females. Freud also believed that boys begin to view their fathers as a rival for the mother‘s affections.
Initiative vs. Guilt Exploration Children need to begin asserting control and power over the environment. Success in this stage leads to a sense of purpose. Children who try to exert too much power experience disapproval, resulting in a sense of guilt. Industry vs. Inferiority School Children need to cope with new social and academic demands. Success leads to a sense of competence, while failure results in feelings of inferiority
3.)Preschool (3 to 5 years):
4.)School Age (6 to 11 The latent period This is a time of exploration years): in which the sexual energy is still present, but it is directed into other areas such as intellectual pursuits and social interactions. This stage is important in the development of social and communication skills and self-confidence. More concerned with peer relationships, hobbies, and other interests. 5.)Adolescence (12 to 18 During the final stage of psychosexual developmentyears): the genital stage. The individual develops a strong sexual interest in the opposite 544
Identity vs. Role Confusion Social Relationships Teens needs to develop a sense of self and
sex. Where in earlier stages the focus was solely on individual needs and, interest in the welfare of others grows during this stage. 6.)Young Adulthood (19 to 40 years):
7.)Middle Adulthood (40 to 65 years):
8.)Maturity(65 to death):
545
personal identity. Success leads to an ability to stay true to you, while failure leads to role confusion and a weak sense of self. Intimacy vs. Isolation Relationships Young adults need to form intimate, loving relationships with other people. Success leads to strong relationships, while failure results in loneliness and isolation. Generativity vs. Stagnation Work and Parenthood Adults need to create or nurture things that will outlast them, often by having children or creating a positive change that benefits other people. Success leads to feelings of usefulness and accomplishment, while failure results in shallow involvement in the world Ego Integrity vs. Despair Reflection on Life Older adults need to look back on life and feel a sense of fulfillment. Success at this stage leads to feelings of wisdom, while failure results in regret, bitterness, and despair.
II.) Behavioral Theories: Behavioral psychology, also known as behaviorism, is a theory of learning based upon the idea that all behaviors are acquired through conditioning. Advocated by famous psychologists such as John B. Watson and B.F. Skinner, behavioral theories dominated psychology during the early half of the twentieth century. Today, behavioral techniques are still widely used in therapeutic settings to help clients learn new skills and behaviors. III.) Humanist Theories: Humanistic psychology theories began to grow in popularity during the 1950s. While earlier theories often focused on abnormal behavior and psychological problems, humanist theories instead emphasized the basic goodness of human beings. Some of the major humanist theorists include Carl Rogers and Abraham Maslow. IV.) Trait theories of personality: Unlike many other theories of personality, such as psychoanalytic or humanistic theories, the trait approach to personality is focused on differences between individuals. The combination and interaction of various traits combine to form a personality that is unique to each individual. Trait theory is focused on identifying and measuring these individual personality characteristics. Gordon Allport‘s Trait Theory. Raymond Cattell‘s theory. Eysenck‘s theory. Influences on Personality Development: The influence comes from a variety of temperament but especially ease of arousal, irritability, fearfulness, sociability, and activity level. The experiential contributions to personality include early attachment relations, parental socialization, identification with parents, class, and ethnic groups, experiences with other children, ordinal position in the family, physical attractiveness, and school success or failure, along with a number of unpredictable experiences like divorce , early parental death, mental illness in the family, and supporting relationships with relatives or teachers. Developmental Changes In The Origin Of The Emotions To Be Regulated Emotion to be Source in child under 5 Source in child over 5 years regulated years Identification, school failure, peer rejection
Fear/anxiety
Unfamiliarity
Anger/resentment
Frustration and punishment Coercion, rejection, risk failure
Violations of parental Failure to meet internalized standards standards The most important personality profiles in a particular culture stem from the challenges to which the children of that culture must accommodate. Most children must deal with three classes of external challenges: (1) unfamiliarity, especially unfamiliar people, tasks, and situations; (2) request by legitimate authority or conformity to and acceptance of their standards, and (3) domination by or attack by other children. In addition, all children must learn to control two important families of Shame and guilt
546
emotions: anxiety, fear , and guilt, on the one hand, and on the other, anger, jealousy, and resentment. Important Derivatives Of Four Processes In Personality Development Process Outcome Identification
Expectation of success or failure, pride vs. shame
Ordinal position
Attitude toward legitimate authority
Social class
Feelings of entitlement and power vs. feeling of impotence and coercion
Parental Values the child holds for achievement, honesty, tolerance to others, socializations responsibility, loyalty, control of aggression, guilt over failure Of the four important influences on personality--identification, ordinal position, social class, and parental socialization--identification is the most important. By six years of age, children assume that some of the characteristics of their parents belong to them and they experience vicariously the emotion that is appropriate to the parent's experience. A sixyear-old girl identified with her mother will experience pride should mother win a prize or be praised by a friend. However, she will experience shame or anxiety if her mother is criticized or is rejected by friends. The process of identification has great relevance to personality development. The child's ordinal position in the family has its most important influence on receptivity to accepting or rejecting the requests and ideas of legitimate authority. First-born children in most families are most willing than later-borns to conform to the requests of authority. They are more strongly motivated to achieve in school, more conscientious, and less aggressive. The child's social class affects the preparation and motivation for academic achievement. Children from middle-class families typically obtain higher grades in school than children of working or lower-class families because different value systems and practices are promoted by families from varied social class backgrounds. The patterns of socialization used by parents also influence the child's personality. Baumrind suggests that parents could be classified as authoritative, authoritarian, or permissive. More competent and mature preschool children usually have authoritative parents who were nurturant but made maturity demands. Moderately self-reliant children who were a bit withdrawn have authoritarian parents who more often relied on coercive discipline. The least mature children have overly permissive parents who are nurturant but lack discipline. 1.)Development Of Personality In Infancy: Personality development: Neonates are born with abilities to perceive and respond to some parts of their world. In an organized and effective way for example reflexes that is in place at birth permit neonates to grope or ―root‖ for the breast, to suck when an object is place in its mouth and to swallow milk and other fluids. Other classes of reflexes which are obvious adaptive values are breathing, blinking, coughing sneezing vomiting and with drawing from painful stimuli. 547
Another class of reflexes is attributed to the immaturity of certain parts of the brain example Moro‘s reflex (when support is withdrawn from the back side of the head the neonate expands its arms to the sides, extends its fingers and bring its arms in ward in a sort of embracesing movement) this reflex and other reflexes in this category normally disappears in early infancy as the brain matures if these reflexes persist too long. It may mean that there is a problem with the infants developing CNS. Newborn senses are very active they respond gustatory, olfactory, auditory, visual and tactile stimuli. New born also learn via classical and instrumental conditioning. Some studies suggest that newborns are capable of imitation. In the first few weeks it glimmers of personality can be seen in the temperament that babies display. Example babies are difficult in the first weeks after birth. They show irregularities in their sleeping, feeding or elimination pattern pattern. They may be easily disturbed, irritable and prone to cry. Evidence suggests that youngsters who show this ―difficult child syndrome‖ are more likely than other infants to develop behavior disturbances in their later life. Children are born with characteristic temperamental differences that are reflected in activity rates and sensitivities. It is these differences that the individual personality pattern will develop. Individual differences are apparent at birth and are shown as responses to food, in crying, in motor activities and especially in sleep. Personality like other physical and mental traits, results from maturation of hereditary traits. Thomas et al have commented on the importance of interpersonal relationship between maturation of hereditary traits and experiences in the development of personality. ―If two influences are harmonized one can expect healthy development of the child; if they are dissonant, behavior problems are almost sure to ensure. A disturbed prenatal environment which can result if the mother is subjected to severe and prolonged stress for example may cause a modification of the newborns behavior pattern. Such disturbances are especially important if they occur in the later part of the fetal period and may cause a state of hyperactivity and irritability in the new born. There is evidence that infant that who is separated from their mothers‘ after birth does not make as good an adjustment to post natal life as infants who remain with their mothers. Physical hazards: The most serious physical hazards are related unfavorable environment, a difficult and complicated birth, a multiple birth, post maturity and prematurity, and conditions leading to infant mortality. Unfavorable prenatal environment: Excessive smoking on the part of the mother for example can affect the development of the fetus. Prolonged and intense maternal stress is another important factor causing the infant to be tense and nervous Difficult and complicated birth: As mentioned earlier a difficult and complicated birth results in temporary and permanent brain damage. If the birth requires the use of instruments as in the case where the fetus is so large that has to be aided in its passage through the birth canal, or in a case of abnormal presentations the chances of head injury are always present. 548
A caesarean section or a premature birth, on the other hand is likely to result in anoxia a temporary loss of oxygen to the brain. If anoxia is severe the brain damage is far greater than is anoxia lasts only for a few seconds. The more complicated the birth the more damage to the brain, the greater the effects of post natal adjustments to the brain. Multiple births: Children of multiple births are usually smaller and weaker than singletons as a result of crowding during prenatal period, which inhibits fetal movement. These babies may be born prematurely which adds to their adjustment problems. Post maturity and prematurity: As already been discussed babies who are large may be delivered instrumentally and therefore are prone for brain damage. As with prematurity, which is a major cause of neonatal deaths, the normal reflexes are not developed and so there is far too much from just maladjustment, the existence itself is at stake. If the neonate makes it alive through the adversities there is a high level of permanent damage either to the nervous system or any supporting system? Psychological hazards: Relatively few psychological hazards of infancy have been studied and there is only scanty research attention. But those that are revealed are of great importance. Traditional beliefs about birth: There have been beliefs that children of multiple births have to be different and inferior to singletons and that premature are doomed to be physical and mental weaklings. There are scientific studies about the effect of time of birth on future development of the child. The spacing of the child also plays a vital role in receiving care from the mother. Helplessness: The fact that new born is helpless is undeniable. The parents‘ capability in caring the child leads to the development of trust or mistrust within the child and the environment. Individuality of the infant: To most people being different is considered as being inferior. The parents tend to plan prior to the behavior based on books, literature or previous experience. But actually every infant exhibits individuality. Each infant responds to situations differently. The first child might be very irritated and crying more during the night as infant, while the second child might be well adjusted and don‘t get irritated and don‘t cry as much. This gets interpreted as misbehavior and taken for medical assistance. Developmental lag: The infants that are prone for developmental lag are those that are premature and those who are injures in birth. Even a full term healthy infant may show developmental lag because of any minor illness or inadequate nutrition. An anxious mother will transmit her anxiety to the infant by the methods of care given. Lack of stimulation intensifies developmental lag. Lack of stimulation: Stimulation reduces that plateau of development and increases development of the new born. Lack of stimulation will result in lack of response or inappropriate response.
549
New parent blues: There are states of depression among new parents. These depressive states tend to be more pronounced in mothers than in fathers and in parents of first babies than in those who have already had one or more children. They are concerned about the extra expense and the new life adjustments to be made and are mostly frightened about the new situation. This will develop anxiety and there by Trans mitted to the child through the care given. Unfavorable attitude on the part of significant people: Assumption of extra responsibilities may cause discomfort among the ‗significant people‘. The sex and appearance may cause differences in attitude of the people to the child. The more in contact the child is going to be with his ‗people the better the development, especially the mother. Names: Names don‘t cause much harm during infancy but it‘s during infancy that the name is put. While growing the name causes threat to his development if the name is an ‗embarrassment‘ of the name is ‗funny‘ or sex-inappropriate. 2.) Development of Personality In Baby Hood: Personality development: Certain personality traits do change even in the baby hood years. These changes may either be quantitative, in that there is strengthening or weakening of a trait already present, or qualitative, in that a socially undesirable trait is replaced by that which is Socially acceptable, for most of the part, personality tends to be quantitative in nature. Young children who are shy will seek the environment that will encourage the development of this trait. At the same time, they will avoid situations that would make them feel ill-at-ease or self conscious. As a result, their shyness becomes stronger rather than weaker with age. The core personality pattern the self concept-remains fundamentally the same. As time goes on, this core becomes less and less flexible then a change in personality pattern will upset the personality balance. Thus early experiences are extremely important in shaping the personality pattern. Physical growth and development occur at gradually decelerated rates throughout the babyhood while development of psychological functions occurs in a rapid rate. Because muscle control follows the laws of developmental direction the earliest skills to be learned are the head, arm and hand skills. To be able to communicate the babies should be able to comprehend what is communicated to them and in turn communicates with others in the form of crying babbling gestures and emotional expressions. Babyhood emotions differ from those of older children, adolescents and adults in that, first they are accompanied by behavior patterns proportionally too great for the stimuli to give rise to them and second, they are more easily conditioned in later ages. Early social foundations are important, because the type of behavior babies show in different situation affects the personal and social adjustments and second, once exist they persist. Play development follows a pattern that is greatly influenced by the baby‘s physical, motor and mental development. In babyhood understanding comes from a combination of 550
sensory exploration, motor manipulation, and towards the end of babyhood through the answers to questions. Discipline‘s role in moral development is mainly in the form of punishment for wrong behavior and different kinds of approval for socially approved behavior. Sex-role typing begins at birth, though the pressure on boys to look and act in a sex appropriate way is stronger than in girls. Evidence of the importance of parent child relationship comes from emotional deprivation, attachment behavior and influences of different sized families. It during the babyhood the adult personality base is laid. Physical hazards: Mortality: Due to various diseases, mortality is a major hazard. Death during the first year is usually due to some illness and in the second year due to accidents. Boys are reported dead more than girls. Crib death: Usually crib death occurs after a long period of sleep, the cause is idiopathic, but commonly seen in babies with breathing difficulty and abnormalities during birth. Malnutrition: Malnutrition may result from inadequate food intake or an unbalanced diet, which will result havoc not only in physical growth but also in mental growth. Mental retardation, carious teeth and increased risk for illnesses tends to build up the temperament and adjustment strategies. The foundations of obesity may be laid during this period because of over feeding and over protection.The foundations of physiological habits are laid on this age like eating, sleeping and eliminating. Psychological hazards: Delayed speech, delayed motor development, and is important as the foundations of the personality are laid during these years. Emotional hazards: These include emotional deprivation, stress, too much affection and dominant emotions are the problems that might cause an undesirable personality. Social hazards The major hazard is the lack of opportunity to become more social and interact with others. These include social phobia and shyness. Play hazards: The hazards from toys being physically smarting is a possibility but the psychological impact are even worse. The child tends to rely on toys for their play mostly rather than interaction, this will lead to isolation. Hazards in understanding: The major hazards seen are in the context of concepts. It‘s relatively easy to replace wrong meanings with correct meaning, and emotional weightings, like chocolate for good behavior and vegetables for bad behavior tends to form likes and dislikes in food.
551
Hazards of morality: There not much to be moral in babyhood, but if the bay learns that doing things that annoy brings attention then that will result ion abnormal aggressiveness in the later period of life. Family relationship hazards: These include separation from mother, failure to develop attachment behavior deterioration of family relationship, over protectiveness, inconsistent training (which results in permissiveness of the parent) and child abuse. 3.) Development of Personality During Early Childhood: Personality development: Early childhood which extends from 2 to 6 years of age, is labeled by parents as problem, the trouble some, or the toy age; by education as the preschool age and by psychologists as pre-gang age, the exploratory age or the questioning age. Physical development proceeds at a slow rate in early childhood but the psychological habits whose foundations where laid in babyhood becomes well established. Early childhood is regarded as the teachable moment for acquiring skills because children enjoy the repetition essential to learning skills; they are adventure some and like to try new things; and they have few already learned skills to interfere with the acquisition of new ones. Speech development advances rapidly as seen in improvement in comprehension as well as in different speech skills. This has a strong impact on the amount of talking young children do and the content of their speech. While emotional development follows a predictable pattern and the variations in this are due to intelligence, sex, family size, child training and other conditions. Early childhood is the pre-gang age; companions play an important role in socialization. Play in this phase is influences by motor skills, the degree of popularity they enjoy among their age mates, the guidance they receive in learning different patterns of play, and socio economic status of their families. Inaccuracies in understanding are common in early childhood because many childish concepts are learned with inadequate guidance and because children are encouraged to view the world in an unrealistic manner to make it more interesting and colorful. Early childhood is characterized by morality by constraint—a time when children learn through punishment and praise, to obey rules automatically, it is also the time when discipline differs, with some children subject to authoritarian discipline while others brought up by permissive and democratic discipline. The common interest in early childhood includes interest in religion and the human body, in self in sex and in cloths. The important aspects of sex role stereotypes and accepting and playing the sex appropriate games. Different family relationships (parent-child, sibling and relationship with relatives) play roles of different degree of importance in the socialization of young children and in their developing self concepts. Physical hazards: Mortality: Death are more often related accidents and are more frequent among boys than girls Illness: 552
Children who are ill for a long period of time lags behind in their learning skills and developmental skills with the increase in vaccination and prophylaxis this have been reduced. Accidents: Young children experiences cuts bruises, infections, burns and other major and minor accidents. Although most of the accidents are not fatal they may contribute to the mental and physical scars later in the development. Unattractiveness: As the years progress children become increasingly unattractive, reaching a view point as they emerge from their childhood. The lesser the attractiveness the worse the behavior will be. Obesity: Obesity is a health hazard as well as beauty hazard. Psychological hazard: Speech hazard: Because speech is a mode of communication and because communication ids need for social belonging, children who unlike their age mates cannot communicate with others will be socially handicapped, and this will lead to feelings of inadequacy and inferiority. The major hazard that the children are due to face is first people expect the children to comprehend what they are saying if they use word that the children do not understand, use pronunciation unfamiliar to children or speak too fast. Second when the quality of speech is so poor that what they say is unintelligible. Their ability to communicate with others is even more jeopardized than if they had not listened to what was being said to them. Third bilingualism is a serious handicap to the social development of the children. Fourth is the content of the speech. Emotional hazards: Dominance of unpleasant emotions like anger, the inability to establish an empathetic complex, development of too strong affection to one person. Social hazards: The young people speech and behavior might make them unpopular among the peers and so deprived of the chance to develop peer-approved behavior. Children are forced to play according to the sex- appropriate way and over do it and male themselves obnoxious to the peers. They might develop unhealthy social attitudes because of the treatment they receive from age-mates. Another major hazard is the use of imaginary companions to compensate the lack of real companions. Parental encouragements to spend too time with others children and too little time with their children. Play hazards: A certain amount of solitary play is encouraged and teaches the child to be self-sufficient. Another form of hazard is that children love to watch television than to play indoors or outdoor games. This will result in depleted development both mentally as well as socially. It‘s a major problem because it‘s only through play the child socializes with his peers and if enough opportunities are not given for the play then that will result in social stagnation and isolation.
553
Hazards in concept development: The hazards are inaccuracy in understanding, and development of concepts below the level of the peers and emotional weighing of concepts are even more serious hazard. Moral hazards: The major hazards are inconsistent discipline slows down the process of learning to conform to social expectations. The second is if the children is not reprimanded fro misbehaviors and if they are permitted to get temporary satisfaction from the admiration and envy of their peers when they misbehave, this is likely to encourage them to persist in their behavior. The third is too much emphasis on punishment and too little emphasis on rewards of good behavior can lead to unfavorable attitudes towards those in authority. But the most serious being the young children who are subjected to authoritarian discipline, which puts major emphasis on the external controls and are not encourage to develop the internal controls over their behavior that form the foundations to the conscience in the later period of life. Hazards in sex-role typing: There are three common and serious hazards in sex-role role during this time. First, the children do not learn the sex-role stereotype commonly accepted by their peers, whether they be traditional or egalitarian, they will view behavior different than their peers do. Second when girls are trained to conform to the traditional stereotypes for member of their sex that learn, indirectly, from these stereotypes that females are regarded as inferior physically and mentally inferior to the members of the male sex. This lay the foundations to the inferiority complexes that are seen in girls and strife in what they are actually capable of doing. And if the child does not learn the sex stereotypes, they form a misfit within the system of society they belong to. Family relationship hazards: The presence of parents and appropriate care develops the personality as a whole, a girl child will be submissive to the males in the house hold and boys will dominate the house activities. Other familial relationship also plays a vital role in the development of personality of the child like for example the presence of a step mother or step father, or the loss of the parent to identify with will result in confusions in identifying the role of the child and his influence in the society. Child abuse is also a family relationship hazard and though there is very less study regarding child abuse in the family evidence suggests that it is more common among male relatives with the fathers and stepfathers the usual offenders. Older brothers more often abuse their younger siblings than sisters. 4.) Personality Development during Late Childhood: Personality development: Late childhood which extends from 6 years until children become sexually mature at approximately age 13 for girls and 14 for boys is labeled by parents as sloppy or quarrel some age and educators call them as elementary school age; psychologists call them as gang age or age of conformity or the age of creativity. Physical growth is slow and relatively at even rate is influenced by health nutrition, immunization, sex and intelligence. The skills of late child hood can be categorized roughly into four major groups; self help skills, social help skills, school skills and playskills. The help of handedness develops all of these. While the areas of speech 554
pronunciations, vocabulary and sentence structure develop rapidly as does the comprehension, the content of speech starts to deteriorate. Older children learn to control their overt expressions of their emotions and to use emotional catharsis to clear their systems of the pent up emotionality caused by social pressure to control their emotions. The gang formation occurs at this age, which confirms to the patterns of behavior and to the values and interests of others. As gang member‘s children often reject parental standards, develop an antagonistic attitude toward members of the opposite sex. And become prejudiced with non-gang members. The socio economic status of the older children varies from popular to that of social isolate. Once a Childs status is established in a group it is difficult to change whether the status is of a leader, follower or isolate. Play interests of the older children and the amount of time they devote to play depends more on the degree of social acceptance they enjoy. Than on any other condition. There is a rapid increase in understanding and in accuracy of concepts partly as a result of increased intelligence and partly as a result of increased learning opportunities. In late childhood most people develop moral codes influenced by moral standards of the groups in which they are identified, and a conscience which guides their behavior in place of external controls needed when they where younger. The interests of older children are broader than those of younger children and include many new subjects like names clothes, the human body, sex, school, future vocations, status symbols and autonomy. Sex-role typing is influenced by children‘s appearance, behavior, aspirations, interests, attitudes towards members of the opposite sex and self-evaluation. The deterioration of family relationships, characteristic of late childhood, affects children‘s personal and social adjustments and has a strong impact on their personalities through its effects on their self-evaluations. This is especially serious when the gap between their ideal and real self-concepts is large because it acts as an obstacle in their search for identity. Physical hazards and psychological hazards: As previously discussed the effects of illness and disease have been considerably reduced as there is improvement in the medicine and treatment modalities. More over with the use vaccines and prophylaxis the incidence, prevalence and mortality has decreased considerably from the previous age groups, though there still exists the risk of death due to accidents. Obesity: This is mainly due to glandular condition but it is far more often due to over eating and less play and exercise. Obesity is not only a hazard for their health but also for their social interactions. Obese children loose out on active play so the loose recognition there by making them introverts later on in their life, in addition their playmates often tease and taunt them. Sex-inappropriate body builds: Girls with muscular body build and boys with feminine body build are more often ridiculed by their peers and pitied by adults. This leads to personal and social maladjustment.
555
Physical disabilities: Many disabilities are more common after accidents and there fore more common among boys than among girls. The reaction to such a condition results from the degree of disability. While some children may sympathies the child others will ignore, ridicule and tease the child. Thus making the ill child prone to social phobia and personality maladjustment. Awkwardness: As older children begin to compare with their playmates, they often discover that their awkwardness and clumsiness prevent them from doing what their playmates do from keeping pace with them in play. They start thinking that they are inferior to their playmates and mark them selves as martyrs. This feeling develops the base of inferiority complex seen later in the development. Homeliness: If other people react unfavorably and communicate their feelings by the way they treat homely children, this becomes a hazard. Attractiveness plays a vital role but this if not handled ion the proper way it can lead to superiority complex of inferiority. Psychological hazards: Speech hazard: A smaller than average vocabulary handicaps children in their school work as well as in their communication. Speech errors such as miscommunications and mispronunciations and grammatical mistakes and speech defects such as stuttering or lisping may make the children so self conscious that they will speak only when necessary. Children who have difficulty speaking the language used in school may again handicap the child further more, and make them feel that they are different. Egocentric speech, critical and derogatory comments and boasting antagonize their peers. Emotional hazards: Children are considered immature by both agemates and adults if they continue to show unacceptable patterns of emotional expression such as temper tantrums, anger and jealousy are so prominent that children are unpleasant to be with. Social hazards: There are five types of children that are affected by social hazards. Children who are rejected, voluntary isolates, geographically or socially mobile children who find acceptance by already form gangs difficult, children whom there exists a group prejudice on the basis of religion or race. Play hazards: Children who lack social acceptance are deprived of opportunities to learn the games and sports essentials for gang belonging, children who are restricted from fantasizing and become regular conformist in the future. Conceptual hazards: Children who idealized self-concepts are usually dissatisfied with themselves as they are the way other treat them. When their social concepts are based on stereotypes, they tend to become prejudiced and discriminatory in their treatment of others. Because such concepts are emotionally weighted, they are likely to persist and to continue to affect their social adjustments unfavorably. 556
Moral hazards: 1. The development of moral code based on peer and mass media concepts of right and wrong which may coincides with adult codes. 2. A failure to develop a conscious as an inner control over behavior. 3. Inconsistent discipline which leaves children unsure of what they are expected to do. 4. Physical punishment which serves a model for aggressiveness in children. 5. Finding peer approval of misbehavior so satisfying that such behavior becomes habitual. 6. Intolerance of wrong doing of others. Hazards associated with interests: There are two common hazards with childhood interests; first being uninterested in things which age mates consider as important and second developing unfavorable attitudes towards interests that would be valuable to them, as in the case of health or school. Hazards of sex-role typing: There are two common hazards in late childhood, failure to learn the elements of the sex roles their age-mates regard as appropriate and unwillingness to play the approved sexrole. Family relationship hazards: Friction within family has 2 serious effects: it weakens family ties, and it leads to habitual unfavorable patterns to people and problems which are carried out side the home. Hazards to personality development The development of unfavorable self concepts and the carry over from the early childhood of egocentrism are the major hazards in personality development as a whole. 5.) PUBERTY: In spite of the fact that puberty is a short period that overlaps the end of childhood and the beginning of adolescence, it is a time of rapid growth and change. It occurs at different ages for the boys and girls and for individuals within each sex group. There are three stages of puberty—the prepubescent, the pubescent and the post pubescent. The criteria for most often used to determine the onset of puberty are the menarche in girls and nocturnal emission in males. Puberty is caused by hormonal changes which because they are not controllable to date, come at variable times. The average for girls is 13 years and in boys 14 to 14 ½ years. The time needed to complete the changes during the puberty is 2-4 years. The puberty growth spurt—the time when pubertal changes take place more rapidly—are variable because it is influenced partly by heredity and partly by environmental factors. There are four major changes in puberty, changes in body size, changes in body proportion, development of primary and secondary sex characteristics. The most rapid growth in body size comes during the year or two before the sex organs begin to function and then tapers of. Changes in body proportion are influenced by the age of sexuall maturing. The primary sex characteristics—sex organs grow and develop rapidly during puberty and become functionally mature in approximately in the middle of puberty. The secondary characteristics—the physical features that distinguish from males and females—develop according to predictable patterns and by the end of puberty all are at their mature or near mature levels.Puberty changes the physical well being of the 557
individuals as well as attitudes and behavior. Because these effects tend to be unfavorable especially during the early parts of puberty. The two major concerns of puberty are normalcy and sex-appropriateness. Physical hazards and psychological hazards: Physical hazards of puberty are minor compared with the psychological hazards. The most common is the tendency to develop unfavorable self concepts; to become under achievers unwilling ness to accept changed bodies or socially approved sex roles and deviant sexual maturing. Because the three A‘s of happiness acceptance, affection, and achievement are often violated during the years puberty tends to be one of the most unhappy periods of the life span, and tends to be habitual. 6.) Adolescence: Adolescence, which is the period extending from sexual maturity to the age of legal maturity (18 years), is divided into early and late adolescence. It is an important period of time. A time of change, a problem age, the time to search identity, a dreaded age, a time of unrealism and the threshold of adulthood, these are the terms used to descibe this period of life. Because mastery of the developmental tasks of adolescence requires major changes in children‘s habitual attitudes and patterns of behavior, many adolescents reach legal maturity before attaining the tasks and hence carry many unfinished tasks to adult hood. Even though physical growth is far from complete, when puberty ends it slackens during adolescence and much of the changes occur then is internal rather than external. When physical growth will be complete is influenced by sex and age of maturing and thus causing many concerns for the boys and girls. While traditionally adolescence is a period of heightened emotionality, a time of storm and stress there is a little evidence that this is universal or persistent as popularly believed. The important social changes in adolescence include increase peer group influence more mature patterns of social behavior, new social groupings and new values in the selection of friends and leaders and social acceptance. The most important and universal interests fall into seven major categories; recreational interests, personal and social interests, educational interests, vocational interests, religious and interest in status symbols. The major changes in morality consists of replacing specific moral concepts with generalized moral concepts of right and wrong; the building of moral code based on individual moral principles; and control of behavior through the development of conscience. Sex interests and behavior, which center around heterosexuality, have 2 separate distinct elements, the development of pattern of behavior involving the members of the two sexes. The development of attitudes relating to relationship between members of the two sexes. There are a number of effects in the sex-role typing on adolescents, the most important of which are masculine supremacy, sex bias, underachievement in activities regarded as sex inappropriate, and fear of success in the part of adolescent girls because of possibility of facing the stigma of sex-inappropriateness. Relationships between adolescents and members of their families tend to deteriorate in the early adolescence though these relationships often improves as adolescence draw to a 558
close especially among adolescent girls and their family members. Most adolescents are anxious in to improve their personality in the hope of advancing their status in the social group, many of the conditions influencing their self concepts are beyond their control. Physical hazards and psychological hazards: The most common being suicide, there are others as well. Awkwardness, a sexinappropriate body build and homeliness are too common to be overlooked. The major psychological hazards transcend upon failure to make transition to maturity— which is the most important developmental task of adolescence. This is usually due to obstacles they have little or no control. The areas in which immaturity due to failure to make the transition to more mature behavior are especially common are social sexual and moral behavior and immaturity in family behavior. When immaturity is pronounced, it leads to self-rejection with its damaging effects on personal and social adjustments. Most adults remember adolescence as an unhappy age. Studies of adolescence have revealed that this is truer than of late adolescence 7.) Adult Hood: Personality development: Adulthood—the largest period of the life span—is usually subdivided into three periods; early adulthood, which extends from eighteen to approximately 40 years; middle adulthood or middle age which extends from approximately 40-60 years and late adulthood or old age which extends till death.. Early adult hood is the settling down or reproductive age, a problem age and one of emotional tension; a time of social isolation; a time of commitments; and often a time of dependency, of value changes, or creativity and of adjustments to new life pattern. There are certain aids to mastering the developmental tasks of early adulthood—physical efficiency, motor and mental abilities, motivation, and a good role model. Because many of the interests carried over from the adolescence are no longer appropriate for the adult role, changes in all areas of interests are inevitable. The greatest change is narrowing down the range of interests. Personal interests in early adulthood include interest in appearance, in clothes and personal adornment; in symbols of maturity and status symbols; in money and in religion. Even though the recreational activity of adults serve much the same purposes as play activities do in child hood, the recreational interests of adults may differ in many respects from the play interests of childhood due to changes in roles and life patterns. The major recreational interests of young adults include talking, entertaining, hobbies, and amusements which most of it is enjoyed at home. Social activities in early adulthood are often greatly curtailed because of vocational and familial pressures. As a result, many young adults experience as Erickson says an isolation crisis, a time of loneliness due to isolation from the social group. During early adulthood social participation is often limited and changes in friendship, social groupings, and in values placed on popularity and leadership status are inevitable. Social mobility in men comes mainly through their own efforts while in women it comes mainly through marriage to upper status men, or those who, through their achievements, have been able to climb the social ladder. Most young married women find sex-role adjustment very difficult, especially when they are forced into the traditional roles after playing more egalitarian roles before marriage. 559
Difficulties in mastering the developmental tasks are often increased by such stumbling blocks as in adequate foundations, physical handicaps, and discontinuities in training parental over protectiveness, prolongation of peer group influence and unrealistic aspirations. Vocational and family adjustments in early adulthood are difficult because of limited foundations on which to build their adjustments due to the newness of the roles these adjustments require. The major problems in vocational adjustments consist of selection of vocation, achieving stability in the selection made and adjustments in the work situations. The ever increasing number of family-life patterns makes marital adjustments difficult, especially when the family pattern that fits the individual‘s needs differs from that approved by the social group. Most common conditions contributing to the maladjustment in marriage are limited preparation for marriage, early marriages, unrealistic and Romanticized concepts, mixed marriages, lack of identity in marriage and marked role difference after marriage. Parenthood is regarded as a crisis as it changes the attitudes values and goals. This is especially for women who will have to give up careers for which they were trained and they where successful. Personality develops or drifts with the changes in the home situation. Vocational hazards like job dissatisfaction and unemployment contribute to an unfavorable personality. Most common Physical hazards and psychological hazards: The most common and most important physical hazards is physical unattractiveness because it is differential to the individuals personal and social adjustments. The two important religious hazards in early adulthood is the adjustments to a new religious faith in place of childhood family faith and in-law-pressure to adopt another faith in mixed marriages. These are hazards to good personal and social adjustments. Vocational hazards like job dissatisfaction and unemployment contribute to an unfavorable personality. Most common marital hazards that lead to the personality problems are competitiveness in marital relationships, sexual adjustments acceptance of family economic status and role changes, relationships with in-laws and adjustment to parenthood. Finding a congenital family group to adopt with especially in social mobility, and acceptance of traditional sex-roles are the major psychological hazards most young people must cope with their personal and social life. Success in adjustment to adult hood can be assessed by 3 criteria; achievement in life pattern chosen by the individual degree of satisfaction, and success of personal adjustment. 8.) Development of Personality in Middle Adulthood: Personality development: Adjustment in the middle adulthood can be difficult due to the foundations laid earlier. There are four important characteristics of middle age 1. It‘s a dreaded age. 2. A time of transition and of stress. 3. A time of achievement and of evaluation. 4. A time of emptiness and that of boredom. 560
The success of adjusting to physical changes in middle age is aided by camouflaging the signs of ageing. Changes in interests are depending upon role changes. Middle age people as a group have a greater interest in clothing and appearance because of the influence of vocational success. Interest in religion in middle age is usually greater than in early adulthood and is often based on personal and social needs. Interests in strenuous activity wanes, there is a shift from recreational activities involving large group to those involving only a small number of people. Recreational activity are adult rather than family oriented as they where in early adulthood, over all there is a narrowing down of recreational interests. Social interests in the middle age are greatly influenced by social class status, sex and marital status. Vocational adjustments of middle age men and women are complicated by factors such as social attitudes, increased use of automation, group work, increasing important of the role of wives, compulsory retirement dominance of big business and necessity for relocation. Adjustment for single parent is more difficult in women than in men. Adjustment due to the loss of spouse due to death is different from due to other factors such as divorce or extra relationships. Chances of remarriage are slimmer in women as time progresses while men have no problem with that. While adjustment approaching retirement and approaching old age, should be important developmental tasks Psychical hazards and Psychological hazards: The most important hazards are acceptance of traditional belief about middle age, idealization of youth, unrealistic aspirations, and changes in roles, in interests and in value placed on status symbols. An unattractive appearance, lack of social skills, preference for family contacts, financial problem, family pressures and obligation social mobility and a desire for popularity are other hazards. Vocational hazards can be failure to reach earlier goals or decline in creativity, boredom, the growing tendency towards bigness in business and industry. Marital hazards are opposition to child‘s marriage, sexual adjustments, care of an elderly parent, loss of a spouse and remarriage. 9.) Personality Development in Old Age: Wisdom: Those who do achieve a sense of wholeness and integrity may develop one of the hallmarks of successful ageing: wisdom. Many cultures traditionally rely on selected elderly people for advice about complex life problems. One reason may be that older people who have been attentive to their experience often have a perspective on reality that is richer and more informed than the view that most young people take. Some have also suggested that a wise person is one who has a ―balanced investment in self as well as in others‖ and who combines ―experience, reflectiveness, and emotional balance‖. Retirement: Retirement is a traditional marker of old age. For some people retirement signifies lossloss of a familiar day routine, loss of valued social interactions, loss of well established roles and even loss of income. For many others though, retirement is a welcomed transition, one that offers new opportunities and new freedom. Retirement can alter ones collection of daily acquaintances and it can greatly increase the time husband and wife spends together. Both changes can bring on adjustments and new personal growth. 561
The individual response to freedom depends on many factors, but two of the most important seem to be job satisfaction and income. People who find their jobs unrewarding often welcomes retirement. So are those people whose post retirement income meets their pre-retirement living standards. We need to distinguish between scheduled, long anticipated retirement and unscheduled retirement caused by sudden illness or a demand from supervisors that one quit the job. Such unscheduled retirements tend to produce anxiety and depression. Scheduled retirements do not. Grand parenthood ―second round parents: For many, one of the special delights of old age is having grand children. The roles played by the grand parent differ from family to family. A typical urban style of grand parenting is ‗the formal style‘, in which the grand parent take an ongoing interest in their grand child and occasionally give the child special treats, but carefully limit their role so as not to interfere with their parents. The second common role is an informal, playful approach in which grand children are seen as a source of leisure activity and mutual fun. The third most common role is the distant figure role, in which grand parents are benevolent but have only brief, infrequent contact with their grand children. Younger grand mothers, who have a job and a living spouse, emphasize the social orientation and not deeply involved in the grand mother role. Older grand mothers, most of whom are widowed and who do not have jobs, emphasize the personal orientation and are more involved with their grand children. Widows and widowers coping with loss: One of the most painful inevitabilities of intimate relationships in old age is that one partner will lose the other and face the pain of bereavement. As difficult as it is to develop and sustain a warm, intimate relationship with single partner, it can be even more difficult to face life without the partner. Women have a longer life span than men, making them more susceptible to this phenomenon. But women in general cope better than men. Middle class women with strong investment in their roles as wives report strong disruption after the death of the husband. How ever, women who, in addition to their marriages, have had active lives in the community or workplace report loneliness but relatively less disruption in their life styles. There is also evidence that older widows, particularly those who had advance warning of their husbands impending death adjust better than do younger widows and those for whom the death was unexpected. Some widows and widowers eventually cope with their loss by remarrying, the most common reason being companionship. In most cases, the companion ship seemed to work well. Facing mortality and death: Acceptance of death is a major developmental task in old age. For some elderly people, the awareness grows gradually and eventually fits as warmly and comfortably as a familiar sweater. For others though the knowledge dawns starkly, some times with the diagnosis of a terminal illness. Psychiatrist Elisabeth Kübler-Ross proposed that the psychology of the dying process involves five stages:562
1. Denial stage: informed of a terminal illness, the individual reacts with shock and disbelief. 2. Rage and anger: particularly of the idea that others will live while he or she is not. 3. Bargaining: the person accepts the inevitability of death but pleads for a bit more life, some times trying to negotiate with god for a few extra months. 4. Depression: a kind of anticipatory self mourning. 5. Acceptance: anger and depression subside, and the person becomes quietly expectantnot happy about death, yet ready for it nonetheless. Acceptance of death is likely to come easier if he or she can reflect positively on a life well lived. Hazards to personal and social adjustments in old age: Physical hazards and their prevention: Diseases and physical handicaps: Elderly people are most commonly affected by circulatory disturbances, metabolic disorders, involutional mental disorders, disorders of the joints, tumors (both benign and malignant), heart disease, rheumatism, arthritis visual and hearing impairments, hypertension, gait disorders and mental and nervous conditions. These cannot be prevented but we can be ready for it. As nurses we must educate the people through the Medias of communication about the difficulties of old age that occur due to the habits during the adulthood. We encourage exercise, prevent exposure to opportunistic infections and periodical complete health check can improve quality of life. Malnutrition: Malnutrition in old age is due to psychological causes than economic. The most common psychological causes are lack of appetite resulting from anxiety and depression, not wanting to eat alone, and food aversion stemming from earlier prejudices. Even when their food intake is not deficient qualitatively or quantitatively, many older people do not get their full value from their food because of malabsorption resulting from digestive or intestinal disturbances or failure of the endocrine system to function as it formerly did. To conquer this problem the nurse must encourage nutritious food served well at the right time with a good company can improve intake of food. Vitamin and mineral supplementation can also meet the clients‘ needs. Dental disorders: Sooner or later, most elderly people lose some or all of the teeth. Those who must wear dentures often have difficulty in chewing food that are rich in protein, such as meat, and may concentrate on those high in carbohydrates. Chewing difficulties also encourage the swallowing of larger and coarser food masses, which may lead to digestive disorders. Ill fitting dentures or the absence of teeth often causes lisping and slurring, which interferes with the other person‘s speech and causes embarrassment. Better dental check up and replacement of ill fitting dentures by good ones will help the clients. Soft and semi fluid diet can be encouraged so that nutrition and the gastrointestinal tract do not have strain. Sexual deprivation: Sexual deprivation or unfavorable attitudes towards sex in old age affect the old person in much the same way that emotional deprivation affects the young child. Happily married elderly couples live healthier and longer than those who never married, who have lost a 563
spouse, or who became sexually inactive. The need for companionship at any time of life is not expendable. That doesn‘t mean to send them on dates. But if they do find some one to replace their loneliness it may not be discouraged. Accidents: Older people are more accident prone than younger ones. Even when the accidents are not fatal, they frequently leave the individual disabled for life. Falls which may be due to environmental obstacles or to dizziness, giddiness, weakness or defective vision are most common accidents among older women, while older men are most common in motor vehicle accidents, either as drivers or as pedestrians. Accidents caused by fie are also common in old age. The nurse can instruct the vulnerable clients to never leave with out company. Psychological hazards and their prevention: Acceptance of traditional stereotypes: The first psychological hazard is acceptance of the traditional beliefs and cultural stereotypes of the aged. This is hazardous because this encourages the elderly to feel inadequate and inferior. Even worse they begin to stiffen their motivation to do what they are capable of doing. While both the men and women are influenced by the cultural belief, women tend to be more affected than men. The nurse can focus on the fact of uniqueness of the individual. He or she need not do the same things as other people do. Nurses and care givers can encourage activity of their kind, interest, involve them in planning, and assist them when needed. Effects of physical changes in aging: The second hazards are the feelings of inferiority and inadequacy that come with physical changes. The loss of an attractive, sex-appropriate appearance may lead both men and women to feel rejection by the social group. Loss of hearing interferes with communication with other people adding to difficulty in speaking because of missing teeth or poorly fitted dentures. By the use of modern technology, hearing aids are available for better acoustics. Visual capabilities can also be improved by the use of corrective lenses and proper nutrition. There by improving their confidence and averting inadequacy. Changes in life pattern: The necessity for establishing a different, more appropriate pattern of life is the third psychological hazard many elders face. They may for example, no longer need a large house, but many older people cling to their home and possessions and to the life style associated with them. Part of the depression at the loss of the possession is due to our feeling that we must go without certain goods that we expected the possessions to bring in their train. Yet in every case there remains, over and above this a sense of shrinkage of our personality, a partial conversion of us to nothingness, which is a psychological phenomenon by itself. Encouraging hobbies are essential to stay on their path as to not forget their life pattern. Suggesting cost effective and less straining activities to replace their abnormal life style can be encouraged. Channels for the old can be encouraged with songs, movies and T.V shows of the past can be telecasted for them so that they don‘t get bored with the new style of music and other activities associated with it. 564
Tendency to “slip” mentally: The fourth psychological hazard is the suspicion or realization that ,mental decline has set in. many elderly people realize that they are becoming some what forgetful, that they have difficulty learning new facts and names and that they cannot hold up under pressure as well as they used to. The practice of maintain diary can be useful as they can be used to remind of appointments and birthdays etc. and to record instances of the day, thoughts and comments from within, help the elderly to nevr slip from what they think they ought to know or do. Feelings of guilt about idleness: The fifth psychological hazard is guilt about not working while other people still are. Because most elderly need to feel useful if they are to be happy and well adjusted, attempts are made to get them interested in volunteer work. It is claimed that it is suitable for retired people as it presents a challenge for the individual, thus generating self respect, while at the same time winning social approval and esteem. Reduced income: After retirement, many elderly people are unable to afford the leisure time activities thay consider worthwhile. It is usually serious during widowhood if the husbands‘ former pensions end with their deaths.The society has to be educated about this. And strategies after retirement can be formulated and the retirement income can be planned well ahead. There are many companies who give insurance and pension plans, so they can approach them for help. Nurses Responsibilities for Promoting A Proper Personality: The nurses follow the three level of prevention:1) Primary Prevention: The primary prevention starts with identifying the population in high risk for personality disturbances and problems. This is followed by help plan for the child and proper preparation of the parent along with genetic counseling. Once planned the focus is on the prevention of hazards during the antenatal period. This is ensured by prompt antenatal care including diet, isolation from exposure to infection and radiation, drugs habits like smoking, alcoholism—that are avoided, proper treatment for the diseases like diabetes, hypertension, jaundice, avoiding travel, family support, a place for proper delivery and an uncomplicated labor, or at least well managed labor. Postnatal care is also important for the child like avoiding infection and mother child bonding. And guidance through out the growth of the child with identification and treatment of aliments and prophylaxis when ever and where ever needed. Prevention in childhood is through help develop a healthy family and environment, health teaching the child and family, 2.) Secondary Prevention: Secondary prevention is facilitated by early identification and treatment of physical as well as psychological problems associated to health as a whole: holistic approach. Nurse acts as a resource person as to identify the problem, its treatment, where is it available what will be the expenditure and prognosis. The nurse will be more institutionalized in this level and will constrain the service to the walls of an agency of health care. 3.) Tertiary Prevention: Here the nurse tries to identify the cause of the present illness. Early identification of the symptoms of relapse of the disease is done. Observation and its side effects of drugs the 565
person is taking is also continuously monitored. Rehabilitation is focused—physical, vocational/occupational—through family and individual therapies. The nurse who is the tertiary level may be working in an out-patient or in patient department, a school health nurse or a vocational nurse hospice or geriatric CONCLUSION: Personality is never stable and is unique. It includes the physical, psychological social and spiritual aspects of man. Basically a good personality can be identified by the level of adjustment to the situations. And hence they form the personality.
566
BIBLIOGRAPHY: Elizebeth B Hurlock; developmentasl psychology a life span approach; 5th edition; tata McGraw Hill; chapters 3-14, pages 52-449 Cliford T morgan, Richard A King, John R Weisz, Joh schopler; introduction to psychology; 7th edition; tata McGraw Hill, chapter 11, 12; pages 409-505 Ann j Zwenner; basic psychology for nurses in india; chapter 13,14, pages 144-166 L Dodge Fernald, peter S Fernald; MUNNS introduction to psychology; 5th edition; AITBS publications; part 2 chapter 3 59-84 Barry D Smith; Psychology science and understanding; international edition; tata McGraw Hill; chapter 10,11 pages 343-413 Bhatia and Craig; elements of psychology and mental hygiene for n nurses in India; orient Logman; chapter 15; pages 229-247 B S Suresh; psychology for nurses; gajanana publishers; 2nd edition; chapter 5; pages 43-54 SK mangal; general psychology; sterling publishers pvt. ltd; chapter 16; pages 253275 Jacob anthikad; psychology for graduate nurses; 3rd edition; jaypee publishers;chapter 4,5; pages 25-50 April o‘Connel, Jacquline Whitmore, Vincento‘connel; choice and change; prentice hall publications; 3rd edition; chapter 2; pages 29-64 http://findarticles.com/p/articles/mi_g2602/is_0004/ai_2602000429/pg_2?tag=artBod y;col1 http://psychology.about.com/od/psychosocialtheories/Psychosocial_Theories_of_Pers onality.htm http://psychology.about.com/od/personalitydevelopment/a/personality-dev.htm
567
PERSONALITY DEVELOPMENT, ADOLESCENCE,ADULTHOODOLD AGE Introduction: Development: The development means a progressive series of changes that occur as a result of maturation and experiments. As Van Den Daele as pointed out, ―development implies qualitative change‖. This means that development does not consist merely of adding inches to one‘s height or of improving one‘s ability. Instead, it is a complex process of integrating many structures and functions. Personality: According to ―Allport‖ ―Personality is a dynamic organization within the individual of those psycho-Physical systems that determine his unique adjustment to his environment.‖ It is only with the growth and development, at each stage of his life helps for bringing desirable harmonious development in their personalities. DEVELOPMENTAL THEORIES: Human development and behavior have been studied since the beginning of the 20th century, and theories that explain human responses expected at certain ages during life have been developed. Although a psychological approach is common to all /developmental theories, each theory has a different focus. The theories discussed cognitive, social, and instinctual influences on human growth and development. 1.) Theory o f Psychoanalytic Development: Sigmund Freud: Freud's (1923/1974) theory emphasizes the effect of instinctual human drives on behavior. Freud identified the underlying stimulus for human behavior as sexuality, which he called libido. Libido is defined as general pleasure-seeking instincts rather than purely genital gratification. Four major components of Freud's theory are: The unconscious mind. The id. The ego. The superego. The unconscious mind: contains memories, motives, fantasies, and fears that are not accessible to recall but that directly affect behavior. The id is the part of the mind concerned with self-gratification by the easiest and quickest available means. Defense mechanisms are a means of unconscious coping to reduce stress in the conscious mind when the id's impulses cannot be satisfied. The ego: is the conscious part of the mind that serves as a mediator between the desires of the id and the constraints of reality so that one might live effectively within one's social, physical, and psychological environment. The ego includes one's intelligence, memory, problem solving, separation of reality from fantasy, and incorporation of experiences and learning into future behavior. Development of the ego allows the infant, by 6 months of age, to view self as separate from others and to begin to alter behaviors in response to cues. Ego development continues throughout life. 568
The superego: is the part of the mind that represents one's conscience and develops from the ego during the first year of life, as the child learns praise versus punishment for actions. The superego represents the internalization of rules and values so that socially acceptable behavior is practiced. In addition, Freud described a series of developmental stages through which all people must pass. The stages of development are based on sexual motivation. 1. Oral Stage (Ages 0 to 18 Months): During the oral stage, the infant uses his or her mouth as the major source of gratification and exploration. Pleasure is experienced from eating, biting, chewing and sucking. The infant's primary need is for security. A major conflict occurs with weaning. 2. Anal Stage (Ages 8 Months to 4 Years): This stage begins with the development of neuromuscular control to allow control of the anal sphincter. Toilet training is a crucial issue, requiring delayed gratification as the child compromises between enjoyment of bowel function and limits set by social expectations. 3. Phallic Stage (Ages 3 to 7 Years): The child has increased interest in gender differences, his or her own gender and conflict and resolution of that conflict with the parent of the same sex (named the Oedipus complex in boys and the Electra complex in girls, based on feelings of intimate sexual possessiveness for the opposite-sex parent).Curiosity about the genitals and masturbation increase during this stage. 4. Latency Stage (Ages 7 to 12 Years): This stage marks the transition to the genital stage during adolescence. Increasing sexrole identification with the parent of the same sex prepares the child for adult roles and relationships. 5. Genital Stage (Ages 12 to 20 Years): At this stage, sexual interest can be expressed in overt sexual relationships. Sexual pressures and conflicts typically cause turmoil as the adolescent makes adjustments in relationships. II.) Theories of Psychosocial Development: Erik Erikson: Erikson's (1963) developmental theory was based on Freud's work but was expanded to include cultural and social influences in addition to biologic processes. His psychosocial theory is based on four major organizing concepts:1. Stages of development. 2. Developmental goals or tasks. 3. Psychosocial crises. 4. The process of coping. Erikson believed that development is a continuous process made up of distinct stages, characterized by the achievement of developmental goals that are affected by the social environment and significant others. He identified eight stages that progress from birth to old age and death. Each stage is characterized by a developmental crisis to be mastered, with possible successful or unsuccessful resolution of the crisis. Unsuccessful resolution at any one stage might delay progress through the next stage, but mastery can occur later. A discussion of the developmental stages follows. 569
1. Trust versus Mistrust (Infancy): The infant learns to rely on caregivers to meet basic needs of warmth, food, and comfort, forming trust in others. Mistrust is the result of inconsistent, inadequate, or unsafe care. 2. Autonomy versus Shame and Doubt (Toddler): As motor and language skills develop, the toddler (ages 1 to 3 years) learns from the environment and gains independence through encouragement from caregivers to feed, dress, and toilet self. If the caregivers are overprotective or have expectations that are too high, shame and doubt, as well as feelings of inadequacy, might develop in the child. 3. Initiative versus Guilt (Preschool): Confidence gained as a toddler allows the preschooler (ages 4 to 6 years) to take the initiative in learning, so that the child actively seeks out new experiences and explores the how and why of activities. If the child experiences restrictions or reprimands for seeking new experiences and learning, guilt results, and the child, hesitates to attempt more challenging skills in motor or language development. 4. Industry versus Inferiority (School-Aged Children): Focusing on the end result of achievements, the school-aged child gains pleasure from finishing projects and receiving recognition for accomplishments. If the child is not accepted by peers or cannot meet parental expectations, a feeling of inferiority and lack of self-worth might develop. Think back to Juan, the 8-year-old boy described in the case file at the beginning of the chapter. The nurse could help to foster Juan's industry by offering positive reinforcement for his ability‘s to calm down when spoken to in Spanish. The nurse also could incorporate activities into Juan's plan of care that would provide him with opportunities to succeed. 5. Identity versus Role Confusion (Adolescence): With many physical changes occurring, the adolescent is in transition from childhood to adulthood. Hormonal changes produce secondary sex characteristics and mood swings. Trying on roles and even rebellion are considered normal behaviors as the adolescent acquires a sense of self and deciding what direction will be taken in life. Role confusion occurs when the adolescent is unable to establish identity and a sense of direction. 6. Intimacy versus Isolation (Young Adulthood): The tasks for the young adult are to unite self-identity with identities of friends and to make commitments to others. Fear of such commitments results in isolation and loneliness 7. Generativity versus Stagnation (Middle Adulthood): The middle adult years are a time of concern for the next generation as well as involvement with family, friends, and community. There is a desire to make a contribution to the world. If this task is not met, stagnation results, and the person becomes self-absorbed and obsessed with her or his own needs or regresses to an earlier level of coping. 8. Ego Integrity versus Despair (Later Adulthood): As one enters the older years, reminiscence about life events provides a sense of fulfillment and purpose. If one believes that one's life has been a series of failures or missed directions, a sense of despair might prevail. 570
III.) Theory of Cognitive Development: A.]Jean Piaget: Piaget (1969) developed a theory of cognitive development from infancy through adolescence. Piaget believed that learning occurs as a result of the internal organization of an event, forming a mental schema (plan) and serving as a base for further schemata as one grows and develops. Intellectual growth is a continual restructuring of knowledge to progress to higher levels of problem solving and critical thinking. Two continual processes of assimilation and accommodation stimulate intellectual growth in the child. Assimilation is the process of integrating new experiences into existing schemata; accommodation is an alteration of existing thought processes to manage more complex information. Piaget described four stages of cognitive development, which are discussed here. 1.) Sensorimotor Stage (Birth to 24 Months): This stage is marked by progression through a series of developmental stages; for example: 0 to 1 month: Demonstrates basic reflexes, such as sucking. 1 to 4 months: Discovers enjoyment of random behaviors (such as smiling or sucking thumb) and repeats them. 4 to 8 months: Relates own behavior to a change in environment, such as shaking a rattle to hear the sound or manipulating a spoon to eat. 8 to 12 months: Coordinates more than one thought pattern at a time to reach a goal, such as repeatedly throwing an object on the floor; only objects in sight are considered permanent. 12 to 18 months: Recognizes the permanence of objects, even if out of sight; can understand simple commands. 18 to 24 months: Begins to develop reasoning and can anticipate events. 2.) Preoperational Stage (Ages 2 to 7 Years): This stage is characterized by the beginning use of symbols, through increased language skills and pictures, to represent the preschooler's world. This stage is divided into two parts: the preconception stage (ages 2 to 4 years) and the intuitive stage (ages 4 to 7 years). Play activities during this time help the child to understand life events and relationships. 3.) Concrete Operational Stage (Ages 7 to 11 Years): During this stage, children learn by manipulating concrete or tangible objects and can classify articles according to two or more characteristics. Logical thinking is developing, with an understanding of reversibility, relations between numbers, and loss of egocentricity, in addition to the ability to incorporate another's perspective. 4.) Formal Operational Stage (Age 11 Years or Older): This stage is characterized by the use of abstract thinking and deductive reasoning. General concepts are related to specific situations and alternatives are considered. The world is evaluated by testing beliefs in an attempt to establish values and meaning in life. B.]Robert J. Havighurst: Havighurst (1972) believed that living and growing are based on learning, and that a person must continuously learn to adjust to changing societal conditions. He described learned behaviors as developmental tasks that occur at certain periods in life. Successful 571
achievement leads to happiness and success in later tasks, whereas unsuccessful achievement leads to un-happiness, societal disapproval, and difficulty in later tasks. The developmental tasks arise from maturation, personal motives, and values that determine occupational and family choices, and civic responsibility. The developmental tasks, by age, follow. 1.) Infancy and Early Childhood: Developmental tasks for infancy and early childhood include: Achieving physiologic stability. Learning to eat solid foods. Learning to walk and talk. Forming simple concepts of social and physical reality. Learning to relate emotionally to parents, siblings, and other people. Learning to control the elimination of body wastes. Learning to distinguish between right and wrong. Learning sex differences and sexual modesty. 2.) Middle Childhood: Developmental tasks for middle childhood include: Learning physical skills necessary for games. Learning to get along with age-mates. Developing fundamental skills in reading, writing, and mathematics. Developing a conscience, morality, and a scale of values. Achieving personal independence. 3.) Adolescence: Developmental tasks for adolescence include: Accepting one's body and using it effectively. Achieving a masculine or feminine gender role. Achieving emotional independence from parents and other adults. Preparing for a career. Preparing for marriage and family life. Desiring and achieving socially responsible behavior. Acquiring an ethical system as a guide to behavior. 4.) Young Adulthood: Developmental tasks for young adulthood include: Selecting a mate. Learning to live with a marriage partner. Starting a family and rearing children. Managing a home. Getting started in an occupation. Taking on civic responsibility. Finding a congenial social group. 5.) Middle Adulthood: Developmental tasks for middle adulthood include: Accepting and adjusting to physical changes. Attaining and maintaining a satisfactory occupational performance. 572
Assisting children to become responsible adults. Relating to one's spouse as a person. Adjusting to aging parents. Achieving adult social and civic responsibility. 6.) Later Maturity: Development tasks for later maturity include: Adjusting to decreasing physical strength and health. Adjusting to retirement and reduced income. Adjusting to death of a spouse. Establishing an explicit affiliation with one‘s age group. Adjusting and adapting social roles in a flexible way. Establishing satisfactory physical living arrangements. 7.) Entering the Adult World: The years of the middle to late 20s (age 22-28) are a time to build on previous decisions and choices, and to try different careers and lifestyles. By the late 20s, the young adult enters the age-30 transition period. The individual often feels uneasy that something is missing. During this transition, decisions are made either to find a new direction in life or to make a stronger commitment to previous choices. 8.) Settling Down: In the settling-down phase (age 30-40), the adult invests energy into the areas of life that are most personally important. The areas of investment are primarily family, work, and community. The individual strives to gain respect, status, and a sense of authority. 9.) Midlife Transition: Midlife transition (age 40-45) involves a reappraisal of one's goals and values. The established lifestyle may continue, or the individual may choose to reorganize and change careers. This is an unsettled time, with the individual often anxious and fearful. 10.) The Pay off Years: The years from 45 to 65 are a time of maximum self-direction and self-approval. Physical and mental changes increase an awareness of one's aging and mortality. IV.) Theories of Moral Development: A.]Lawrence Kohlberg: Kohlberg (1969) developed a theory of moral development in levels that closely follow Piaget's theory of cognitive development. Kohlberg recognized that a person's moral development is influenced by cultural effects on one's perceptions of justice in interpersonal relationships. A child's beginnings of moral development result from caregiver and child communications during the early childhood years, as the young child tries to please his or her parents The concept of morality emerges as a subset of a person's beliefs or values and governs choices made throughout life. Rules and regulations established by society are eventually challenged and evaluated as a person either accepts societal rules into his or her own internal set of values or rejects them. The levels of moral development include preconvention, conventional, and post conventional. Each level is further divided into separate stages. 1.) Preconvention Level: The preconvention level is based on external control as the child learns to conform to rules imposed by authority figures. At stage 1, punishment and obedience orientation, the 573
motivation for choices of action is fear of physical consequences of authority‘s disapproval. As a result of the consequences, a perception of goodness or badness develops. At stage 2, instrumental relativist orientation, the thought of receiving a reward overcomes fear of punishment, so actions that satisfy this desire are selected. 2.) Conventional Level: The conventional level involves identifying with significant others and conforming to their expectations. The person respects the values and ideals of family and friends, regardless of consequences. In stage 3, "good boy-good girl" orientation, the person strives for approval in an attempt to be viewed as "good." At stage 4, "law and order" orientation, behavior follows social or religious rules from a respect for authority. In his later work, Kohlberg maintained that many adults are at this stage because they think abstractly and view themselves as members of society. 4.) Post conventional Level: The post conventional level involves moral judgment that is rational and internalized into one's standards or values. At stage 5, social contract and utilitarian orientation, correct behavior is defined in terms of society's laws. Laws can be changed, however, to meet society's needs, while maintaining respect for self and others. Stage 6, universal ethical principle orientation, represents the person's concern for equality for all human beings, guided by personal values and standards, regardless of those set by society or laws. Justice might be internalized at an even higher level than society. Few adults ever reach this stage of development. B.]Carol Gilligan: Gilligan (1977/1982) originally worked with Kohlberg. As she listened to women discuss their own real-life moral conflicts, she recognized that there was a conception of morality from the female viewpoint that was not represented in Kohlberg's work. Gilligan's theory views females as developing a morality of response and care, and males as developing a morality of justice. In Gilligan's theory, males and females have different ways of looking at the world. Males are more likely to associate morality with obligations, rights, and justice. Females are more likely to see moral requirements emerging from the needs of others within the context of a relationship.' 1.) Level 1-Selfishness: In level 1, the focus is on one's own needs. "Should" and "would" are the same. Morality is seen in terms of sanctions by society. Relationships are often disappointing, and as a result, a woman might isolate herself to avoid getting hurt. 2.) Level 2-Goodness: In level 2, moral judgment is based on shared norms and expectations, and societal values are adopted. Acceptance by others becomes critical, and the ability to protect and care for others is seen as the defining characteristic of female goodness. This characteristic is upheld through beliefs that one is responsible for the actions of others but that others are responsible for the choices they make. 3.) Level 3-Nonviolence: In level 3, a changed understanding of self and a redefinition of morality allow reconciliation of selfishness and responsibility. Nonviolence (the injunction against 574
hurting) governs all moral judgments and actions. Care becomes a universal obligation toward self and others. V.) Theory of Faith Development: J runes Fowler: Fowler (1981) postulated a developmental theory of the spiritual identity of humans, based on work by Piaget, Kohlberg, and Erikson. Fowler describes faith as follows: ―Faith is not always religious in its content or context.... Faith is a person's or group's way of moving into the force field of life. It is our way of finding coherence in and giving meaning to the multiple forces and relations that make up our lives. Faith is a person's way of seeing him or herself in relation to others against a background of shared meaning and purpose. Faith, therefore, is not necessarily religious, but it comprises the reasons one finds life worth living‖. Fowler's theory is composed of a pre stage and six stages of faith development. The age when a certain stage occurs varies, but the sequence does not. Equilibrium, or a plateau in faith development, can occur at any stage from stage 2 and beyond. 1.) Stage 1-Intuitive: Projective Faith Intuitive-projective faith is most typical of the 3- to 7-year-old child. Children imitate religious gestures and behaviors of others, primarily their parents. They take on their parents' attitudes toward religious or moral beliefs without a thorough understanding of them. Imagination in this stage leads to long-lived images and feelings that they must question and reintegrate in later stages. 2.) Stage 2-Mythical: Literal Faith: Mythical-literal faith predominates in the school-aged child, who is having more social interaction. Stories represent religious and moral beliefs, and the child accepts the existence of a deity. The child can appreciate the perspectives of others as well as the concept of reciprocal fairness. 3.) Stage 3-Synthetic: Conventional Faith: Synthetic-conventional faith is the characteristic stage for many adolescents. As the person experiences increasing demands from work, school, family, and peers, the basis for identity becomes more complex. The person has an emerging ideology but has not closely examined it until now. The person begins to question life-guiding values or religious practices in an attempt to stabilize his or her own identity. 4.) Stage 4 – Individuative: Reflective F a i t h : Individuative-reflective faith is crucial for older adolescents and young adults because they become responsible for their own commitments, beliefs, and attitudes. Many adults do not /develop to this stage, and for some people, it does not emerge until they are in their 30s or 40s. Searching for self-identity no longer defined by the faith compositions of significant others is a primary concern.
575
5.) Stage 5 – Conjunctive: Faith: Conjunctive faith integrates other viewpoints about faith into one's understanding of truth. One is able to see the nature of the reality of one's own beliefs. Along with this realization, one observes the divisions of faith development among people. 6.) Stage 6-Universalizing: Faith: Universalizing faith involves making tangible the values of absolute love and justice for humankind. The faith relationship is characterized by total trust in the principle of actively ―being-in-relation‖ to others in whom we invest commitment, belief, love, risk, and hope, and in the existence of the future, regardless of what religion or image of faith. THE ADOLESCENT AND YOUNG ADULT: Introduction: The adolescent and young adult years are a time of both change and stability. Adolescence begins with puberty and extends from 12 to 20 years of age; the young adult period is considered to be the 20s and 30s. However, these time periods are highly individualized. A person is defined as an adult when he or she is "physically and psychologically mature, ready to assume adult responsibilities and be self-sufficient" (Murray & Zentner, 2001, p. 525). After experiencing rapid growth and development during adolescence, the young adult completes physical growth and develops internal and external controls and values acceptable to society. There are no specific measurements of maturity; each person is an individual and a wide range of normal values and behaviors are considered healthy. Physiologic Development: Changes in the adolescent's body transform him or her from a child to an adult in appearance. Physiologic development includes the following: The feet, hands, and long bones grow rapidly, accompanied by an increase in muscle mass (especially in boys). Primary and secondary sexual development occurs, with maturation of the genitalia; presence of body hair; breast development and menstruation in girls; facial hair growth, voice changes, and spermatogenesis in boys. Puberty (the time when the ability to reproduce begins) begins at 9 to 13 years of age in girls (with menstruation usually beginning between 10 and 14 years of age) and at 11 or 14 years of age in boys. Sebaceous and auxiliary sweat glands become active. Full adult size is reached, although some young men might continue to grow in their 20s. Puberty can be divided into the following three stages: Pre pubescence: Secondary sex characteristics begin to develop, but the reproductive organs do not yet function. Pubescence: Secondary sex characteristics continue to develop, and ova and sperm begin to be produced by the reproductive organs. Post pubescence: Reproductive functioning and the development of secondary sex characteristics reach adult maturity. 576
Adolescent Sexual Development: Stage Males Pre pubescence: Progressive enlargement of testicles, seminal ducts, prostate gland Enlargement and reddening of the scrotal sac Increase in length and circumference of penis Appearance of downy pubic hair
Females Progressive enlargement of the ovaries Ripening of graafian follicles Rounding of the hips Appearance of breast buds Enlargement of the fallopian tubes, vagina, and uterus Appearance of downy pubic hair Pubescence: Increase in amount, Increase in amount, pigmentation, and curling pigmentation, and curling of of pubic hair pubic hair Growth spurt involving Growth spurt involving height and weight height and weight increase increase Menarche Deepening of the voice due Appearance of axillary hair to growth of larynx Enlargement of vulva and Enlargement of testicles clitoris Increased pigmentation and Development of breast growth of scrotum tissue Growth of penis in length Ovulation and circumference Beginning of spermatogenesis Post pubescence: Completion of sexual Completion of sexual growth and development growth and development Fertility Fertility Psychosocial Developmen: Freud's Theory: The adolescent and young adult is in Freud's genital stage. The libido reemerges in a mature, adult form, and the individual is capable of full sexual function. There is a sense of self and others, extending to other adults and peers of the opposite gender. Creativity and pleasure are found in love and in work. Erikson's Theory: Based on Erikson's theory, the adolescent tries out different roles, personal choices, and beliefs in the stage called identity versus role confusion. Self-concept is being stabilized, with the peer group acting as the greatest influence. The young adult, in the intimacy-versus-isolation stage, needs to complete tasks such as achieving independence from parents, establishing intimate relationships, and choosing 577
an occupation or career. If such developmental tasks are not accomplished, the young adult becomes isolated and self-absorbed. Havighurst's Theory: According to Havighurst, more mature relationships with both boys and girls of the same age are achieved, a masculine or feminine social role is developed, one's personal appearance is accepted, and a set of values and an ethical system as a guide to behavior are internalized. Levinson's Theory: Based on Levinson's theory of individual life structure, the years from 18 to 22 are characterized by early adult transition (Levinson, Darrow, Klein, et al., 1978). This is a time of making initial career choices, establishing personal relationships, and selecting personal values and lifestyles. During the years from 22 to 28, the young adult builds on previous choices, but there might be a transient quality to occupational choices and friendships. Gould's Theory: Gould's (1972) theory of transformation views young adults /as having established their own control as adults separate from the family. They want to enjoy the present but also build for the future C OGNITIVE D EVELOPMENT : The cognitive develop ment of adolescents is less visible than the physical development but still represents a major change in the way adolescents think about themselves, their peers and rela tionships, and the world around them. Piaget's Formal Operations Revisited: This cognitive advance is primaril y due to the final development of the frontal lobes of the brain, the part of the brain that is responsible for organizing, understanding, and decision making. Teenagers begin to think about hypothet ical situations, leading to a picture of what an ―ideal‖ world would be like. Many become convinced that such a world is possible to achieve if onl y everyone else would just listen to the teenager. Although headed into an adult st yle of thinking, adolescents are not yet completel y free of egocentric thought. At this time in life, however, their egocentrism shows up in their preoccupation with their own thoughts. They do a lot of intro spection (turning inward) and may, become convinced that their thoughts are as important to others as they are to themselves. Two ways in which this adolescent ego centrism emerges are the personal fable and the imaginary audience (Elkind, 1985; Lapsley et al., 1986; Vartanian, 2000). In the personal fable, adolescents have spent so much time thinking about their own thoughts and feelings that they become convinced that they are special, one of a kind, and that no one else has ever had these thoughts and feelings before them. "You just don't understand me, I'm different from you" is a common feeling of teens. The personal fable is not without a dangerous side. Because they feel unique, teenagers may feel that the y are somehow protected from the dangers of the world and so do not take 578
the precautions that they should. This may result in an unwanted pregnancy, severe injury or death while racing in a car, drinking and driving, and drug use, to name a few possibilities. "It can't happen to me, I'm special" is a risky but com mon thought. Moral Development: Another important aspect in the cognitive advances that occur in adolescence concerns the teenager's understanding of "right" and "wrong." Harvard Universit y professor Lawrence Kohlberg was a developmental ps ychologist who, influenced by Piaget and others, developed a theory of the development of moral thinking. Through looking at how people of various ages responded to stories about people caught up in moral dilemmas Kohlberg (1973) outlined three levels of moral development, or the knowledge of right and wrong behavior. Although these stages are associated with certain age groups, adolescents and adults can be found at all three levels. For example, a juvenile delinquent tends to be preconvention in moral thinking. Level of Morality
How Rules Are Understood
Example
Preconvention morality: (typically very young children)
The consequences determine morality; behavior that is rewarded is right, that which is punished is wrong.
A child who steals a toy from another child and does not get caught does not see that action as wrong. A child criticizes his or her parent for speeding because speeding is against the stated laws A reporter who wrote a controversial story goes to jail rather than reveal the sources identify.
Conformity to social norms Conventional morality: (Older children, adolescents, is right; nonconformity is and most adults.) wrong. Moral principles determined Post conventional morality: (about 20 percent of the adult by the person are used to population) determine right and wrong and may disagree with societal norms.
Health o f the Adolescent and Young Adult: Although adolescence and young adulthood are times of maximum physiologic development and health, a wide variety of health problems can occur. Health promotion focuses on nutrition, relationships with self and others, and safety. Young adults should have a tetanus and diphtheria booster every 10 years, and it is recommended that college students receive the meningococcal vaccine (CDC, 2002c). See Examples of NANDA Nursing Diagnoses: Adolescence. Injuries: Injuries are the leading cause of death for adolescents and young adults. Motor vehicle crashes are the most common cause of mortality, often associated with the use of alcohol or other drugs. 579
Substance Abuse: Smoking and the use of illegal drugs (such as marijuana and cocaine) might be a problem, and the use of alcohol is significantly related to risk-taking behavior. Suicide: The suicide rate of adolescents has increased drastically, with suicide being more prevalent in adolescents than in any other age group. Suicide is the third leading cause of death of adolescents and young adults (CDC, 2002a). Although females attempt suicide more often than males, males are more likely to succeed Pregnancy: The United States leads the developed countries in the number of pregnancies among adolescents 15 to 19 years old. These pregnancies are physically, psychologically, and economically costly for the adolescent mother, the infant, the family, and society. Nutritional Problems: Fad dieting and habitually eating fast foods are common among adolescents and young adults. For those obsessed with body image (particularly girls and young women), severe eating disorders can result. The most common are anorexia nervosa (compulsive dieting to the point of self-starvation) and bulimia (a destructive cycle of binge eating followed by self-induced vomiting in an effort to prevent weight gain). Sexually Transmitted Diseases: Adolescents and young adults who engage in unprotected sexual intercourse are at a higher risk for contracting sexually transmitted diseases (STDs) and their complications than are adults. Lack of knowledge, lack of psychosocial maturity, embarrassment, and the denial of the need to plan ahead and use condoms are the most common reasons for this increased risk. Trichomonal and monilial infections, as well as human Papilloma virus, are common. Chlamydial infections occur in both genders, as do syphilis and herpes simplex type II (genital herpes). These STDs pose serious health threats. Acquired immunodeficiency syndrome (AIDS) poses the greatest single threat to individuals and society as a whole. Although AIDS can be transmitted through means other than sexual contact, transmission is primarily through genital, oral, or anal sexual activities. AIDS is a major cause of death in the world, and its incidence is predicted to increase still further. Examples of NANDA Adolescence Nursing Diagnoses Nursing Diagnoses Possible Related Factor Imbalanced Nutrition: More Than Body Compulsive overeating Requirements Imbalanced Nutrition: Less Than Body Self-imposed dieting Requirements Risk for Deficient Fluid Volume Extended hours of football practice in heat Risk for Injury Risk-taking behavior while driving Lack of knowledge about water safety Risk for Trauma Perceived inability to be popular Teenage pregnancy 580
Social Isolation
Obesity Fear of failure in school Frequent use of alcohol and drugs
Risk for Impaired Parenting Disturbed Body Image Anxiety Ineffective Health Maintenance
Role of the Nurse in Promoting Health and Preventing Illness: A true assessment of adolescent development must include the profound changes in reproductive functioning. Teaching activities to promote health for adolescents and young adults are listed in Teaching to Promote Health at Home 19-5 (previous page). Perhaps one of the more significant nursing activities for individuals in this stage is facilitating healthy family relationships. Mutual respect, open communications, and accurate information exchange among family members pave the road for a healthy transition from /adolescence to adulthood. Acute illness is often more of an annoyance than of serious consequence. If hospitalized, an adolescent's and young adult's motivation to recover and to resume normal activities is strong. Because independence and self-sufficiency are important to adolescents and young adults, they will not easily accept the dependent sick role. Although chronic illnesses are less common, their occurrence can lead to delayed development, loss of independence, and permanent changes in personal and career goals. Prolonged hospitalization, long-term care, or home care increases the adolescent's feelings of isolation and may disrupt normal development. Educational and recreational activities should be provided if at all possible. ADULTHOOD: Introduction: The changes that occur during our adult years may not seem as striking or dramatic as those that typify our childhood and adolescence, but they are no less real. Many of the adjustments that we make as adults may go unnoticed as we accommodate to physical changes and psychological pressures. An adult's health may become a concern for the first time. Psychological and social adjustments must be made to marriage, parenthood, career, the death of friends and family, retirement, and, ultimately, one's own death. Our adult lives end with death, but when adulthood begins is not easy to say. Legally, adult status is often granted by governments-at age 18 for some activities, at age 21 for others. Psychologically, adulthood is marked by two phenomena that at first seem almost contradictory: 1. Independence, in the sense of taking on responsibility for one's actions and no longer being tied to one's parents, and 2. Interdependence, in the sense of building new commitments and intimacies in interpersonal relationships. Following the lead of Erikson (1968) and Levinson (1974, 1986), well consider adulthood in terms of three overlapping periods, eras, or seasons: early adulthood (roughly ages 18 to 45), middle adulthood (approximately ages 45 to 65), and late adulthood (over 65). Presenting adult development in this way may mislead us, so we should be careful. Although there is support for the notion of developmental stages in 581
adulthood, these stages may be better defined by the individual adult than by the developmental psychologist (Datan, et al., 1987). In fact, some psychologists find little evidence for any orderly transitions in the life of adults (Costa & McCrea, 1980; McCrea & Costa, 1984), while others find significant sex differences in what determines the stage or status of one's adult life (Reinke, et al., 1985). Early Adulthood: If anything marks the transition from adolescence to adulthood, it is choice and commitment independently made. The sense of identity fashioned during adolescence now needs to be put into action. In fact, the achievement of a strong sense of self by early adulthood is an important predictor of the success of intimate relationships later in adulthood (Kahn, et al., 1985). With the attainment of adult status, there are new choices to be made. Advice may be sought from elders, parents, teachers, or friends, but as adults, individuals make their own choices. Should I get married? Should I stay single? Perhaps I should live with someone. Who? Should I get a job? Which one? Do I need more education? What sort of education? How? Where? Should we have children? How many? When? Many of these issues are first addressed in adolescence, during identity formation. But for the adult, these questions are no longer abstract. They are very real questions that demand some sort of response. Levinson calls early adulthood the "era of greatest energy and abundance and of greatest contradiction and stress" (1986, p. 5). In terms of our physical development, we are at something of a peak during our 20s and 30s, and we're apparently willing to work hard to maintain that physical condition (McCann & Holmes, 1984; Shaffer, 1982). Young adulthood is also a season for finding our niche, working through the aspirations of our youth, raising a family. On the other hand, it is a period of stress, taking on parenthood, finding and keep-tag the "right" job and keeping a balance among self, family, job, and society at large. Let's take a brief look at two decision making processes of young adulthood, the choice of mate and family, and the choice of job or career. It is Erikson's claim (1963) that early adulthood revolves around the basic choice of intimacy versus isolation. Failing to establish close, loving, or intimate relationships may result in loneliness and long periods of social isolation. Marriage is certainly not the only source of interpersonal intimacy, but it is the first choice for most Americans. More young adults than ever are postponing marriage plans, but fully 95 percent of us do marry (at least once). In fact, we're more likely to claim that happiness in adulthood depends more on a successful marriage than any other factor, including friendship, community activities, or hobbies (Glenn &C Weaver, 1981). Beyond establishing an intimate relationship, becoming a parent is generally taken as a sign of adulthood. For many, parenthood has become more a matter of choice than ever before because of more available means of contraception and new treatments for infertility. Having one's own family helps foster the process of generatively that Erikson associates with middle adulthood. This process reflects a growing concern for family and for one's impact on future generations (Chilman, 1980). Though such concerns may not become central until one is over 40, parenthood usually begins much sooner. There is no doubt that having a baby around the house significantly changes established routines, often leading to negative consequences (Miller & Sollie, 1980). The freedom for spontaneous trips, intimate outings, and privacy is in large measure given up in trade for 582
the joys of parenthood. As parents, men and women take on the responsibilities of new social roles- that of father and mother. These new roles in adulthood add to the already established roles of being a male or a female, a son or a daughter, a husband or a wife, and so on. Choosing to have children (or at least choosing to have a large number of children) is becoming less popular (Schaie & Willis, 1986). Although many people still regard the decision not to have children as basically selfish, irresponsible, and immoral (Skolnick, 1978), there is little evidence that such a decision leads to a decline in wellbeing or life satisfaction later in life (Beckman & Houser, 1982; Keith, 1983). Jeffrey Turner and Donald Helms (1987) claim that choosing a career path involves seven identifiable stages. Let's review their list: 1. Exploration: There is a concern that something needs to be done, a choice needs to be made, but alternatives are poorly defined, and plans for making a choice are not yet developed. This period is what Daniel Levinson (1978) calls "formulating a dream." 2. Crystallization: Some actual alternatives are being weighed, pluses and minuses are associated with each possibility, and although some are eliminated, a choice is not made. 3. Choice: For better or worse, a decision is made. There is a sense of relief that at least one knows what one wants, and an optimistic feeling that everything will work out develops. 4. Career clarification: The individual's self-image and career choice are meshed together. Adjustments and accommodations are made. This is largely a matter of fine tuning one's initial choice, "I know I want to be a teacher; now what do I want to teach, and to whom?" 5. Induction: The career decision is implemented. This presents a series of potentially frightening challenges to one's own values and goals. 6. Reformation: One finds that changes need to be made if one is to fit in with fellow workers and do the job as one is expected to do it. 7. Integration: The job and one's work become part of one's self, and one gives up part of self to the job. This is a period of considerable satisfaction. If someone were to make the wrong career decision, it is most likely to happen in the third stage of choosing a career path, but probably won't be recognized until the fourth or fifth stage. In such cases, there is little to do but begin again and work through the process, seeking the self-satisfaction that comes at the final stage. Unfortunately for many, "starting over" can be troublesome, and occasionally even an impossible thing to do. When this is the case, the person is often stuck with making the best of whatever possibilities do exist. Middle Adulthood : As the middle years of adulthood approach, many aspects of one's life become fettled. By the time most people reach the age of 40, their place in the framework of society is fairly well set. They have chosen their lifestyle and have grown accustomed to it. They have a family (or have decided not to). They have chosen what is to be their major life work or career. "Most of us during our 40s and 50s become 'senior members' in our own particular worlds, however grand or modest they may be." (Levinson, 1986, p. 6). The movement to middle adulthood involves a transition filled with reexamination (Levinson, et al., 1974; Sheehy, 1976). During the middle years, one is forced to contemplate one's own mortality. One's "middle-age spread," loss of muscle tone, facial 583
wrinkles, and graying hair are evident each day in the mirror. At about the age of 40, sensory capacities begin to diminish. Most people in this stage now notice obituaries in the newspaper where more and more people of the same age are listed every day. Effects of Aging on Health: It is in middle age that many health problems first occur, although th eir true cause may have begun in the young adulthood years. Young adults may smoke, drink heavil y, stay up late, and get dark tans, and the wear and tear that this lifest yle causes on their bodies will not become obvious until their forties and fifties. Some of the common health problems that may show up in middle age are high blood pressure, skin cancer, heart problems, arthritis, and obesit y. High blood pres sure can be caused by lifest yle factors such as obesit y and stress but may also be related to here ditary factors (Rudd and Osterberg, 2002). Sleep problems, such as loud snor ing and sleep apnea (in which breathing stops for 10 seconds or more), may also take their toll on physical health. Robert Havighurst (1972) says there are seven major tasks that one must face in the middle years: 1. Accepting and adjusting to the physiological changes o f middle age: Although there certainly are many physical activities that middle-aged persons can engage in, they sometimes must be selective or must modify the vigor with which they attack such activities. 2. Reaching and maintaining satisfactory performance in one's occupation: If career satisfaction is not attained, one may attempt a mid-career job change. And, of course, changing jobs in middle age can be more a matter of necessity than choice. In either case, the potential for further growth and development or for crisis and conflict exist. 3. Adjusting to aging parents: This can be a major concern, particularly for "women in the middle" (Brody, 1981) who are caring for their own children and parents at the same time. In spite of widespread opinions to the contrary, individual concern and responsibility for the care of the elderly has not deteriorated in recent years (Brody, 1985). In fact, 80 percent of all health care for the elderly is provided by the family. 4. Assisting teenage children to become happy and responsible adults: During the middle years of adulthood, parents see their children mature through adolescence. Helping prepare them for adulthood (leaving the nest) becomes a task viewed with ambivalence. 5. Achieving adult social and civic responsibility: This task is similar to what Erikson calls the crisis of generativity vs. stagnation. People shift from thinking about all that they have done with their life to considering what they will do with what time is left for them and how they can leave a mark on future generations (Erikson, 1963; Harris, 1983). 6. Relating to one's spouse as a person: and (7) developing leisure-activities: Although all seven of these tasks are clearly related and interdependent, this is particularly true of these last two. As children leave home and -financial concerns diminish, there is more time for one's spouse and for leisure. Taking advantage of these 584
changes in meaningful ways provides a challenge for some adults whose whole lives previously have been devoted to children and career. C OGNITIVE D EVELOPMENT : Intellectual abilities do not decline overall, although speed of processing (or reaction time) does slow down. Compared to a you nger adult, a middle-aged person may take a little longer to solve a problem. However, a middle-aged person also has more life experience and knowledge to bring to bear on a problem, which counters the lack of speed. In one study (Salthouse, 1984), for exa mple, older typists were found to out perform younger t ypists, even though they t yped more slowl y than the younger subjects. Changes in Memory: Changes in memory abilit y are probably the most notice able changes in middle-age cognition. People find them selves having a hard time remembering a particular word or someone's name. This difficult y in retrieval is prob abl y not evidence of a physical decline (or the beginning of Alzheimer's disease) but is more likely caused by the stresses a middle aged person experiences and the sheer amount of information that a person of middle years must try to keep straight (Craik, 1994; Launer et al, 1995; Sands and Meredith, 1992). How to Keep Your Brain Young: People who exercise their mental abilities have been found t o be far less likel y to develop memory problems and even senile dementias such as Alzheimer's in old age (Ball et al., 2002; Colcombe et al., 2003; Fiatarone, 1996). "Use it or lose it" is the phrase to remember. Working challenging crossword puzzles, for example, can be a major factor in maintaining a healthy level of cognitive functioning. Reading, having an active social life, going to plays, taking classes, and staying physicall y active can all have a positive impact on the continued well -being of the brain (Bosworth and Schaie, 1997; Cabeza et al., 2002; Singh -Manoux et al., 2003). PSYCHOSOCIAL D EVELOPMENT : How do adults deal with the issues of work, relationships, parenting, aging, and death? In adulthood, concerns involve career, relationships, famil y , and approaching old age. The late teens and earl y twenties may be college years for many, although other young people go to work directl y from high school. The task of choosing and entering a career is very serious and a task that many young adults have difficult y accomplish ing. A college student may change majors more than once during the first few years of college, and even after obtaining a bachelor's degree many ma y either get a job in an unrelated field or go on to a different t ype of career choice in graduate school. Those who are working may also change careers several times (perhaps as many as five to seven times) and may experience periods of unemployment while between jobs. 585
Erikson's Intimacy versus Isolation: Forming Relationships: In young adulthood, Erikson saw the primary task to be finding a mate. True intimacy is an emotional and psychological closeness that is based on the abilit y to trust, share, and care, while still maintaining one's sense of self. Young adults who have difficult y tr usting others and who are unsure of their own identities may find isolation instead of intimacy-loneliness, shallow relationships with others, and even a fear of real intimacy. For example, many marriages end in divorce within a few years, with one partner leaving the relationship -and even the responsibilities of parenting to explore personal concerns and those unfinished issues of identit y. Erikson's Generativity versus Stagnation: Parenting: In middle adult hood, persons who have found intimacy can now focus outward on others. Erikson saw this as parenting the next generation and helping them through their crises, a process he called generatively. Educators, supervisors, health care provisional‘s, doctors, and communit y volunteers might be examples of p ositions that allow a person to be generative. Those who are unable to focus outward but are still dealing with issues of intimacy or even identit y are said to be stagnated. People who frequentl y hand the care of their children over to grandparents or other relatives so that they can go out and "have fun" may be unable to focus on anyone else's needs but their own. Erikson's Ego Integrity versus Despair: Dealing With Mortality: As a person's life enters the stage known as late adulthood, the realit y of one's eventual death becomes harder and harder to ignore. Erikson (1980) believed that at this time, people look back on the life they have lived in a process called a life review. In the life review people must deal with mistakes, regrets, and unfinished bus iness. If people can look back and feel that their lives were relativel y full and come to terms with regrets and losses, then a feeling of integrity or wholeness results. Integrit y is the final completion of the identit y, or ego. If people have many regre ts and lots of unfinished business, they feel despair, a sense of deep regret over things that will never be accomplished because time has run out. Late Adulthood: The transition to what we are here calling late adulthood generally occurs in our early to mid-60s. Perhaps the first thing we need to acknowledge is that persons over the age of 65 comprise a sizable and growing proportion of the population in the United States. More than 30.4 million Americans were in this age bracket (byl988), and the numbers are increasing by an average of 1,400 per day (Fowles, 1990; Kermis, 1984; Storandt, 1983). This is an increase of 18% since 1980, compared to an increase of 7% for the under 65 population. By the year 2020, Americans over 65 will make up nearly 20 percent of the population (Eisdorfer, 1983). Because of the coming of age of the "baby boom" 586
generation, by the year 2030, there will be about million older persons in the Unites States (Fowles, 1990). Ageism; Ageism is the discriminatory practice or negative stereotyping that is formed solely on the basis of age. Ageism is particularly acute in our attitudes about the elderly (Kimmel, 1988). One misconception about the aged is that they live in misery. Sensory capacities are not what they used to be. But, as Skinner (1983) suggested, "If you cannot read, listen to book recordings. If you do not hear well, turn up the volume of your phonograph (and wear headphones to protect your neighbors)." Many cognitive abilities suffer with age, but others are developed to compensate for most losses (Salthouse, 1989). Some apparent memory loss may reflect more of a choice of what one chooses to remember rather than an actual loss. There is no doubt that mental speed is reduced, but the accumulated experience of years of living can, and often does, far outweigh any advantages of speed. Aging: Introduction: The aging process, or senescence (from the latia senescence, ―to grow old‖), is characterized by a gradual decline in the functioning of all the body is system – cardiovascular, respiratory genitourinary endocrine and immune, among others. But the belief that old age is invariably associated with profound intellectual and physical infirmity is a myth. Ageism, a term coined by Butter, refers to the discrimination toward old persons and to the negative stereotypes about old age that are held by young adults. In Butter‘s scheme people often association old age with loneliness, poor heath, servility, and general weakness or infirmity. Myths about Aging: Myth: All older people are alike. Fact: Older people are uniquely individual. Myth: Older people live in Institutional settings. Fact: Only few (about 4%) of older people are in institutional settings. Myth: The Majority of older people are lonely and isolated from their families. Fact: The majority of older people live in a family setting. Many older people Live learn their children and have regular contact with friends and family. Myth: Older people cannot learn. Fact: Older people are capable of learning and enjoy learning. The senior ―Elderhostel‖ program is a good example of this. Theories of Aging: Even though the process of aging is not well understood, several theories have been proposed as a way to explain the aging process. Not all have been accepted either when first published or at present. Biological theories: Several biological theories have been developed to explain the process of aging. The cellular interaction theory suggests that an organism‘s individual cells are influenced by other cells. The somatic mutagenesis theory states that as alls divide, they develop spontaneous mutation. These mutations eventually lead to death (Kane et al, 1994). 587
The error catastrophe theory process that errors occur in deoxyribonucleic acid (DNA), ribonucleic acid (RNA), and protein synthesis. Each error augments the other and culminates in an error catastrophic (Kane et al, 1994). The oldest and most general biological theory of aging is the wear – and tears theory. This theory maintains that just as parts of mechanism wear, out, parts of the human body also deteriorate with each year of use. According to this theory, we wear out our bodies just by living (Berger, 1994). Psychosocial Theories: The first theoretical approach in gerontology came from the University of Chicago and resulted in the disengagement theory. In brief, the disengagement theory Cumming and Henry, 1961) maintain that society and individuals disengage in a neutral withdrawal, allow the individual to invest in more self-focused activities and establish balance at this stage of life. Many critics of the disengagement theory embrace an opposing theory called the activity theory. Activity theory states that older persons need and want to come involved with a variety of activities. The new involvements substitute for changes that come with growing older and the roles that were lost with retirement (Berger, 1994; Gelfard, 1994). Continuity Theory: Each person copes with the later years of life in much the same way as they coped with the earlier period. Aging is seen as a continuation of the earlier life rather than as a separate period (Berger, 1994; Gelfand, 1994). Exchange theory: Views elders with great esteem as a result of their experience and greater knowledge of love and history. The elder ―exchanges‖ this knowledge for a position of deferment and respect for younger individuals (Gelfand, 1994). Humanistic theory: Views people as unique, self determined, worthy of respect, and guided by a variety of basic human needs (Berger 1994). Humanistic theorist such as Maslow described that an individual‘s behavior is motivated by universal needs that range from the most basic (food, sleep, safety) to the highest need of self actualization. If the basic needs are not met, self actualization cannot be attained (Maslow, 1956). Harry stack Sullivan‘s interpersonal theory (1956) involves developing satisfactory interpersonal relationships as a sign of maturity. As these relationships are lost the individual may also experience a loss of interpersonal theory. Classification of Aging: Gerontology – the study of aging has become a new specialization to accommodate to the changing demographic patterns. One scheme that developmental psychologists are finding useful is to divide those over age 65 into two groups: 1) The young – old and. 2) The old-old. The distinction is not made on the basis of one‘s actual age but on the basic of psychological social and health characteristics (committee on an Aging society, 1986; Neugarter and Neugarter, 1986).
588
1) Young – old: ages between 65 to 74 (80-85%) - ―Vigorous and competent men and women who have reduced their time investments in work or homemaking. - Relatively comfortable financially and relatively well educated, and are wellintegrated members of their families and communities‖ (Neugarten and Neugarten, 1989). 2) Old-old: Poor nutrition - Smoking. - Alcohol consumption. - Inadequate calcium intake. - Not maintaining a sense or autonomy and control over one‘s life circumstances. - Lack of social support. Older adults can also be described as Well-old – healthy Sick –old – have an infirmity that interferes with fractioning and requires medical psychiatric attention. Biology of Aging: Aging generally means the aging of cells. In the most commonly held theory, each cell has a genetically determined life span during which if can replicate itself a limited number of times before if ties. Structural changes in cells occur with age. Moreover, not all organ systems deteriorate at the same time, a person does not disintegrate like the one – horse shay in Oliver Wendell Holues‘s poem. The Deacon‘s Master piece which ―went to pieces all at once.‖ Old Age Developmental Theories: Segued Freud: Increasing control of the ego and id with aging results in increased autonomy. Regression may permit primitive nodes of fractioning to reappear. Erik Erickson: The central conflict in old age is between integrity, the sense of satisfaction people feel reflecting on a life productively lived. And despair the sense that life has little purpose or meaning. Contentment in old age course only with getting beyond narcissism and into intimacy and generativity. Heinz Kohut: old people must continually cope with narcissistic injury as they attempt to adapt to the biological psychological and social losses associated with the aging process. The maintenance of self-esteem is a major task of old age. Bernice Negatron: The major conflict of old age relates to giving up the position of authority and evaluating achievements and former competence. It is a time of reconciliation with others and resolution of grief over the death of others and the approaching death of self. Daniel Levinson: Ages 60-65 is a transition period (―the late adult transition‖)/ people who are narcissistic and too heavily invested in body appearance are liable to become preoccupied with death creative mental activity is a normal are healthy substitute for reduced physical activity.
589
Developmental Tasks of Aging: Developmental tasks refer to age – appropriate skills that need to be accomplished. Erik Erickson‘s stages of development (1950) are widely cited as a way of viewing development across the lifespan. In Erick son‘s (1963) account of the life course, old age brings developmental confliction integrity versus despair. Integrity versus despair: To achieve integrity, in Erickson‘s sense of this term, means to integrate one‘s attitudes beliefs motives and experiences in such a way that they fit together comfortably and form a coherent whole. One result is a feeling of satisfaction with a life well- lives. Without this integrity, the older person feels a growing sense of despair a team that time is running out before the pieces of life‘s puzzle can be assembled in a satisfying way. This despair can show up in various ways as perpetual irritability and disgust or as a nagging fear of death – but at its core is a sense of incompleteness, of a life that is hot yet whole. Wisdom: Those who so achieve a sense of wholeness and integrity may develop one of the hallmarks of successful aging: Wisdom. Many cultures traditionally rely on selected elderly people for advice about complex life problems (Gutmann, 1977). The philosopher‘s Schopenhauer‘ depicted life as embroidery viewed differently at different ages. Life could be compared to embroidery of which we see the right side during the first half of life, but the back in the last half. This back side is less scintillating but more instructive if reveals the pitter-pattering of the threads. A clear, illusion free view of life‘s ―inter patterned thread‖ is one part of what many mean by the concept of wisdom. Some have also suggested that the wise person is one who has a ―balanced investment in self as well as in others‖ and who combines ―experience, reflective ness, and emotional balance‖ (Birren and Renner, 1980). Retirement: Retirement, a traditional marker of old age in many is not nearly the painful event that some popular stereotypes suggest. Retirement can be a time of vital aging in which the individual after a lifetime of work has the time of pursue interests and hobbies there was to time for previously. Certainly there are some people for whom retirement signifies loss – loss of a familiar daily routine, loss of valued social interactions, loss of a well established role, and even loss of income. Forerunning others though retirement is a welcome transition one that offers new opportunities and new freedom. Although different people react differently to retirement recent evidence suggests that it is welcomed by more than two-thirds of elderly working people and that it has few really negative effects. A recent survey of six longitudinal studies (pal more et, al 1984) found that retirement has few, it any addresses effects on social activity health happiness or life satisfaction. And ―real life‖ evidence that retirement is attractive continues to mount. Life Review: Some elderly adults inject their wisdom into memories or autobiographic that summarizes hard earned lessons from the school of life. Most, however, simply conduct informal life reviews through long conversations with their families and friends sometimes sparked by images in the family album or a chance recollection. Through these life reviews the older person can detect common threads of meaning running 590
through the diverse experiences of their 60 plus years. Paradoxically the process of life review goes on at the same time that much of life is still enfolding. Many issues in the still are confronted after the age of 60. Grant parent hood: For many, one of the special delights of old age is having grandchildren. In many western societies though, grant patent hood is a ―role less role‖ (Clevein 1978). One study (Neugartion and Weinstein, 1964) identified several different ―Styles‖ of filling the grant parent role. The formal style: Grant parent take an ongoing interest in their grand child and occasionally give the child special treats but carefully limit their role so as not to interfere with the parents. The fun –seeker style: an informal, playful approach in which grand children are seen as a source of leisure activity and mutual fun Distant –figure style: grant parents are benevolent but have only brief infrequent contact with their grand children. In another look at grandparent hood, Robertson (1977) focused only on grandmothers, distinguishing between a social and a personal orientation. Grand mothers, who adopt the social orientation focus on their perceived duties to set a good example, encourage the grand child to be honest and so on. Those who adapt the personal orientation focus more on the joys and rewards of grandparent hood – (―grand children will keep me happy and youthful; for ex). The orientation taken by ant particular grandmother depends partly on her life circumstances. For ex, younger grandmothers who have jobs and whose husbands are living, emphasize the social orientation and are not deeply involved in the grandmother role. Mental changes in old age: Learning: - More cautions. - More time to integrate their responses. - Less capable of dealing with new material. Reasoning: - General reduction in the speed. - Reaches a conclusion in both inductive and deductive reasoning. Creativity: - Tend to lack the capacity for, or interest creative thinking. - Significant creative achievements are less common among older people than among younger ones. Memory: - Poor recent memory. - Better remote memories. Recall: - Recall affected more by age than recognition - Use cues especially visual auditory and kinesthetic ones, to aid their ability fore call. Reminiscing: - To reminisce about the past becomes increasingly more marked with advancing age. 591
-
Sense of humor: - Comprehension of the topic/comic tends to decrease with advancing age. - Common stereotype of the elderly – humorless people. Vocabulary: - Learning new words more infrequent than frequent Mental Rigidity: - Tends to become more pronounced wit advancing age. - Believe that old values and ways of thinking or doing things are better than new ones. Changes in Interest In Old Age: Like the physical, psychological and lifestyle changes in old age, changes in interest ate inevitable. A number of conditions are responsible for this the most important of which are given below. Some Common Conditions Affecting Change of Interest in Old Age - Health: Changes in health and energy are reflected in an increased interest in sedentary pursuits and a decreased interest in activities requiring strength and energy - Economic Status: older people who have inadequate money to meet their daily needs often have to give up many of the interests that ate important to them and concentrate on the ones they are afford, regardless of whether they ate meaningful to them or meet their needs. - Place of Residence: If they live in their own homes with family members their interests are for more likely to remain static that if they go to live with married children or in a retirement home. Sex Marital status Values Personal interest 1. Interest in self. 2. Interest in appearance. 3. Interest in clothes. 4. Interest in money. Interest in self: - Become increasingly more preoccupied with them as they grow older. - Become ego centric and self centered to the point where they think more about themselves then about others. - Preoccupation with themselves by talking endlessly about their past expecting to be waited on and wanting to be the center of attention. Interest in appearance: - Cease to care about their clothes or become careless about grooming. - Few are dirty and slovenly in appearance. - Do not take the time and trouble to make the most of their looks or to camouflage the tell tale signs of physical aging as well as they could. Interest in clothes: Depends to some extent upon how socially active the elderly are partly on their economic status and partly on how willing they are to accept the fact that they are growing old and must adjust to if. 592
- Some elderly continues to wear style they wore earlier and refuse to dress according to the current fashion. - Others by contrast – very fashion conscious and may choose clothes that they are designed for those young enough to be their children or even their grand children. - The problem of finding ready made clothes that are becoming affects elderly men also but less than it affects women. Interest in Money: - Generally reviewed and becomes more intense as old age progresses. - Retirement or unemployment may leave the elderly with greatly reduced in comes or with no income at the unless they are eligible for social serenity or welfare relief. Recreational Interest: Elderly men and women tend to remain interested in the recreational activities they enjoyed in early adulthood, and they change these interests only when necessary. Common conditions responsible for changes in recreational activities Health: As health gradually fails and as physical disabilities such as poor eyesight set in, the individuals acquire an interest in recreational activities that require a minimum of strength and energy and can be enjoyed in the home. Economic status: Reduced income after retirement may force the castigation on or elimination of recreational activities such as movie going that cost money. This is especially true of people in the lower socioeconomic groups. Education: The more formal education a person has, the more intellectual recreational activities, such as reading will be cultivated. Those with limited education must often depend mainly on television for recreation. Marital status: Elderly people who have been accustomed to engaging in recreation with their spouses must make radical changes in their patterns after the loss of a spouse through divorce or death. a women accustomed to playing cards or going to community clubs with her husband may have to cultivated new recreational interests when she is left alone. Living conditions: Elderly persons who live in a home for the aged have recreational provided for them that are suited to their physical and mental abilities. Those who live in their own homes or with a married child have fewer opportunities for recreation especially if their economic status is poor or if failing health or transportation problems prevent them from participating in community-sponsored recreational activities. Sources of social contact affected by aging: - Close personal friendships with members of the same sex, many of which date back to adolescence or the early years of marriage often end when one of the friends dies or moves away, and it is unlikely that the old person will be able to establish another such relationship. Friendship cliques: These cliques are made up of couples who banded together when they were younger because of mutual interests stemming from the husband‘s business 593
associations or because of the wives mutual interests in their families or community organizations. - Formal groups or club: As leadership roles in formal groups and clubs are taken over by younger members and as the activities are planned mainly around their interest‘s older people feel unwanted in these organizations and discontinue their membership in them. The same principle holds true in the case of retirement. Men or women who retire earlier than others of their age groups or than their friends are deviant in the sense that they do not fit into the social life dominated by those who still work. One of the advantages of institutional living for the elderly is that if provides opportunities for contacts with contemporaries whom they usually do not have if they live in their own homes or in the house of grows children. Religious Interests: An analysis of research studies relating to attitudes towards religion and religious practice in old age has provided some evidence of greater interest in religion with advancing interest. Instead of a turn to or away from religion in old age most people carry on the religious beliefs and habits formed earlier in life. As loyalty has pointed out: ―The attitude of older people about religion is probably most often that with which they grew up or which they have accepted as they achieved intellectual maturity. Patterns of worship and of church attendance have remained much the same or have been modified by circumstances which, to the individual are logical modifications. Some common effects of religious changes during old age: Religious tolerance: With advancing age, the individual adheres less strictly to religious dogmas and adopts a more lenient attitude towards the church, the dergy and people of different faiths. Religious Beliefs: Changes in religious beliefs during old age are generally in the direction of acceptance of the traditional beliefs associated with the individual‘s faith. Religious Observances: Decline in church temple attendance and participation in religious activities in old age is due less to lack of interest than to factors such as failing health, lack of transportation, embarrassment about not having proper clothing or being able to contribute money and etching unwanted by the younger members women equine to participate in religious activities more than men do because of the opportunities they offer for social contacts. There is also evidence, as Covolt has pointed out, that ―The religious have a reference group that gives then support and security the nonreligious are more likely to lack each social support‖. Interest in Death: Facing up to the inevitability of death is a major developmental task of old age. For some elderly people, the awareness grows gradually and eventually fits as warmly and comfortably as a familiar sweater for others, though, the knowledge downs starkly, sometimes with the diagnosis of terminal illness mark twain one admitted that although he knew everyone had to die, he had always felt that an exception would be made in his cape. Deep down many share mark twain‘s feeling that ―It can‘t relief happen to me‖. ―When will I die?‖ ―What is likely to cause my death?‖ 594
―What can I do to die as I wish to die?‖ ―An I justified in taking my life?‖ ―How can I have a ―Good‖ Death?‖ Hazards to Personal And Social Adjustment In Old Age: At few times during the life span are there more potentially serious hazards to good personal and social adjustment than there are in old age. This is due partly to the physical and mental decline that makes the elderly people more vulnerable to potential hazards than they were earlier, and partly to lack of recognition of these potential hazards on the part of the social group. Common physical hazards characteristic of old age: 1. Diseases and physical handicaps 2. Malnutrition: Malnutrition in old age is due to more psychological than to economic causes such as lack of appetite resulting from anxiety and depression not wanting to eat alone, and food aversion stemming from earlier prejudices. 3. Dental disorders: Sooner or later, most elderly people lose some or all of their teeth causing difficulty in chewing 4. Sexual deprivation: Happily married elderly people are healthier and live longer than those who never married who have lost a spouse, or who become sexually inactive. 5. Accidents: Older people are generally more accident prove than younger ones. Even when the accidents are not fatal, they frequently leave the individual disabled for life Falls which may be due to environmental obstacles or to dizziness, giddiness, weakness, or defective vision, are the most common accidents among older women, while older men are most commonly involved in motor vehicle accidents, either as drivers or as pedestrians. Accidents caused by fire are also common in old age. Psychological hazards: Of the many psychological hazards characteristic of old age, the following are the most common and the most serious. 1. Acceptance of cultural stereo types of the elderly: This is hazardous because it encourages the elderly to feel inadequate and inferior. Even worse, it tends to stifle their motivation to do what they are capable of doing. 2. Effects of physical changes of aging: The second psychological hazard of old age stems from feelings of interiority and inadequacy that come with physical changes. The loss of an attractive, Sex appropriate appearance may lead both men and women to feel rejection by the social group. 3. Changes in life patterns: The necessity for establishing a different, more appropriate pattern of life is the third psychological hazard many elderly people face. They may, for example, no longer need as large home how that their children are grown and have homes of their own. Streib has explained why giving up homes and cherished possessions is so traumatic to many older people. ―Part of our depression at the loss of possessions is due to our feeling that we must now go without certain goods that we expected the possessions to bring in their train. Yet in every case there remains, over and above this, a sense of the shrinkage of our personality a partial conversion of ourselves to nothingness which is a psychological phenomenon by it self‖. 595
4. Tendency to ―Slip‖ Mentally: The fourth psychology hazard is the suspicion or realization that mental decline has started to set in. Many elderly people suspect or realize that they are becoming some what forgetful, that they have difficulty learning and new names or facts, and that they cannot hold up under pressure as well as they used to instead of adjusting their activities to conform to their mental state, they withdraw from all activities that might involve competition with younger people, and thus they experience all the problems, described earlier, that social disengagement brings. 5. Feelings of Guilt about idleness: The fifth psychological hazard is guilt about not working while other people still are many older people of today, who grew up in a more work oriented society, feel guilty after retirement or after their home responsibilities have diminished. Because most elderly people need to feel useful if they are to be happy and well adjusted attempts are made to get them interested in doing volunteer work in their communities. 6. Reduced income: The sixth psychological hazard is the result of reduced income. After retirement, many elderly people are unable to afford the leisure time activities they consider worth while, such as attending lectures or concerts or participating in various community activities. Women, even more than men, find a reduced income a hazard to their personal and social adjustments. 7. Social disengagement: The seventh and by forth most serious psychological hazards in old age is social disengagement. As was explained earlier, this may be voluntary, but for more often it is involuntary due to poor health, limited financial resources, or other conditions over which the elderly have little or no control. The elderly, who are disengaged either voluntarily or involuntarily, become socially isolated. As a result they lack the social support they had in times of trouble or stress when they were younger. This is especially serious if they are widowed or have few family members to truth to with their problems. Adjustments in Old Age: Old men are more interested in steady work than in advancement which they realize is not likely to be forth coming. As a result, they are usually more satisfied with their jobs than younger men. Attitudes toward work: Workers can have either of these two attitudes toward any job. If they have a society maintaining attitude toward their work, their leisure time will be more important to them than time on the job. If, on the other hand, they have an ego involving attitude, the time they spend on the job will take on greater significance for them and leisure time will decrease in significance the prevailing cultural attitude toward work also influences the other worker‘s attitude fig it. Vocational opportunities for older workers: Unfortunately,. When older men and women lose their jobs, often through no fault of their own, they find that there are very few job opportunities open to them even if they are eager to work and are able to do so the most important reasons for these difficulties are following: 596
Condition Limiting Employment Opportunities for Older Workers: 1. Compulsory retirement: Most industries, business, and governmental bureaus do not requires to hire men or women who are approaching the mandatory retirement age because of the time, energy, and expense that would be involved in training them for the jobs. 2. Hiring policies: When the personnel departments of business and industry are in the hands of younger people, the older worker‘s difficulties in finding employment are greatly increased. 3. Pension plan: Close correlation between the existence of a person plan in business and industry and the failure to make use of workers over sixty five years of age. 4. Social Attitude: 5. Fluctuation in business cycles: When business condition are poor, older workers are generally the first to be laid off and are then replaced by younger workers when the situation improves 6. Kind of work: Skilled semiskilled and unskilled workers find that their strength and speed decrease with age and that their employers also decrease as a result. 7. Sex: Women more than men generally find it more difficult to hold their jobs or to get men ones as they grow older. Vocational Hazards: There are two important vocational hazards in old age prevention from working and retirement. These are hazardous to self esteem and may even lead to feelings of use ness and martyrdom. As such, they are therefore hazardous to good personal and social adjustment. 1. Prevention from working: The first serious vocational hazard in old age, is prevention from working when one wants to work. Those who resist retirement, and who thus refuse to prepare themselves psychologically for it by becoming involved in new interests and activities, will make poorer adjustment that those who are better prepared for the changes that retirement brings. 2. Retirement: The second serious vocational hazard in old age is retirement monk has explained why this is so: ― Retirement entails a loss of status and prestige, ―a role less‖ situation where appropriate, or at least clearly defined, social positions and role expectations are notoriously absent---- once a person is unable to perform his occupational roles, his former claims to prestige, competence, and social position are no longer valid, thus precipitating the likelihood of an identify breakdown‖. An unfavorable attitude toward retirement affects the individual‘s health often causing physical decline and premature death. As Horowitize has pointed out, retirement shock is the new sickness of the aged. Adjustment to Old Age: Age: How successfully men and women will adjust to the problems arising from the physical and mental changes that accompany aging and from the changes in status that occur at this time will be influenced by many factors, some of which are beyond their control. Adjustment to changes in family life in old age: Relationship with spouse. Changes in sexual behavior. 597
Relationship with offspring. Parental dependency. Relationship with grandchildren. Adjustment to loss of a spouse in old age: Adjustment problems for men. Adjustment problems for women. Age differences in remarriage. Adjustment problems of remarriage. Cohabitation in old age. Adjustment to single hood in old age. Assessment of Adjustments to Old Age: There are many criteria that can be used to assess the kind of adjustment elderly people make, four of which are especially useful 1. Quality of behavior pattern. 2. Changes in emotional behavior. 3. Personality changes. 4. Life satisfaction or happiness. 1. Quality of behavior patterns: Studies of well adjusted and poor adjusted old people have shown that those whom others consider well adjusted have traits one would expect in a person who has followed the activity theory, while those who seen poorly adjusted have characteristics associated with the disengagement theory. Common Characteristics of Good and Poor Adjustment in Old Age: Good Adjustment: - Strong and varied interests. - Economic independence makes independence in living possible. - Many social contacts with people of all ages, not just the elderly. - The employment of work which is pleasant and useful but overtaxing. - Participation in community organizations. - The ability to maintain a comfortable home without exerting too much physical effort. - The ability to enjoy present activities without regretting the past. - A minimum of worry about self or others. - Enjoyment of day-to day activities regardless of how repetitions they may be. - Avoidance of criticism of others, especially members of the younger generation. - Avoidance fault finding especially about living conditions and treatment from others. Poor Adjustment: - Little interest in the world of today or the individuals‘ role in it. - Withdrawal into the world of fantasy. - Constant reminiscing. - Constant worry, encouraged by idleness. - A lack of drive, leading to low productivity in all areas. - Loneliness due to poor family relationship. - Involuntary Geographic isolation. - Involuntary residence in an institution or with a grown child. - Constant complaining and criticizing of anything and everything. 598
- Refusal to take in activities for the elderly on the grounds that they are ―boring‖. 2. Changes in emotional behavior: Studies of elderly people have shown that they tend to be apathetic in their affective life. They are less responsive than they were when they were younger and show less enthusiasm. It is not unusual for the elderly person to show signs of repression in emotional behavior, such as negativism, temper tantrums, and excitability characteristics of a child When the affective emotions of the elderly are, on the whole, less intense than they were earlier, their resistant emotions may become very strong, for ex old people are likely to be irritable quarrel some, erotchety, and contrary fears and worries, disappointments and dissensions, and feelings of presentations are for more common than the pleasanter emotional states. 3. Personality changes: As long ago as Plato‘s time, it was recognized that the personality pattern, prior to old age influenced people‘s reactions to old age. This, in turn determined how much changes will take place in their personalities when they become old. This point of view has how been substantiated by modern studies of personality which emphasize that although changes in personality do occur, they are quantitative rather than quantitative. Although the elderly may, for example become more rigid in their thinking more conservative in their actions more prejudiced in their attitudes towards others, and more self centered, these are not new traits that developed as they aged. Instead, they are exaggerations of lifelong traits that have become more pronounced with the pressures of old age. When pressures are too severe to adjust to and personality breakdowns occur, there is still evidence that the predominant traits, developed earlier, will be dominant in the pattern the breakdown. Effects of Radical Changes: A radical change in the self-concept at any age and for any reasons is likely to lead to a breakdown in the personality structures of minor or major severity. Advancing age and its pressures bring an increase in personality breakdowns and in the number of individuals committed to mental institutions. Mild form: - Disturbances of memory. - Falsification of memory. - Faulty attention. - Disturbances of orientation conversing time, place and person. - Suspiciousness. - Disturbances in the ethical domain. - Hallucinations and delusion (persecution). - Anxiety. - Preoccupation with bodily functions. - Chronic fatigue compulsion and hysterical disorders. - Neurotic depressions. - Sex deviations. Serious form: - Mental disease. - Trend in serious emotional disorders psychoses with cerebral arteriosclerosis. 599
- Senile dementia predominates. - Senile psychoses. - Criminal behavior – larceny, theft alcoholism. - Suicidal tendency. There is evidence that most personality breakdowns in old age are not the result of brain damage but rather of social conditions which give rise to feelings of insecurity. These are especially serious when there is a history of poor adjustment. 4. Happiness: The fourth criterion that may be used to assess the kind of adjustment elderly people wake is the degree of self-satisfaction or happiness they experience. According to Erickson, old age is characterized by either ego-integrity or despair. Even those who have been successful or reasonably successful may become dissatisfied in old age. As Erickson has commented, ―Despair is there for everyone, no matter how much he has accomplished. Causes of happiness in old age: As is true of other times in the life span, happiness in old age depends upon fulfillment of the ―Three A‘s of happiness – acceptance, affection and achievement. Barett has described what makes elderly people happy in this way:―The older person who is financially secure, able to utilize his free time constructively happy in his social contracts and able to contribute services to others will find the later Congruous period of life truly recording. He will retain a superior self-concept, remain highly motivated rarely become neurotic or psychotic and live out his life happily. He will not suffer from psychosocial deprivation, nor will be become senescent. When one is adequately prepared for retirement these may truly be the ―golden years‖. CONCLUSION: Personality development in adolescence, adulthood and aging , which helps in development of intellect that takes them beyond the limitations of childhood thought.
600
STRESS AND ADAPTATION Introduction: Stress is an inevitable part of every day life. At times it is mild, as when we must go without food or sleep for longer period than usual or when fail to achieve a minor goal. When financial resources are completely unavailable, stress become intense. We react to this situation in various ways, some time successfully or irritated. Sometimes by more deviant reaction. Definition of Stress: Stress as an internal state which can be caused by physical demands on the body (disease condition, exercise, extremes of temperature and like) or by environmental and social situations which are evaluated as potential harmful, uncontrollable or exceeding our recourse of coping. The physical, environmental and social causes of the stress state are termed Stressors. 75% of bodily diseases are stress related. Stress is often a factoring heart disease and cancer, two of the leading causes of death. Types of stress: No one achieves a complete adjustment not for long. Adjustment is a continuous process of satisfying once needs rather something fixed and static and it involves virtually all aspects of human behavior. STRESS | | | |--------------------------------| | | | | Frustration Conflict Frusturation: When someone is prevented from satisfying a need of desire we say frustration has occurred. The most common reaction to frustration is Persistent, vigorous effort, aggression (either direct or displaced) and escape or withdrawal. Using your exam as an example, the I st reaction you would probably have to persist or study even harder for the next in that class if you then do well it will be the end of your frustration. If you do properly again however you may behave with aggression, which is very common reaction. Aggression a forceful attack or hostile behavior. It can be direct or displaced. Direct Aggression: In your case would be physical or verbal abuse of the tutor who gave you exam. Escape or Withdrawal: This is another common reaction to frustration physical withdrawal. In your case you would drop the study programe or quit the job. Psychological escape can be done by day dreaming.
601
Conflict: You experience conflict when you have to choose between two things. When you chose which food to eat it is a temporary conflict but when you choose a career it is a major conflict and could long last. Approach means something about which you feel positive such as a beautiful sarries and shirt or getting high mark in exam. Avoidance means something about which you feel negative such as how much many spend to buy a saree or how much you work hard to get good marks. Approach-Approach Conflict: Often you must choose between two equally attractive objects or events. Hall I buy a chocolate or Vanilla? Cotton or wool? It is called approach –approach conflict. You are able to take quick decision and conflict is minor and temporary. AERO DANCE – AVAODANCE CONFLICT: The alternatives are equally UN alternative or repellent. Approach – Avoidance Conflict: A child starts to pat a dog but he afraid and pulls back his hand. Multiple Approaches – Avoidance Conflict: This is probably more like conflict in heal life than any other. This is because most conflicts do not have a completely negative or completely positive choice you may offered two jobs. One may be boring but very good salary and the other may be interesting work with poor pay. Types of Barriers: 1.) External Barriers: Floods, power failures and transportation breakdown are social in the sense that they are placed in our way by other people. When parents force a child to sit on toilet make him refrain from sex play, make him stay in his room or deny him the privilege of watching television. 2.) Internal Barriers: They are personal limitations and disabilities which toward one‘s aspiration. Example weakness, unattractiveness, lack of skill or low intelligence may stand in the way of achievement. Physical handicap may prevent one from following certain occupation. Internal barriers are more lasting than external barriers. Psycological Significance of Barriers: Objects and events become barriers too adjustment only when they c=block goals which the individual is aware that they impede his progress towards the goal. Barrier which the individual fails to recognize have no psychological significance. For an individual who is mentally retorted the college carrier is impossible. His extremely low intelligence constitutes an impossible internal carrier. But it is not frustrating him. He knows little or nothing of college. Behaviour in Response to a Barrier: When the individual is pursuing a goal and encounters a barrier. He must find an alternative way of reaching his goal, or he must find another objective.
602
Theories of Stress And Adaptation: Coehloetal (1980) noted that positive emotions are associated with immunity or rapid recovery from certain physical disorders; other researches have found that negative emotions states induce or aggravate some physical disorders (colline 1983).These similar findings are important. Because they reinforce holistic approach to health promotion, restoration and maintenance. Some theorists have tried to link specific disorders to particular conflict or personality traits. Franz Alexander (1960) proposed that scientific conflicts are likely to produce dysfunction deterioration in particular organ or organ system. For example an individual who is conflicted between arise for closeness and fear of closeness might express the conflict somatically by developing a neurodermatities such as psoriasis or eczema. A related hypothesis was offered by Durbar (1954) who complied psychological data on more than 1600 individual and developed personality profiles linked with specific disorders, in which mind and body factors could be identical. Durbar formulated a specific personality theory to explain the etiology of certain disorders person with rheumatoid arthritis; for instance were described as quiet, affable individuals whose pleasant exterior concealed considerable hostility. Coping With Stress: Too much stress for any person will have a damaging upon the body and emotations. Living healthy does not mean removing all stress from your life. It means being able to control it, so that will not be harmful. The earliest way of get rid of stress is to get rid of what is causing it. But it cannot always be done. For example you will not be able to get rid of marriage our quit job or drop out of school because it has become too stressful to you. Following suggestions are made to help you to cope with stress in life. (i) Exercise: physical exercise such as sports, yoga, dancing or walking will relive the physical tension which buildup in the body from stress. Do it daily or four times in a week. (ii) Meditate: to quite body and promote relaxation (iii) Relax: your body regularly through a systemic method of tensing, relaxing all your muscles. (iv) Slowdown: your pace of life move more slowly and deliberately. (v) ORGANISE: your life with priorities so that you will always accomplish what must be done at the right time. (vi) BALANCE: your life activities with more play family and friends and time for yourself. (vii) Make your goals realistic: Understand what you cannot do or be. (viii) Develop healthy social relationship: people will support and help you in stressful situation. (ix) Practice Coping Statements: These are things you say to yourself when in a stressful situation. When you are ready to take an exam for example you may be thinking: I am scared‖, ―I won‘t remember the right thing‖, ―and I am not smart enough to pass‖. You should use your coping statements to replace your negative thoughts. Then you would think that ―I am keyed up and ready to go‖. If I forgot something ―I‘ll just wait for a moment‖ or ―I‘ll do my very best‖. 603
Our Mental or Adjustment Mechanism: We have seen that certain situations are factors influence with the smooth development of the individual, and cause severe emotational conflicts and frustrations. These conflicts and frustrations threaten the individual‘s psychological balance. But the human individual is equipped with mental capacities to protect himself against such psychological dangers, as much as his body is equipped with powers to protect against physical dangers or distress. (I) Compensation: When an individual makes an attempt to make up for a deficiency by directing his energies to some other aspect of one‘s personality in which no deficiency exists, he is using the mechanism of compensation. The individual tries to overcome a failure or deficiency in one area through achieving recognition in another area, and thus able to enhance his self esteem which has been threatened. For example, an academically prior student may work hard and may show his abilities in dramatics, or a person with a physical handicap may strive hard to excel in his work. The compensationary reaction may work in another way too. The individual may work hard in the area in which he is deficient and may overcome his defect or weakness to the astonishment of others. A boy for example, with weak muscles and short stature, may work very hard to become a prominent athlete. Sometime the compensationary behavior may be socially harmful. A boy who is physically week and deficient may turn in to a bully and may select boys who are weaker, and then he may maltreat them. (i) Rationalisation: It is one of the most popular mechanisms used by us. The person who has been frustrated or who cannot solve the problem successfully and consequently feels discomfort and restless, tries to listen is feelings of anxiety and guilt by using this device. He behaves and reacts in a certain way in response to frustration and instead of justifying his actions by real and true reasons. Often students postpone their work on difficult assignment in favor of some other less important work and the reason given is ―This is to be done immediately – It is needed first‖ If we cannot do a o=job well or successful, we often satisfy our self by saying ‗It doesn‘t pay to work hard on this job‘. Thus rationalization often takes the formed justification or excuse-making. The rationalization takes a special form called the sour-grapes-mechanism. This name is driven from a fable about the fox that spent considerable time and effort jumping for some grapes which were beyond his reach as it could not succeed in his effort. He considered itself by saying, ‗The grapes are sour and hence undesirable‘. We often insist that things we cannot achieve are not worth having. Another form that rationalization takes in knows as the sweet lemon mechanism, which is the opposite of ‗sour-grapes-mechanism‘. The central theme of the mechanism which is also based on a fable is that this best of all possible world and whatever happens is all for the best. A house-wife who lives in a small house because of limited financial reasons. (Which are the actual reasons). May extol the virtues of small houses and may say that they are much costlear and comfortable. The difficult with this mechanism, as with others is that we are not aware that we are destroying facts or deceiving ourselves. We develop wrong perception. 604
(ii) Projection: We often attribute to others our own short comings, desire or moral defects as a means of lessening our own sense of suit or inadequacy. A student nurse who has cheated in an examination may suffer herself by saying that others also have cheated. A surgeon whose patient does not respond as well as anticipated may tend to blame the theatre nurse who helped the doctor at the time of operation. It has been observed that people who are most critical are often projecting their own short comings on others. this way we may gain some release of emotional tension. A special form of projection is called displacement or transference. (iii) Identification: It is an adjustment mechanism which enables one to achieve satisfaction from the success of other people, group or organization (cruse). Boys often identify themselves with their father, girls with their mothers. A businessman who has not yet achieved success in business may identify himself with a well-known and established businessman. When we do not posses certain qualities and cannot achieve certain ambition, we seem to achieve these qualities and achieve these ambitions vigorously by identifying ourselves with a person who possess those qualities and who has succeeded in achieving those ambitions. Hero worshipping is a form of it. Identification can be a source of danger in another way also. If we assume the attitudes or behavior characteristics of another person with whom her identify, again and again the danger is that we may thereby loose our own identity. (iv) Substitution: Is an adjective mechanisms in which original goals or desire are substituted by others? A student who has not been accepted for admission by a medical school may satisfy herself by becoming a nurse. (v) Sublimation: It is a form of the mechanism of substitution in which our unacceptable desires or activities are redirected in to social desirable channels. For example it is said about Dante that while walking in the street of Florence he saw and immediately fell in love with a young girl by name Beatrice. Dante could not marry her as she belongs to a higher social class. He never spoke to her and saw only once for a few minutes. But this denial of his desire or frustration server as the basis for several volume of sublime poetry. (vi) Repression: When we lost a discomforting idea or desire deliberately out of our mind or field of attention, we call it suppression, but when this process takes place unconsciously, we call it repression. A group of repression desires and ideas strongly emotionally toned forms a complex. (vii) Regression: Some people do not meet the problems of life, its strain and stress, in a mature way. They revert or retreated to an infantile or childish level of behavior and thus avoid the painfulness of suffering a conflict or tension. This mode of behavior is called regression. For example five year old child may regress when a new sibling is born and he feels neglected. Unloved and depressed. Thus feeling insecure, he may resort to behavior patterns of earlier year. He may start bed-wetting or he may find difficult in feeding 605
himself. It sometimes constitutes a sevire danger to personality development, indecisive and afraid of change or new ventures. (viii) Negativism: Some individuals react to frustrating situations by becoming negative. This means they refuse to attack the problem or obstacle which confronts them; instead they become contradictory, stubborn and do the opposite of what should be done. A nurse may come across quite a few patients who have developed this mechanism. Such patients will not co-operate in the treatment planed for them. They will maintain their ego by resisting the appeals and suggestions of others, since these might degrade the ego. (ix) Sympathism: In sympathies, the individual avoids the necessity of solving his problems by obtaining the sympathy of others. (xii) Withdrawal: Some people tend to withdrew from the situation in which they experience difficulty. A student who is afraid of achieving success in social relationship may see the company of other students. He may remain in home or he may refuse to participate in sports or social games. (xii) Pfantasy or Day-Dreaming: Day dreaming is a kind of withdrawal. Many of us resort to when we are face to face with real problems. Instead of attempting to solve problem in a realistic manner, we withdraw our self into a world of phantasy where we need not face failures, where we succeed in every undertaking of ours. E.g.: Movie novels and play. Excessive day-dreaming may result in the loss of contact with hard facts of life and may lead to psychotic disorders called schizophrenia. Besides these, there are other adjustment mechanism such as dissociation, egocentralism, reaction-formation and others. Support Systems: The saying, ‗No man is island‘, is of particular importance to stress management. A support system of family, friends and colleagues who will listen and offer advice and emotional support is beneficial to a person experiencing stress. Support system can reduce stress reactions and promote physical and mental wellbeing. Nursing research as documented the correlation of positive social support and the reduction of symptoms in chronic diseases. Traver and Kline-Leidy note a reduction in sensation of dyspnea and frequency of asthmaticatiacts in adult with chronic asthma who had strong family, social and employer support. Kempand Hatmaker (1989) studied social support and the stress response in high risk pregnancy. Their results identified lower urine catecholamine (epinephrine) levels in mother with strong family support system. Nurses can use various methods to help clients build support system, such as encouraging family to visit, making support sps available, encouraging recreational activities. Nurses can use therapeutic communicational skills to encourage clients to express their feelings and identify the causes of stress. When stress is a result of confusion or wrong information, a nurse can use teaching techniques to help relieve client‘s stress. If stress results differences between expectations and realities, a nurse can help clients gain 606
stronger self-concepts or body images. All of these is the result of social isolation. Nursing strategies are aimed at helping clients develop new social network. SUMMARY: The human individual is as much equipped with mental capacities to protect himself against conflicts and frustration as with physical energy and process to safeguard against physical dangers or distress. They mental capacities give raise to ‗proactive devices‘ known as mental mechanism or defense mechanism. These adjustment mechanisms help the individual overcoming threats to his ego and thus in maintaining inner balance or harmony. We might ever redirect our impulses and desires in to socially desirable channels and get the satisfaction that we seek other mechanism that may function or be adapted include repression, regression, sympathies, negativism, withdrawal and day-dreaming. The welladjusted individuals use them sparingly and in socially desirable ways, whereas the maladjusted individuals including the psychoneurotic and psychotics use them very frequently and in appropriately.
607
BIBLOGRAPHY: (1) ANN.J.ZWEMER, ―Basic psychology for nurses in India‖BI publications Pvt Ltd. Chennai 1st edition reprint in 2002. Page no : 100-115 (2) Clifford Morgan, Richard A king, John R Weisz john Schopler ―Introduction to Psychology ―. The Mc Grath-Hill companies, New York, 7th edition, reprint in 2005. Page no: 326-329, 323 – 325, 321. (3) Nornman.L.Munn.L.Dofge., Fernald Jr. Peters Fernall ―Introduction to Psychology‖, under the editorship of Leonard Carmichael OxfordIBIT publishing Ltd. New Delhi 1st edition, reprint in 1967. page no: 497-513 (4) MUNN‘S ―Introduction to Psychology‖ Fernald? Fernald. A.I.T.B.S publishers Abd distributers 5th edition page no: 431-435 (5) Ellen.H.Janosik, Janet.L>Davies, ―Mental health and Psychiatric nursing‖ Little brown and company. Boston page no: 270-271 (6) B.D.BHATIA ―ELEMENTS OF PSYCHOLOGYAND MENTAL HYGENE FOR NURSES IN INDIA‖ Orient logman limited, New Delhi 1st published Dec 1955 reprinted in 1995 Page no: 282-295. (7) Potter and Perry ―Fundamental of Nursing‖, 3rd edition, page no 920.
608
CRISIS AND ITS INTERVENION Introduction: A crisis is a disturbance caused by a stressful event or a perceived threat. Crisis or stressful events are common phase of life today. They may be social, psychological or biological in nature. The person‘s usual way of coping becomes ineffective in dealing threat, causing anxiety. Crisis intervention is a brief focused and time limited treatment strategy that has been shown to be effective in helping people adaptively cope with stressful events. Definition: According to Caplan (1964) ―… Psychological disequilibrium in a person who confronts hazardous circumstances that for him constitutes an important problem which he can for the time being neither escape nor solve with his customary problem solving resources‖. A A crisis is defined as a point that requires a change in the usual method of functioning. The change requires adaptation, learning and growth. Crisis intervention refers to the methods used to offer immediate, short-term help to individuals who experience an event that produces emotional, mental, physical, and behavioral distress or problems. A crisis can refer to any situation in which the individual perceives a sudden loss of his or her ability to use effective problem-solving and coping skills. A number of events or circumstances can be considered a crisis: life-threatening situations, such as natural disasters (such as an earthquake or tornado), sexual assault or other criminal victimization; medical illness; mental illness; thoughts of suicide or homicide; and loss or drastic changes in relationships (death of a loved one or divorce, for example). Difference between Stress & Crissis: Stress: Stress is a feeling that's created when we react to particular events. Is it primarily an external response that can be measured by changes in glandular secretions, skin reactions, and other physical functions, or is it an internal interpretation of, or reaction to, a stressor; or is it both. A state of affair involving demand on physical or mental energy". ( According to oxford dictionary ) A condition or circumstance (not always adverse), which can disturb the normal physical and mental health of an individual. In medical parlance 'stress' is defined as a perturbation of the body's homeostasis. Stress, nonetheless, is synonymous with negative conditions. Crisis: In a crisis an imbalance occurs that results in confusion & disorganization. An active crisis state may last 4-6 weeks. A person is confronted with an overwhelming threat & cannot cope. The person will either adapt at this point & develop new coping skills OR decompensate (not adapt) to a lower level of functioning.
609
Causes of crises: Crises are more common in those with severe mental illness and personality disorders. There are many potential causes of a crisis, including: Adolescence. Menopause. Retirement Redundancy. Becoming homeless. Changes of role, e.g. getting married, having a child, more demanding job. Relationship problems, e.g. with partners or child. Conflict: usually due to a difficult choice where neither alternative is acceptable. Serious injury or loss of a limb. Bereavement. Post traumatic stress. Non-compliance with medication in someone with pre-existing severe mental illness. Phases In The Development Of A Crisis: The development of a crisis situation follows a relatively predictable course. Caplan (1964) has outlined four phases through which individual progress in response to a precipitating stress or and which culminate in the state of acuts crisis. Phase I: The person has an increase in anxiety in response to a traumatic event if the coping mechanisms work, there‘s no crisis if coping mechanisms do not work (are ineffective) a crisis occurs. Phase II: When previous problem – solving technique do not relieve the stress or, anxiety increase further: The individual begins to feel a great deal of discomfort at this point. Phase III: *All possible resources, both internal and external are called upon to resolve the problem and relieve the discomfort: The individual may try to view the problem from a different perspective or even to over look certain aspects of it. New problem solving techniques may be employed and if effectual resolution may occur at this phase. *Anxiety continues to increase & the person asks for help. (If the person has been emotionally isolated before the trauma they probably will not have adequate support & a crisis will surely occur). Phase IV: Is the active crisis – here the person‘s inner resources & supports are inadequate. The person has a short attention span, ruminates (goes on about it), & wonders what they did or how they could have avoided the trauma. Their behavior is impulsive & unproductive. Relationships with others suffer they view others in terms of how can they help to solve the problem. The person feels like they are losing their mind this is frightening – Be sure to teach them that when the anxiety decreases that thinking will be clearer. Types of Crisis: There are 4 types of crisis:a) Maturational Crisis. b) Situational Crisis. c) Adventitious Crisis. d) Socio-cultural Crisis. 610
A.) Maturational Crisis: Development psychology describes a series of steps that must be taken in growing towards maturity. During this process the transitional periods between stages can upset psychological equilibrium. Maturational crisis are developmental events requiring role changes. For eg : successful progression from early childhood to middle childhood requires the child to become socially involved with people outside the family with the more from adolescence to adulthood, financial responsibility in expected. Both social and biological pressure to change can precipitate a crisis. The nature and extent of the maturational crisis can be influenced by role models, interpersonal resources, and the case of the other sin accepting the new role. Positive role models show the person how to act in the new role. Interpersonal sources encourage the training out of new behaviour to active role changes. Transitional period during adolescence, parenthood, marriage, midlife and interment are key times for the onset of maturational crisis. B.) Situational Crisis: Situational crisis occur when a life event upsets an individual or groups psychological equilibrium eg: loss of job, loss of loved one, unwanted pregnancy, onset or worsening of a medical illness, divorce, school problems & witnessing a crime etc. A situational crisis is a response to a traumatic event that is usually sudden & unavoidable. It usually follows the loss of an established support or role. The threat or loss of a role viewed as necessary to maintain self-image usually will lead to a crisis state. Situations that affect the way people perceive themselves include loss of a job, failure in school, loss of a spouse, birth of a retarded child, or diagnosis of a terminal or chronic illness. C.) Adventitious Crisis: These crises are accidental, uncommon and unexpected events. Multiple losses with major environmental changes result. Eg: fires, earthquakes, hurricanes or floods, which disrupts, entire community and are adventitious crisis. Unlike maturation and situation crisis, adventitious crisis do not occurs in the lives of everyone. When they do occur they challenge every coping mechanism because of the severity of the stress. If the reconstruction phase does not begin with in 6 months after disaster. The likelihood of lasting psychological problems is greatly increased. D.) SOCIO-CULTRUAL CRISIS: Social crisis is one arising from the cultural values that are embedded in the social structure. Eg: The loss of job stemming from discriminatory practices based on age, race, sex, sexual preference or class is a primary example of a socio-cultural crisis. They type of job loss various markedly from job loss due to illness or poor performance, additionally. Crisis that relates to deviant acts of others whose behaviour violates social norms, such as robbery, rape and incest, may be classified as socio-cultural crisis. 611
Crisis from socio-cultural sources are generally loss amenable to control by individuals. Very often, cultural views & public social policies may be a component of either the identification or the resolution of this crisis. Whenever the crisis originates outside the individual, it is usually beyond the ability of the individual alone to control and manage. Crisis Theory: Baldwin‘s ten corollaries to crisis theory. 1. Each individual‘s tolerance for stress is idiosyncratic and finite. Emotional crisis have no relationship to psychopathology and occur over among the well adjusted. 2. Emotional crisis are self limiting events in which crisis resolution either adaptive or maladaptive. 3. During a crisis state psychological defenses are weakened or absent, and the individual has cognitive or affective awareness of issues and memories previously well defended against & less accessible. 4. During a crisis state the individual has enhanced capacity for both cognitive and effective learning because of the vulnerability of the state and the motivation produced by emotional equilibrium. 5. Adaptive crisis resolution is frequently a vehicle for resolving conflicts. 6. A small external influence during crisis state can produce disproportionate change in a shorter period than therapeutic change that occurs during non-crisis state. 7. Resolution of emotional crisis is not necessarily determined by previous experience or character structure. 8. Internet in every emotional crisis is an actual or anticipated loss to the individual that must be reconciled as part of the crisis resolution process. 9. Every emotional crisis is an interpersonal event involving at least one significant other person who is represented in the crisis situation directly, indirectly/ symbolically. 10. Effective crisis resolution prevents similar future crisis.
612
Crisis Intervention: Aguilena believes that, Crisis intervention can offer the immediate help a person in crisis needs. It is an expensive short term therapy focused on solving the immediate problem and it is usually limited to 6 weeks. The goal of crisis intervention is for the individual to return to a pre crisis level of functioning often the Person advances to a level of growth that is higher than the pre crisis level because new ways of problem solving have been learned. Purpose of Crisis Intervention: To reduce the intensity of an individual's emotional, mental, physical and behavioral reactions to a crisis. Another purpose is to help individuals return to their level of functioning before the crisis. Helps to cope with future difficulties. Crisis intervention aims to assist the individual in recovering from the crisis and to prevent serious long-term problems from developing. The person becomes more willing to try new ways of problem solving (including professional help) and these results in growth. The 8 Elements of Crisis Intervention: Education: There is a natural ability within most people to recover from a crisis provided they have the support, guidance and resources they need. The very heart of crisis intervention is to face the impact of a crisis. In most cases, a crisis involves normal reactions, which are understandable, to an abnormal situation. Effective crisis counseling provides information; activities and structure that will help us recover and move past the crisis. More importantly, crisis counseling will insure that you do not prolong a crisis and it will help insure you do not create more problems in your life and the lives of others. Confrontation through information and discussion may be an important part of crisis intervention. Observation and awareness: A crisis in our life can be the result of low self-awareness or not recognizing the impact our behavior has on others as well as the impact it has on our self. Increasing your awareness can lead to choices that promote recovery and wellness. You can't help yourself if you cannot see the problem and how you may be contributing to the crisis. In some cases, family dynamics and communication problems within families can prolong a crisis Discovering and using our potential: Every crisis represents an opportunity for personal growth and to discover our highest potential and true self. The greatest hero in any crisis is the person who does not believe he or she is a hero, but is never-the-less prepared for the challenge by the undiscovered qualities and abilities that are only discovered when we are facing tragedy and the "inevitables" of life. While support is important, this does not mean that the person in crisis should not be allowed, encouraged and sometimes required to make decisions and take action to resolve the crisis and improve the quality of their life. Understanding our problems: It is the fundamental intention of all people to do the best they can with the resources and abilities they have during a crisis. During any crisis, it is important to recognize or discover our true and deepest intention. You must keep your 613
intentions in mind no matter what you do or how unskillfully you may act. While our intent is usually to make life better, our behavior can be misguided, misunderstood and less effective than we would hope. Self-understanding as well as understanding how others may keep us "stuck" is important keys to recovery. Creating necessary structure: The most important aspect of crisis intervention and counseling is to provide a social "container" for our experience that will allow us to express, explore, examine and become active in ways that help insure the crisis is not prolonged. For each of us, there are necessary activities and routines in our life during times of distress that provide comfort and support. These do not include alcohol, medications or other drugs. Medications should only be used to prevent a physical or psychological breakdown. The purpose, duration, frequency and potential impacts of medications must be defined in order to make informed decisions. Challenging irrational beliefs and unrealistic expectations: Few people, during times of crisis, have the necessary skills to fully examine what they are thinking, what they assume and what they expect from their self and from others. Our thoughts, especially the ones we don't look at, contribute a great deal too how we feel and what we do next in response to our feelings. Breaking vicious cycles and addictive behavior: Many crises are the result of vicious cycles or addictions. For example, drug and alcohol use can not only destroy our life, but it will confuse how we actually feel about our self, others and the world around us. One cannot know how they feel and what they truly want if their feelings are modified by chemicals, medications, alcohol and other drugs. A painful crisis can lead a person to avoid and escape how they feel. Unhealthy escape and avoidance of emotional pain and distress may involve the use of medication, drugs, alcohol, sex, thrill seeking, parties or working excessively. Taking the role of a "victim" can cause others to rescue a person in crisis. Prolonging the crisis by refusal to deal with a crisis can create supportive relationships. When a person becomes dependent on others and "escapes" to feel better, a vicious cycle can develop. Vicious cycles start with behaviors that are intended to avoid or escape emotional pain, but ultimately these avoidance and escape behaviors create more problems or the same problem we are trying to avoid. The behaviors found in a vicious cycle can actually prolong a crisis. Create temporary dependencies: During a crisis, it is often helpful to form brief relationships with others in order to gain support. Crisis counseling and intervention are very helpful and necessary. A healthy dependency is usually temporary and will always lead to increasing independency. Unhealthy dependencies are long term and create increasing dependency rather than independency. Facing fear and emotional pain: A crisis is usually a time of fear or sadness. How we respond is important. There is "monster" in the world for every person who "runs" in response to their fear or sadness. When we face the darkness in our life, and we are not destroyed by our fears, or sadness, we eventually discover there are no monsters. We discover that we can survive. In time we discover that our pain will fade. Facing emotional pain is the healthiest response. This does not mean we should make our self miserable. But we should not expend a great deal of energy and become involved in activities that help us avoid how we feel and what we think. When people suffer, it is important to help them feel less alone in the world. It is important to help people in crisis 614
solve the problems in their life. People in emotional pain need to be empowered and supported. Description about Crisis Intervention: Individuals are more open to receiving help during crises. A person may have experienced the crisis within the last 24 hours or within a few weeks before seeking help. Crisis intervention is conducted in a supportive manner. The length of time for crisis intervention may range from one session to several weeks, with the average being four weeks. Crisis intervention is not sufficient for individuals with long-standing problems. Session length may range from 20 minutes to two or more hours. Crisis intervention is appropriate for children, adolescents, and younger and older adults. It can take place in a range of settings, such as hospital emergency rooms, crisis centers, counseling centers, mental health clinics, schools, correctional facilities, and other social service agencies. Local and national telephone hotlines are available to address crises related to suicide, domestic violence, sexual assault, and other concerns. They are usually available 24 hours a day, seven days a week. Crisis Intervention and Role of Nurse: Crisis intervention includes 4 steps:a) Assessment. b) Planning and implementation. c) Therapeutic intervention. d) Evaluation. a.) Assessement: The 1st step of crisis intervention is assessment. At this time data about the nature of the crisis and its effect on the patient must be collected, more significant and long standing problems may be identified by the nurse. During these phase the nurse begins to establish a positive working relationship with the patient. A number of specific areas should be assessed, these factors are important in the development and resolution of a crisis that includes: Balancing Factor. Precipitating event/ stressor. Patient‘s perception of the event/stressor. Nature and strength of the patient‘s support system and coping resources. Patient‘s previous strength and coping mechanisms. Balancing Factor: Balancing factors are important to assess because they affect the way an individual perceives and responds to a precipitating stress or the assessment of balancing factors includes perception of the events. Situational support coping mechanisms. Precipitating Event: To help, identify the precipitating event the nurse should explore the patient‘s needs, the events that threat in those needs, and the time at which the symptoms appear. Four kinds of needs that how been identified are related to self-esteem, role mastery, dependency and biological function. Self esteem is achieved when the person attains successful social role experience. Role mastery is achieved when the person attains, vocational, sexual, family role successes. 615
Dependency is achieved when a satisfying inter dependent relationship with other is attained. Biological function is achieved when a person is safe and life is not threatened. The nurse determines which needs are not being met by asking the patient, she looks for obstacles that might interfere with meeting the patients needs what recent experiences have been upsetting? What areas of life have had changes? When did the patient begin to feel anxious? Perception of the event: Patient‘s perception or appraisal of the precipitating event is very important. Eg: (1) An Over weight adolescent girl may be the only girl in the class not invited to a dance. This may have threatened her self esteem. Eg (2) A Man with two unsuccessful marriages may have just been told by a girlfriend that she wants to end their relationship; this may have threatened his need for sexual role mastery. Eg (3) emotionally isolated, friendless women may have had car trouble and been unable to find someone to give her ride to wook. This may have threatened her dependency need. Eg (4) a chronically ill man who has had a recent relapse of his illness may have had his need for biological function threatened. Themes and surfacing memories of the patient gives further dues to the precipitating event. Because most crises involve losses or threats of losses, the theme of the loss is a common one. In assessment the nurse looks for a recent event that may be connected to an underlying theme. Support System & Coping Resources: The patients living situation and supports in the environment must be assessed. Does the patient live alone or with the family? Is there a supportive friend? Assessing the patient‘s support system is important in determining who should come for the crisis therapy sessions. Assessing the patients coping resources is also vital in determining whether hospitalization would be more appropriate than outpatient crisis therapy eg: High degree if suicidal and homicidal risk with weak outside resources. Coping Mechanism: In this step the nurse assess the patient‘s strengths and previous coping mechanisms. How has the patient handled other crisis? How was anxiety relieved? Besides exploring the previous coping mechanisms, the nurse should also note the absence of other possible successful mechanisms. b.) Planning and Implementation: The next step of crisis intervention is planning; the previously collected data are analyzed and specific interventions are proposed. Alternative solutions to the problems are explored, and steps for achieving the solutions are identified. The nurse decides when environmental supports to engage or strengthen and how to do this, as well as which if the patient‘s coping mechanisms to develop and which to strengthen. This process is outlined in the patient education plan for coping with crisis. The expected outcome if the nursing care is that the patient will recover from crisis event and return to a pre crisis level of functioning and improved quality of life. 616
c.) Therapeutic Internation: It can take place on many levels using a variety of techniques. There are four levels of crisis intervention that represent a hierarchy from the most basic to most complex. Each level incorporates the interventions of the preceding level and the progressive order indicates that the nurse needs additional knowledge and still for HighlevelofInterventi
Environmental Manipulation: It includes interventions that directly change the patient‘s physical or interpersonal situation. These interventions provide situational support or remove stress. Important elements of this intervention are mobilizing the patients supporting social systems and serving as a liaison between the patient and social support agencies. General Support: General support includes interventions that convey the feeling that the nurse is on the patient‘s side and will be helping person. The nurse uses warmth, acceptance, empathy, caring and reassurance to provide this type of support. Generic Approach: The generic approach is designed to reach high – risk individuals and large group as quickly as possible. It applies a specific method to all people faced with a similar type of crisis. This intervention is set up to ensure that the course of the crisis results in an adaptive response. Individual Approach: The individual approach is a type of crisis intervention similar to the diagnosis and treatment of a specific problem in a specific patient. The nurse must understand the specific patient characteristics that led to the present crisis and most use the intervention that is mot likely to help the patient develop an adaptive response to the crisis. This type of crisis intervention can be effective with all types of crisis. Techniques Used in Intervention: The nurse uses techniques that are active, focal and explorative to carry out the interventions. The intervention must be aimed at achieving quick resolution. The nurse should be creative and flexible, trying many different techniques, includes: abreaction, clarification, suggestion, Manipulation, reinforcement of behaviour, support of defenses, raising self-esteem and exploration of solutions. 617
Abreation: It is the release if feelings that take place as the patient talk about emotionally changed areas. As feelings about the events are realized, tension is reduced. The nurse encourages abreaction by soliciting the patients feeling about the specific situation, recent events, and significant people involved in the particular crisis. The nurse asks open ended questions and repeats the patient‘s words so that more feelings are expressed. The nurse does not discourage crying or angry outbursts but rather sees them as a positive release of feelings. Clarification: Is used when the nurse helps the patient to identify the relationship between events, behaviour and feelings clarification helps the patient gain a better understanding of feeling and how they lead to the development of a crisis. Suggestion: Is influencing a person to accept an idea or belief. In crisis intervention the patient is influenced to see nurse as a confident, calm, empathic person who can help by believing the nurse can help the patient may feel more optimistic and less anxious. Manipulation: Is a technique in which the nurse uses patient‘s emotions, wishes, or values to their benefit in the therapeutic process? Like suggestion, manipulation is a way of influencing the patient. Reinforcement of Behaviour: It occurs when healthy, adaptive behaviour of the patient is reinforced by the nurse, who strengthens positive responses made by the patient by agreeing with or complementing those responses. Support of Defenses: It occurs when the nurse encourages the use of healthy defenses and discourages those that are maladaptive. Defenses mechanisms are used to cope with stressful situations and to maintain self esteem and ego integrity: The nurse should encourage the patient to use adaptive defenses and discourage those that are madaptive. Raising self - esteem: It is a particularly important technique. The patient in a crisis feels helpless and may be over whelmed with feelings of inadequacy. The nurse should help the patient regain feelings of self-worth by communicating confidence that the patient can participate actively in finding solutions to problems. Exploration of the Solution: Is essential because crisis intervention is geared toward solving the immediate crisis. The nurse and the patient actively explore solutions to the crisis. Modalities of Crisis Intervention: Crisis intervention modalities are based on the philosophy that the health care team must be aggressive and go out to the patient‘s rather than wait for the patients to come to them. Mobile Crisis Programs: Mobile crisis teams provide front line inter disciplinary crisis intervention to individuals, families and communities. The nurse who is a member of a mobile crisis team may respond to a desperate person threatening to jump off a bridge in a suicide attempt, an angry person who is becoming violent toward family members at home etc. 618
Mobile crisis programs throughout the country vary in the service they provide and the procedures they use. However, they are usually able to provide on site assessment. Crisis management, treatment, referral and educational services to patient‘s families, law enforcement offices, and the community at large. Group Wook: Crisis groups follow the same steps that individual intervention follows. The nurse and the group help the patient solve the problem and reinforce the patient‘s new problem solving behaviour. The nurse‘s role in the group is active, focal and present oriented. The group follows nurse‘s example and uses similar therapeutic techniques. The group acts as a support system for the patient and is therefore if particular benefit to socially isolated people. Most crisis groups focus on people who have common traits of stressed, the most significant aspects of the group work were the venting of feelings and the support for healthy future response. Telephone Contacts: Crisis intervention to sometimes practice by telephone rather than through face to face contacts. Listening skills must therefore be emphasired in the nurse‘s role. Manuals written for the crisis worker includes contact such as suicide potential rating scales. Community resources, drug information, guidelines for helping the calles discuss concerns and advice on understanding the limitations of crisis workers‘ role. Disaster Response: As a part of the community, nurses are called on when adventitious crisis strike the community floods, earthquakes, air plane crashes, fires, nuclear accidents and the natural and unnatural disaster. It is important that nurses in the immediate post disaster period go to places where victims are likely together, such as mortgrues, hospitals and shelters. Nurses providing crisis therapy during large disaster use the generic approach to crisis intervention. So that as many people as possible can receive help in a short amount of time. Victim Outreach Programs: Crime has become a loyal issue, concerning people in every walk of life and in every country. Many victim outreach programs use crisis intervention techniques to identify the needs of the victims and than to concept them with appropriate referrals and other sources. Crisis intervention is successful in the acute phase of rape. It uses an integrated frame work of outreach, emergency care and advocacy assistance. These victims need through evaluation, empathic support, information and help with the legal system. The objective of crisis intervention is to validate the crisis and criminal nature of the rape, identify a supportive social network, and self enhancing ways of solving problems. The nurses validation of and response to people in abusive relationships is one component of a unified community wide response that is headed by local domestic violence programs in many
619
Crisis Intervention Team Programe: The Crisis Intervention Team program is a community effort enjoining both the police and the community together for common goals of safety, understanding, and service to the mentally ill and their families. It is to these goals the Memphis Police Department stands committed. The CIT program provides an avenue for the development of community partnerships and the collaboration of working together for community interest of service and care. CIT is about doing the right thing for the right reasons. CIT recognizes a special population that deserves special care, treatment, and service. CIT is not about fame, fortune, nor glory, but rather, one of honor and service. Narcotic/alcohol abuse and the ―deinstitutionalzation‖ of mentally ill citizens has caused many to become homeless and potentially more violent which increases the chances of involvement with law enforcement. As an innovative program, the CIT model encourages communities, families, law enforcement officers, and mental health professionals to act as a compass for consumers of mental illness. Traditional police methods, misinformation, and a lack of sensitivity cause fear and frustration for consumers and their families. Too often, officers‘ respond to crisis calls where they felt at a disadvantage or were placed in a no-win situation. Unfortunately, it is usually after a tragedy that police departments look for change. As a proactive program, CIT acts as a model committed to preventing tragic situations and finding ―win-win‖ solutions for all persons concerned. A response to mentally ill crisis events must be immediate. The National Alliance on Mental Illness/Memphis and the Memphis Police Department agree that an ―immediate response‖ is preferable to that of specialized mental health workers on call or a mobile crisis van response. By offering an immediate humane and calm approach, CIT officers reduce the likelihood of physical confrontations and enhance better patient care. As such, the CIT program is a beginning for the necessary adjustment that law enforcement must make from traditional police responses to a more humane treatment of individuals with mental illness. ProgramBenefits: Since the CIT program began in Memphis, the citizens and the criminal justice system of Memphis have experienced significant benefits of the program. Some of the benefits of the program are listed below. Crisis response is immediate. Arrests and use of force has decreased. Underserved consumers are identified by officers and provided with care. Patient violence and use of restraints in the ER has decreased. Officers are better trained and educated in verbal de-escalation techniques. Officer‘s injuries during crisis events have declined. Officer recognition and appreciation by the community has increased. Less ―victimless‖ crime arrests. Decrease in liability for health care issues in the jail. Cost savings. 620
Health Education: Health education can takes place during the entire crisis intervention process. It is emphasized during the evaluation phase. At this time the patent‘s anxiety has decreased, so better use can be made of cognitive abilities. The nurse plans the intervention to teach the patent how to avoid other similar crisis. Eg: The nurse helps the patent to identify the feelings thoughts, and behaviours experienced following the stressful event. The nurse explains that if these feelings, thoughts, and behavours are again experienced, the patient should immediately become aware of being stressed and take steps to prevent the anxiety from increasing. Nurse also involved in identifying people who are at risk for developing crisis & in teaching coping strategies to avoid the developing of crisis. Evaluation: To evaluate outcome of crisis intervention, a reassessment is made to determine if the stated objectives was achieved .have positive behavioral changes occur? Has the individual developed more adaptive coping strategies? Have they been effective? Has the individual grown from the experiences by gaining insight into his or her responses to crisis situation? Does the individual believe that he or she could respond with healthy adoption in future stressful situations to prevent crisis development? During The evaluation period the nurse & the patient summarize what has occurred during the intervention. The review what the individual has learnt & anticipate how he or she will respond in the future. a determination is made regarding follow up therapy, if needed the nurse provides referral information.
621
BIBLIOGRAPHY: 1. Perry and Pottar, principles and practice of psychiatric nursing, 1st edition, Mosbys publications, page No. 227-242. 2. Fortinash, Holoday Worret; psychiatric nursing care plan, Mosbys publication, 3rd edition, page No.303. 3. A Glod Carol, contemporary psychiatric mental health nursing, FA Davis company. Philadelphia. Page No.144, 148. 4. W. Stuart gail, principles and practice of psychiatric nursing 6th edition, Mosby‘s Publication, page No.228-238. 5. C.Townsend Marry, Psychiatric Mental Health Nursing, F.A.Davis Company, Page No.123-132. 6. Nursing Journal of India. 7. www.wikipedia.com
622
COPING WITH LOSS, GRIEF, DYING & DEATH Introduction: Life itself is a journey where one experiences a lot of things such as the feeling of happiness and sorrows, love and caring, achievement, etc. Not only these, one experiences a series of loss and gain. Loss, grieving and death are experienced by everyone at some time during their life. people may suffered the loss of valued relationships through life changes, such as moving from one city to another, separation, divorce, death of parents, spouse or friends. Loss and grief are experiences that affect not only the clients and their families but also the nurses who for them as well. Loss and death are universal, yet individually unique events of human experiences. Coping mechanisms determine people‘s ability to face and accepts loss and grief is the natural response to loss. Human can anticipate death. Death can be an overwhelming experience that affects the dying persons and their families, significant others, friends and caregivers. The style of dying reflects a person‘s style of living and attitudes about death depends on a person‘s beliefs and emotional strength. Nurses assist the patients in understanding and accepting loss so that life can continue. When patients do not do grief work after a loss, serious emotional, mental and social may occurs. Care of dying patients and their families can be one of the most challenging aspects of nursing care. Because is the final stage of human growth and development, it is essential that nurses be knowledgeable about the process of dying as they are about the process of birth. Definition: Loss: Loss is an actual or potential situation in which that is valued is changed, no longer available or gone. People can experience the loss of body image, sense of well being, a job, personal possessions, beliefs, sense of self, and so on. Grief: Grief is the natural response to loss. It is essential for good mental and physical health. It is a natural part of human experiences Dying: The process of undergoing death is known as dying. Death: Apparent Death: The cessation of life as indicated by the absence of heartbeat or respiration. Legal Death: The total cessation/absence of activity in the brain and the central nervous system, cardio-vascular system and the respiratory system as observed by a physician. Loss: Loss comes in many forms based on the values and priorities learned within one‘s sphere of influence, including one‘s family, friends, society and cultures. A person experiences loss in the absence of an object, person, body parts or functions, emotions, or idea that was formerly present.
623
According to it, loss can be of different types. They are:1) Actual Loss. 2) Perceived Loss. 3) Maturational Loss. 4) Situational Loss. 1.) Actual Loss: Actual loss is any loss of a person or object that can no longer be felt, heard, known, or experienced by the individual. E.g. Loss of arm, child, relationship, role at work, etc. 2.) Perceive Loss: Any loss that is tangible and uniquely defined by the grieving client. It may be less obvious to others. E.g. loss of confidence prestige. 3.) Maturational Loss: It includes any change in the developmental process that is normally expected during a lifetime. E.g. Mothers feeling of loss as a child goes to school for the first time 4.) Situational Loss: It includes any sudden, unexpected external event that is not predictable. Often this types of loss includes multiple losses rather than a single loss, such as an automobile accident that haves a driver paralysed, unable to return to work and grieving over the loss of the passenger in the accident. Source of Loss: There are many sources of loss: Loss of an aspect of oneself. E.g. A body part, a physiological function, or a psycho logic attribute. Loss of an object external to oneself. Separation from an accustomed environment. Loss of a loved or valued person. Factors Influencing Loss Experiences: The factors influencing loss experiences are as follows:1) Childhood experiences. 2) Physical and emotional state. 3) Accumulated loss experience. 4) Visibility. 5) he grief. 6) Availability of resources. 7) Cultural factor. 8) Relationship with the lost person. Factors Affecting Loss: The factors affecting loss are as follows:A. Development stage. B. Religious & cultural beliefs. C. Relationship with the loss object. D. Cause of death. A.) Development Stage: Depending on the client‘s place on the age, the grief response to a loss will be experienced differently. 624
Nurses practice in many setting where children, adolescents and adults, as of growth and development, experience changes that result in loss. E.g. A pregnant women to some degree experience loss after delivery of the first child even when the child is healthy and normal Childhood: Children vary in the reaction to loss and in the ability to comprehend the meaning of death. It is important to understand the way a child‘s concept of death evolves, because the concept varies developmental tasks. Adolescence: Most adolescents value physical attractiveness and athletic abilities. Grief may occur when the adolescent suffers the loss of body part and function. Because of the strong influence of peer groups, adolescents seek approval of their friends and they fear being rejected if a loss affects their acceptance by others even though they have an intellectual understanding of death, adolescents believe themselves to be invulnerable and thus, immune to death, they reject the possibility of their own mortality. Early adulthood: In young adult, grief is usually precipitated by the loss of role or status. E.g. Unemployment or the break- up of a relationship may cause significant grief for the young adult. The concept of death in this age group primarily a reflection of cultural values and spiritual beliefs. Middle Adulthood: During middle adulthood, the potential for experiencing loss increases. The death of parents often occurs during this developmental phase. As an individual ages, it can be especially threatening when peers die, because these death force acknowledgement of one‘s own mortality. Late Adulthood: During this stage, most individual recognise the inevitability of death. It is challenging for elders to experience the death of age-old friends or to find themselves the last one of their children and grandchildren as sources of comfort and companionship. Cultivating friendships in all age groups helps prevent loneliness and depression. B.) Religious & Cultural Beliefs: Religious and cultural beliefs can have a significant effect on an individual grief experience. Every cultural has certain religious beliefs about the significance of death, as well as rituals for care of the dying. Belief about an afterlife, a supreme being, redemption of the soul, and re-incarnation are important aspects that can assist one in grief work. Relationship with the Loss Object In general, the more intimate relationship with the deceased, the more intense grief experience by the bereaved. The death of child poses a particular risk for dysfunctional grieving. The death of a child generally thought to exceptionally painful because it upsets the natural order of things, parents do not expect their children to die before them. 625
The death of the parent or a sibling can pose a major challenge for the children. The child‘s feelings may often go unrecognised by adult who fails to understand the child‘s need to mourn. C.) Causes Of Death: The intensity of grief response also varies according to the cause of death be unexpected, traumatic, or suicide. Unexpected Death: The loss occurring as a result of an unexpected death poses particular difficulty for the bereaved in achieving closure. As roach and Neito (1997) states, any death even an anticipated death, is traumatic experience to the surviving loved ones. Unanticipated death such as a death from a heart attack, Aneurysm, or stroke leaves the survivors shocked and bereaved. Most often the bereaved are capable of working through the grieving process without complication. Traumatic Death: Complicated grief is associated with traumatic death such as death by homicide, violence, or accident. Although traumatic death does not necessarily pre-dispose the survivor to complications in mourning, survivors often suffer emotions of greater intensity then those associated with the normal grief. Suicide: The loss of a loved one to suicide is frequently compounded by feeling of guilt among the survivors. They felt guilty for failing to recognise clues that may have enabled the victim to receive help. These feelings of guilt and self-blame can transform into anger at the victim for inflecting such pain, at themselves, and caregiver. Feeling of shame for having a suicide in the family may also be present. The negative stigma of suicide may prohibit the survivor for successfully resolving their grief. Loss as Crisis: Loss can be viewed as either a situational or a developmental crisis. Loss that occurs in the process of normal development –such as the departure of grown children from the home, retirement from a career and the death of aged parents are developmental crisis that can be anticipated and to some extent prepared for. When caring for clients who are experiencing loss of functional ability resulting from acute or chronic illness, who have experienced loss of a body part (E.g. Amputation of limb, mastectomy) or who are in the process of dying, the nurse needs to consider the influence of these factors not only on the client, but also on the client‘s family and loved ones. All persons concerned experience the loss and may exhibit different expressions of grieving. Responses to Loss: The threat of illness precipitates coping behaviours associated with loss. Dying patients must adapt to the loss of life, other patient must adjust to the loss of health or loss of a limb, a blow to self- concept or a necessary change in the lifestyle. 626
Regardless of the nature of loss, the dynamics of grief present themselves in some form. The response to loss can be described in the following 4 phases:1. Shock and disbelief. 2. Development of awareness. 3. Restitution. 4. Resolution Shock and Disbelief: In the first stages of response to loss, patients demonstrate the behaviours characteristic of denial. They fail comprehend and experience the rational meaning and emotional impact of the diagnosis. When such blatant denial occurs, it is apparent that the problem is so anxiety provoking to the patient that it cannot be handled by the more sophisticated mental mechanisms of rational problem solving This ,phase of denial also may serve as the period during which the patient‘s resources, briefly blocked by the shock can be regrouped for the battle ahead Therefore stripping away the denial may render the patient helpless. Furthermore, although denial has been its obvious hazard denial has been associated with higher rates of survival after myocardial infarction. Nursing Management: The nurse recognizes and accepts the patient‘s illness by watching, monitoring, or changing dressings. In these ways, the nurse communicates acceptance of the patient through tone of voice, facial expression and touch. The nurse must be able to reflect statement of denial back to the patient in such a way that allows the patient to hear them and eventually to examine their incongruity and apply reality by saying something such as, ―In some way you believe that having a heart attack will be helpful to you‖ and ―It seems that it is hard for u to stay in bed‖ By verbalizing what the patient is expressing, the nurse gently confronts behavior but does not cause anxiety and anger by reprimanding and judging. In this phase the nurse supports denial by allowing for it but does not perpetuate it. Instead the nurse acknowledges, accepts and reflects the patient‘s new circumstances. Development of Awareness: In this second stage of loss, the patient‘s behaviour characteristically associated with anger and guilt. The anger may be expressed overtly and may be directed at the staff for oversight, tardiness and minor insensitivities. In this phase the ugliness of reality has made its impact. Displacement of the anger onto others helps to soften the impact of reality on the patient. Such behaviour often alienates the nurse and other personnel. The patient who does not demand has probably withdrawn into depression because of anger directed towards self rather than others. The patient will demonstrate verbal and motor retardation, will likely have difficulty sleeping and may prefer to be left alone. During this phase, the nurse is likely to hear irrational expression of guilt. Patient seek to answer the question, ―why me‖. They attempt to isolate this human imperfection 627
and attribute the cause of the malady to themselves on their past behaviour. Both the patient and their families may look for a person or object blamed. Nursing Management: During the development of awareness, nursing intervention must be directed towards supporting the patient‘s basic sense of self-worth and allowing and encouraging the direct expression of anger. The nurse should provide and respect the patient‘s need for privacy and modesty. The nurses need to guard against verbal and non-verbal expression of pity. A non-defensive, accepting attitude will decrease the patient‘s sense of guilt, and the expression of anger will avert some of the depression. Restitution: In this stage, the client asides the anger and resistance and begins to cope constructively with the loss. The client tries new behaviours that are consistent with the new limitations. The emotional level is one of the sadness, and time spent in crying is useful. As the patient adapts to a new image, considerable time spent going over and over significant memories relevant to the loss. Behaviours in this stage include verbalization of fear regarding the future. Often this goes unexpressed and undetected because they are unbearable for the family to hear. They worry about the future response of their mates to their changed bodies. The patient probably also question a new role in the family. Nursing Management: During restitution, nursing care should again be supportive so that adaptation can occur. Listening to the patient for a lengthy period of time is necessary. If the patient is able to verbalize fears and questions about the future he/she will be better able to define the anxiety and solve new problems. During this stage, the nurse may have the patient consider meeting someone who successfully adapted to similar trauma. Friends may respond differently to the patient who has suffered a permanent disability than to a healthy person. During this time the family had also been going through a similar process. They too have experienced shock, disbelief, anger and sadness. The nurse must also help the family by allowing them to ventilate their repulsion and fear and by showing acceptance of these feelings. Through intensive listening, the nurse provides a sounding board and then redirects the members of the family back to each other so that they can give and receive each other‘s supports. Resolution: It is the stage of identity change. The patients may over identify themselves as invalids. They may discriminate against themselves and make derogatory remarks to test the acceptance of the nurse. The patients are sensitive to the ways in which health care worker response to their bodies. A patient may make negative remarks to test the acceptance of the nurse. As time passes and the patient adapts, the patient moves towards identification as person who has certain limitations due to illness rather than as a ―cripple‖ or an ―invalid‖. 628
The patient no longer uses a defect as a basis of identity. Often the patient reflects on the crisis as a time of growth and maturation. Such a patient achieves a sense of pride at accomplishing the different adaptation and is able to look back realistically on successes and disappointments without discomfort. At this time, the patient may find it useful and gratification to help others by serving as a role model for those people in the stage of restitution who are experiencing their own identity crisis. Nursing Management: The goal of nursing care during resolution stage is to help the patient attach a sense of self-esteem to a rectified identity. Nursing intervention centered on helping the patient find the degree of dependence that is needed and can be accepted. The nurse must accept and recognize with the patient that periods of vacillation between the independence and dependence will occur. Certainly, the nurse can support and reinforce the patient‘s growing sense of pride in rehabilitation. Grief: It is the total response to the emotional experience related to loss which is manifested in thoughts, feelings & behaviours associated with overwhelming distress and sorrow. Bereavement: It is the subjective response experienced by surviving loved one after the death of a person with whom they have shared a significant relationship. Mourning: It is the behavioural process through which grief is eventually resolved or altered. It is often influenced by cultural, religious experiences, and customs. Theories Of Grieving Process: Several theoretical models describe grieving. The theories of Erich Lindemann, George. L. Eagle, John Bowlby and J. William Worden. A.] Lindemann: Following the Coconut Grove Fire in Boston in 1944, Lindemann studied survivors and their families. He coined the phrase ―Grief Work‖ which is still used today to describe the process experienced by the bereaved. He also found that during grief work, the person experienced the freedom from attachment from the deceased and become re-oriented to the environment where the deceased is no longer present and established a new relationship. His classic work is the basis of current crisis and grief resolution theories. Lindemann(1944), Roach & Neito (1997) describe Lindemann‘s theory of a person‘s reaction to normal grief as:a. Somatic Distress. b. Pre-occupation with the image of the deceased. c. Guilt. d. Hostile reaction. e. Loss of pattern of conduct. Somatic Distress: The bereaved experience episodic waves of discomfort in durations, of 10-60 minutes, multiple somatic complaints, fatigue, extreme physical and emotional pain. 629
Pre-occupation with the image of the deceased: The person experienced a sense of unreality, emotional detachment from others, and overwhelming pre-occupation with visualizing the deceased. Guilt: The person consider the death to be a result of their own negligence or lack of attentiveness, they look for the evidence of how they have contribute to death. Hostile Reaction: The person relationship with others become impaired owing to bereaves desire to be left alone and bereaves feeling of irritability and anger. Loss of Patten of Conduct: The person exhibit generalized restlessness and inability to sit stilled, they continually search for something to do. B.] Bowlby: According to Bowlby, grief result when a person experiences a disruption in attachment to a love object. His theory proposes that grief occurs when the attachment bond are severed. The four phases of grieving as cited by him are: Numbness. Yearning & Searching. Disorganization & Despair. Re-organization. C.]Worden: He has identified four tasks that an individual must perform in order to successfully deal with a loss. Accept the fact that the loss is real. Experience the emotional pain of grief. Adjust to the environment without the deceased. Re-invest the emotional energy once directed at the deceased into another relations D.] Engle: Grief is a typical reaction to loss of a valued object. According to him, there are three stages of mourning and progression through each stage is necessary for healing. Stage 1: Shock and Disbelief: Disorientation. Feeling of helplessness. Denial, which provide protection until the person is able to face the reality. Stage 2: Developing Awareness: Guilt. Sadness. Isolation. Loneliness. Feeling of helplessness. Possible anger and hostility towards others. Increasing emotional pain in response to increasing reality to loss. Stage 3: Restitution &Resolution Emergence of bodily symptoms. 630
Possible idealization of the deceased. Beginnings of coming to terms with the loss. Establishment of new social pattern and relationships. Types of Grief: Grief is a universal, normal response to loss. Grief drains people both emotionally and physically. Because it so much emotional energy, relationships may suffer. There are different types of grief. They are:1. Uncomplicated Grief. 2. Dysfunctional Grief. 3. Anticipated Grief. 4. Disenfranchised Grief. 1.) Uncomplicated Grief: Uncomplicated grief is what many individual would refer to as normal grief. Engle also proposed the use of uncomplicated grief to describe a grief reaction that normally follows a significant loss. Uncomplicated grief runs a fairly predictable course that also ends with the relinquishing of the lost object and the resumption of the duties of life. Many grieving people experience feelings of anger or blame and it may be directed towards those perceived to have caused or contribute to the death. Often the anger associated with the grief is directed one‘s self i.e. expressed as guilt or depression. Even though the bereaved have done nothing to cause to death, they often believe that somehow they should have been able to prevent it. 2.) Dysfunctional Grief: It is a demonstration of a persistent pattern of intense grief that does not result in reconciliation of feelings. Persons experiencing dysfunctional grief do not progress through the stages of overwhelming emotions associated with grief and many fails to demonstrate the behaviour commonly associated with grief. The person experiencing pathological grief continues to have strong emotional reactions, does not return to a normal sleep pattern, or work routine; usually remains isolated and displays altered eating habits. The bereaved may have the need to endlessly tell and retell the story of loss but without subsequent telling. A person experiencing the dysfunctional grief continues to focus on the deceased, may overvalued objects that belongs to the deceased and may engage in depressive brooding. The professional caregiver must be aware of these behaviors and refer the pathologically grieving person to professional counselor. 3.) Anticipatory Grief: It is the occurrence of grief work before an expected loss actually loss. Anticipatory grief can be experienced by the terminally ill person as well as the person‘s family. This phenomenon promotes adaptive grieving and therefore frees up the mourner‘s emotional energy necessary for problem solving. 631
Although anticipatory grieving may be helpful in adjusting to the loss, it also has some potential disadvantages. E.g. In case of dying patient, anticipatory grieving may lead to family members distancing themselves and not being available to provide supports. Also if the family members have separated themselves emotionally from the dying client they may seem cold and distant and thus not meet the society‘s expectation of mourning behaviour. This response can in turn prevent the mourner‘s from receiving their own much needed supports from others. 4.) Disenfranchised Grief: The grief that is not openly acknowledged, socially sanctioned, or publicly shared. Grief can become disenfranchised when an individual either is reluctant to recognize the sense of loss and develops guilt feelings or feels pressured by the society to ―get on to life‖ E.g. 1) Extreme sadness over the loss of a pet, and when this mourning might be viewed by others as excessive or inappropriate. 2) A mother‘s sadness over a miscarriage might also considered disenfranchised grief as a lengthy period of mourning may not be publicly expected despite the mother‘s intense feelings of loss and despair. Symptoms of Normal Grief: 1. Feeling: Sadness. Anger. Guilt. Anxiety. Loneliness. Fatigue. Helplessness. Shock/Numbness. Yearning. Relief/Emancipation. 2. Cognition: Disbelief Confusion Pre-occupation about the deceased Hallucination Hopelessness (I‘ll never be ok) 3. Physical sensation: Hollowness in the stomach. Tightness in the chest. Tightness in the throat. Oversensitivity to noise. Feeling of shortness of breath. Muscle weakness. 632
Lack of energy. Dry mouth. 4. Behaviour: Sleep disturbances. Appetite disturbances. Absent minded behaviour. Sighing. Crying. Carrying object that belongs to the deceased. Nurses Grief: Nurses may also experience grief when working specially with the dying patients as a results, this role in supporting the grieving patients and family can become complicated. So, when caring for clients experiencing grief, it is important for the nurses to assess your own emotional well-being. Self-reflection, which is a part of critical thinking, become a valuable tool in asking whether her personal sadness is related to caring for the client or to resolved personal experience from the past. It is not wrong to have a personal feelings and emotions. However, it is appropriate to put her personal family situation before the patient. Part of being a professional is to know when to get away of the situation and to care of oneself. Dying & Death: Stages of Dying: The purpose of knowing about the stages of grief and dying is to recognize what emotions and behaviour can occur and to plan interventions accordingly as they appear. The stages are as follows:1. Denial. 2. Anger. 3. Bargaining. 4. Depression. 5. Acceptence. 1.) Denial: Reaction – ―No-Not Me‖, ―There Must Be A Mistake‖ It served as a buffer to the patient to shield oneself until the individual is able to mobilize alternate defences. Anger: Reaction-―Why Me‖ In this stage the patient /client may developed anger and react hostilely which is directed towards the caregivers or the love ones. Bargaining: Reaction- ―Yes, But‖ In this stage, bargaining is often made with God. It is an attempt to postpone death and is a positive way to maintain hope. Depression: Reaction – ―Yes, ME‖ 633
It is a stage patient goes into a stage of sadness and grief and it is the time of introspection. Usually request only significant others to be with them. The patient struggles with the realities of life and preparing for death. Acceptance: Reaction –―I am Ready‖ The patient resolved to the fact that death is imminent. Peaceful acceptance and positive feeling are often present. The Dying Person’s Bill of Rights: 1. I have the right to be treated as a living human being until I die. 2. I have a right to maintain a sense of hopefulness, however changing its focus may be. 3. I have the right to be cared for by those who can maintain a sense of hopefulness however changing it might be. 4. I have the right to express my feelings and emotions about my approaching death in my own way. 5. I have the right to participate in decision concerning my care. 6. I have the right to expect continuing medical nursing attention even though ‗CURE‘ goals must have change to ‗COMFORT‘ goals 7. I have the right not to die alone. 8. I have the right to be free from pain. 9. I have the right to have my questions answered honestly. 10. I have the right not to deceive. 11. I have the right to have help from and for my family in accepting my death. 12. I have the right to die in peace and in dignity. 13. I have the right to retain my individuality not to be judged for my decisions which may contrary to the beliefs of others. 14. I have the right to expect that the sanctity of the human body will be respected after death. 15. I have the right to be cared for my caring, sensitive, knowledgeable people who will attempt to understand my needs and will be able to gain some satisfaction in helping me face my death. Nursing Care of Dying Patient: Physiological Needs: According to Maslow‘s Hierarchy of needs, physiological needs must be met before others, because they are essential for existence. Areas that are often problematic for the terminally ill client are respirations, fluids & nutrition, mouth, eyes and nose, mobility, skin care and elimination. Respiration: Oxygen is frequently ordered for the client experiencing laboured breathing. Suctioning may be needed to remove secretions that the client is unable to swallow. Fluids & Nutrition: The refusal of food and fluids is almost universal in dying clients. It is believed that the client is not feeling thirst and hunger. Although the issue of permitting dehydration in terminally ill clients is often met with great resistance. 634
Artificial nutrition often increases the client agitation leads to increased use of limb restraints and increases the risk of aspiration pneumonia. Hospice nurses have indicated that withholding artificial nutrition is not painful. Regardless, in every situation, the client the client‘s own wishes must always take precedence. If the comatose client has not previously made his wishes known, family members must be given accurate and truthful information. For the person in irreversible coma, withholding artificial nutrition does not causes death rather it allows life to take its natural course and it should be discontinue to support nutritionally if the client request. Mouth, Eyes & Nose: Mouth: Oral discomfort is the only documented side effect of dehydration in the terminally ill client. Both the administration of oxygen and mouth breathing increase the need for meticulous oral care. Caregiver can use saliva substitutes and moisturizers to alleviate discomfort. Regular brushing of teeth should be encouraged and the tongue must also be given the same attention as is the rest of the mouth. Ice chips and sips of favourable beverages should be offered frequently and petroleum jelly applied to the lips. Oral care must be given every 2-3 hrs to maintain the client‘s comfort. Eyes: Due to the dryness the eyes may become irritated and artificial tears can alleviate this discomfort Therefore wiping off the tears from inner to outer cantus to remove the discharges. Nose: The nares may become dry and crusted. Oxygen given by the cannula can further irritate the nares. So, a thin layer of water soluble jelly applied to the nares will be helpful to alleviate discomfort. Mobility: As the client‘s condition deteriorates, mobility decreases. Te client become less able to move about in bed or to get out of the bed and requires more assistance. Therefore physical dependence increases the risk of complication related to immobility. E.g Atrophy &pressure ulcer. Nursing Management: Frequently re-positioning according to the patient and considering the underlining condition of the patient such as arthritis & lung disease. Passive range of motion exercise should be done 2 times (twice) a day to prevent stiffness and aching of the joints. Using a wheelchair can also increase the client‘s environmental space, giving the client more mobility, control, and independence.
635
Skin Care: Prevention of pressure ulcer is the priority. These are painful and can cause secondary complication such as sepsis and are costly to treat. In addition to the care of the pressure point keeping the skin clean moisturized promotes healthy tissue. The skin should be inspected twice daily. Gentle massages with soothing lotion are comforting. Bed bath are adequate if the client cannot get into the tub or sit in the shower chair. Elimination: Constipation may occur due to the side effects of the analgesics and the lack of physical activities. Fluids and foods with high fibre contained can be effective preventive measures for the client with adequate oral intake. It can also be alleviated by maintaining a scheduled time for bowel elimination and administering suppositories if necessary The client may have incontinence of bladder and bowel, so the nurse need to check the client frequently, clean the skin the peri-wash, apply a moisture barrier after each incontinence episode. Comfort Pain relief Keep the patient clean and dry. Provide a safe and non threatening environment. Provide a respectful, careful attitude to provide psychological comfort by establishing good rapport. Physical environment: A soothing physical environment can significantly increase the clients comfort Adequate lighting enhances vision without causing discomfort associated with harsh, glaring light. Provide night light if patient requires As the client circulation slightly sluggish, the body temperature will fall, so providing a light weight comforters will be helpful to warmth without adding uncomfortable weight. Provide quite and calm environment.( even the phone can be removed if patient find it disturbing. Psychosocial needs: Death presents a threat to not only ones physical existence but to ones psychological integrity. Even though in the presence of the nurse, the family members should be encouraged and invited to participated in the clients care, if they desire to do so and the client is willing Maintain a well groomed appearance is important. cutting the nails, shaving the beard will help to promote patients dignity. Combing and brushing the hair not only improves appearance but is also a comforting and relaxing activity for many clients. Spiritual needs 636
The nurses play a major role in promoting the dying clients spiritual comfort. Dying persons are among the most vulnerable members of the human family. Communicate empathy. Play music. Use touch. Pray with the client. Contact clergy if requested by the client. Read religious literature aloud, at the patient request. Support for the family: The family member needs to be involved in the care of their dying lived one. Guilt may be increased by the feeling of powerlessness. Involving the family members in the treatment is a helpful intervention The families facing the impending death of the loved one require much support from the nurses and the care givers. o Being with the family members is extremely important o Provide assistance and guidance if the family members have limited coping skills and inadequate supporting system. o She must be supportive and non judgmental Legal consideration during death: The Patient Self Determination Act (PSDA) was incorporated into the Omnibus budget reconciliation Act (OBRA) of 1990. The Act was intended to provide a legal means for individuals to determine the circumstances under which life sustaining treatment should or should not be provided to them. The individuals choice are validated by advanced directives An advanced directive is any written instruction including a living will or durable power of attorney for health care that is recognised under state law( Taylor 1995) The act applied to hospitals, long term care facilities , home care agencies, hospice programs, and certain health maintenance organisations (HMOS) All the clients entering into the healthcare system through this organisation must be given information regarding the complete care. It is necessary not only to inform about the care but also the need to indicate the wishes in regarding to artificial feeding, intubation, chemotherapy, surgery, blood transfusion etc. Although the living will and durable power of attorney for health care are legal documents, they do not preclude the need for resuscitation The medical record must have a written DNR (Do-Not-Resuscitate) order from a physician if this is in agreement with the client wishes and with the advanced directives. In the absence of this order resuscitation is not initiated. Ethical consideration during dying: Death is often fraught with ethical dilemmas that occur almost daily in health care settings. Many health care agencies have ethics committees to develop and implement policies to deal with and to end-to-life issues Ethical decision making is a complex issue. One of the most ethical dilemmas is determining the difference between killing and allowing someone to die with holding life-sustaining treatment methods. 637
The ANA distinguish reliving pain and mercy killing( euthanasia or assisted suicide) Pain relief is a central value in nursing, where as euthanasia is viewed as unethical. The ANA‘s position is that increasing dose of medication to control pain in terminally ill client is ethically justified even at the expenses of maintaining life. Care Of The Body After Death: Body changes: Rigor Mortis: The stiffening of the body that occurs about 2-4 hrs after death. It results from the lack of Adenosine Triphosphate (ATP), which is not synthesized because of the lack of glycogen in the body. Its lack causes the muscles to contract, which in turn immobilizes the joints. Rigor mortis starts in the involuntary muscles (heart, bladder, and so on) then progresses to the head, neck and trunk, and finally reaches the extremities. Because the deceased families often wants to view the body, and because it is important that the deceased appear natural and comfortable, nurses need to position the body, place dentures in mouth, and close the eyes and mouth before rigor mortis sets in. Rigor mortis usually leaves the body about 96 hrs. After death. Algor Mortis: It is the gradual decrease of body temperature after death. When blood circulation terminates and hypothalamus ceases to function, body temperature falls about 1degree centigrade (1.8 F) per hour until it reaches room temperature. Simultaneously, the skin loses its elasticity and can easily be broken when removing dressing or adhesive tape. Livor Mortis: After the blood circulation has ceased, the skin become discoloured. Red blood cells break down, releasing haemoglobin, which discolours the surrounding tissues. This discoloration is known as LIVOR MORTIS Tissues after death become soft and eventually liquefied by bacterial fermentation. The hotter the temperature, the more rapid the changes. Therefore, bodies often stored in cool place to delay the process. Embalming reverse the process through injection of chemicals into the body to destroy the bacteria. Legal Aspects of Death: Of many legal ramifications of human death, the most basic for the nurses is that death must be certified by a physician. In circumstances of unusual death, an autopsy (post-mortem examination) may be required. Nurses have a responsibility to be aware of the legal ramifications of death in the jurisdiction in which they practice Nursing Intervention: Nursing personnel may be responsible for the care of a body after death. Make the environment clean and pleasant as possible and to make the body appear natural and comfortable. Remove all the equipments and supplies from the bedside. Remove the soiled linen in order to make the room free from odour. 638
Care of the body may be influenced by religious law, the nurse should check the client‘s religion and make very attempt to comply. The body should be placed in a supine position with the arm either at the sides, palms down, or across the abdomen. The wrist band should be left on unless it is too tight. A pillow should be placed under the head and the shoulders to prevent blood from discolouring the face by settling in it. The eyelids are closed and held in place for a few seconds so that they remain closed. Dentures are usually inserted to help give the face a natural appearance. The mouth should be closed (a role towel under the chin will hold it closed). Soiled areas of the body are washed or a complete bath should be given. Absorbent pads are placed under the buttocks to take up any faeces and urine released because of the relaxation of the sphincter muscles. A clean gown should be placed on the client, and the hair is brushed and combed. All the jewelleries are removed except the band in some instances, which is taped to the finger. The top bed linen should be adjusted neatly to cover the client till the shoulders. All the client‘s valuables including clothing are listed and placed in a safe storage area for the family to take away or to handover it to them. After the body has been viewed by the family, additional identification tags are applied, one to the ankle and one to the wrist if the client‘s wrist identification band was not left in place. The body should be wrapped in a shroud (a large rectangular or square piece of plastic a cotton material used to enclose a body after death). Another identification tag should be applied to the outside of the shroud. Then the body should be taken to the morgue for cooling, if arrangement has not been made to have a mortician pick it up from the client‘s room or the client should be hand over to the family members after recording and reporting. CONCLUSION: By acquiring the above knowledge of the clients in the state of LOSS, GRIEF, DEATH and DYING the group will be able to appreciate the nursing practice in managing such a client.
639
BIBLIOGRAPHY: 1. Potter & Perry‘s ―Basic Nursing; Essentials For practice‖ 5th edition, published by Mosby, 2004, Noida, New Delhi. Page No. 39-40 2. Kozier, Erb, Blais & Wilkinson‘s ―Fundamental of Nursing‖ 5th edition, published by Addison-Wesley, New York. Page No. 852-874 3. Carol Taylor, Carol Lillis, Priscilla Le Mone‘s ―Foundation Of Nursing, The Art & Science of Nursing Care‖ 4th edition, published by J.B.Lipincott, 2001, Philadelphia. Page No. 726-750 4. Barbara Christensen, Elaine Kockrow‘s ―Foundation of Nursing‖ 2nd edition, published by Mosby, Chicago, London Page No. 1569-1585 5. Hudak‘s ―Critical Care Nursing: A Holistic Approach‖ 6th edition, published by J.B.Lipincott Company.1994, Philadelphia. Page No. 9-21 6. www.answer.com 7. www.google.com JOURNALS 1. The ICFAI Journal of Healthcare Law May 2006. 2. The ICFAI Journal of Healthcare Law, November 2007.
640
PHASES OF COUNSELLING Before proceeding to the counselling it is better to identify some common phases of the counselling process, although it is difficult to divide such a carried process into neat clearly defined phases. These phases include the following:I. Establishing relationship. II. Assessment. III. Setting goals. IV. Intervention. V. Termination and follow-up. The phases may overlap each another, e.g. the assessment may begin even while the phases of establishing the relationship is still going on or goal setting may start while assessment is still going on. These phases are in the progressive movement and collectively describe the counselling process.
Fig. Phases of counselling Phase – 1: Establishing Relationship: It is the core phase in the process of counselling. It affects the progress of the process and acts as a curative agent in itself. It should be recognised that each counsellee-counsellor relationship is unique and hence it is not possible to have a generalised relationship. It includes each factor as respect, tryst and a sense of psychological comfort. Begin this phase with adequate social skills: Introduce yourself. Listen attentively and remember the client‘s name Always address the individual by his/her preferred name. Ensure physical comfort. Do not interrupt the individual while he/she is talking. Observe the non-verbal communication. The relationship is not establish in just a single session but may require several sessions before he/she becomes comfortable with you and accepts you into his/her inner world. Phase – 2: Assessment: The major purpose of this phase is to provide direction to the individual and counsellor.
641
In this phase the individual are encourage to talk about their problems, counsellor ask questions, collect information, seeks his/her views observe and possibly help the individual to clearly state his/her problem. This is the data collecting phase and it involves several skills such as: Observation. Enquiry. Making association among facts. Recording. Making educated guesses. Recording of information should be done systematically and promptly. Phase – 3: Setting Goal: The major purpose of this goal is to provide direction to the individual and counsellor. It involves making a commitment to a set of condition, a course of action, or an outcome. Setting goals help us to know how well counselling is working and when counselling may be concluded. The process of setting goals is cooperately done by the counsellor and the individual. It requires: The skill of drawing inference. Differentiation and Teaching the individual to think realistically. It should be emphasised that the goal are not fixed for all time to come and can be changed whenever new information is received or new insight is developed. Phase – 4: Intervention: It is a point which is the more influenced by the view point a counsellor holds about a counselling process. After setting the goals the question that follows is ―how shall we accomplish these goals?‖ the intervention used will depend upon the approach used by the counsellor, the problem approach used by the counsellor, the problem and the individual. Hence the choice of the intervention is a process of adaptation and the counsellor should change the intervention when the selected intervention is not working. This is similar with the medical treatment. When one treatment does not work the practitioner tries the alternative treatment. The counselling skills needed are skill in handling the interventions, knowledge of its effects and the ability to read client‘s of its effects and ability to read client‘s reaction. Individual can b asked in the beginning about what intervention they have earlier so that other intervention can be used. Phase – 5: Termination and Follow-Up: All counselling has its ultimate criterion a successful termination. It must be done without destroying the accomplishments gained and should be done with sensitivity, intention and by fading. It is not unusual for the individual to have a feeling of a sense loss; hence termination should be planned over few sessions. Follow-up appointment can also be fixed for sometimes.
642
UNIT-IX
643
SYLLABUS Unit Hours IX
10
Content Nursing practice: �Framework, scope and trends. �Alternative modalities of care, alternative systems of health and complimentary therapies. �Extended and expanded role of the nurse, in promotive, preventive, curative and restorative health care delivery system in community and institutions. �Health promotion and primary health care. �Independent practice issues,- Independent nurse-midwifery practitioner. �Collaboration issues and models-within and outside nursing. �Models of Prevention, �Family nursing, Home nursing, �Gender sensitive issues and women empowerment. �Disaster nursing. �Geriatric considerations in nursing. �Evidence based nursing practice- Best practices �Trans-cultural nursing.
644
FRAMEWORK, SCOPE AND TRENDS Framework: Introduction: Society and its health care need always evolving. As a result, health care faces many challenges, including rising costs, shortage of professionals, an aging population, the introduction of new technology and difficulties with access to care. The demand for collaborative, innovative clinical practitioners to act as leaders in healthcare has never been stronger. Nurses in advanced nursing practice are well positioned to respond to the evolution of health care. In particular advanced nursing plays a key roll in meeting the health needs. By building the nursing knowledge, advancing the nursing profession and contributing to a sustained and effective health-care system. Definition of Nursing Practice: Advanced nursing practice is an umbrella term describing an advanced level of clinical nursing practice that maximizes the use of graduate educational preparation, in depth nursing knowledge & expertise in meeting the health needs of the individuals, families, groups, communities & populations. It involves: Analyzing & synthesizing knowledge. Understanding, interpreting & applying nursing theory & research. Developing & advancing nursing knowledge & the profession as the whole. Characteristics of Nursing Practice: In advanced nursing practice, nurses build on their expertise in a speciality area, integrating and consistently displaying the following features and characteristics: Provision of effective and efficient care, delivered with a high degree of autonomy, Demonstration of leadership and initiation of change to improve client, organization and system outcomes. Deliberate, purposeful and integrated use of in-depth nursing knowledge, research and clinical expertise. Depth and breadth of knowledge that draws on a wide range of strategies to meet the needs of clients and to improve access to and quality of care. Ability to explain and apply the theoretical, empirical, ethical and experiential foundations of nursing practice. Understanding, development and dissemination of evidence-based nursing knowledge. Ability to initiate or participate in planning, coordinating, implementing and evaluating programes to meet client needs and support nursing practice. Demonstration of advanced judgment and decision-making skills. Critical analysis of and influence on health policy. Development of the Framework: One of the first priorities of the vice president and CNO (Chief Nursing Officer) of the Calgary Health Region was to develop a vision for nursing in the region. Through the development of this vision, it became apparent that a mission for nursing was also essential. As this work progressed, an evident need emerged to establish a definition of 645
professional practice and a guideline or framework that nurses could utilize on a daily basis to achieve the vision and mission of nursing in the region. Approval of the Framework: After several months of consultations with nurses across the Region, discussion at Regional Nursing Council and numerous revisions, the final draft of the professional Practice Framework was approved by Nursing Council and distributes during Nurses Week 2003. The Professional Nursing Practice Framework for the Calgary Health Region is depicted in Figure 1. Figure1. Professional Nursing Practice Framework, Calgary Health Region
The Art of Nursing: Nurses demonstrate ethical, insightful, caring practice by focusing on the health and well-being of individuals, families and communities is health and during episodes of illness and transition.
Attributes of Practice: Autonomous professional practice in nursing requires taking personal responsibility for excellence in practice and effective collaboration with multidisciplinary team members in meeting the health needs of the population.
Competence: Nurses‘ competence is grounded upon nursing theory, scientific knowledge and experience, and is reflected in everyday practice. It is enhanced through continuous learning, shared through mentorship and supported through intra and interprofessional dialogue.
Personal Commitment: Nurses demonstrate commitment to the profession by valuing nurses and nursing, contributing of the advancement of the profession and continually striving for excellence in patient care.
646
The framework is congruent with the values of the Calgary Health Region (Honesty, Integrity, Dignity, Trust, Respect, Responsiveness, Creativity and Learning). It reflects elements that are common to other professional practice frameworks described in the literature. The framework reinforces the prerequisites for the promotion of safe, competent and ethical nursing practice that are inherent: in the standards of practice & the professional body that regulates the practice of registered nurses in the province. The framework logo depicted in Figure 1 was designed by one of the members of Regional Nursing council and is an expression of her belief that the nurse‘s cap has traditionally been an important symbol of professionalism in nursing. Implementation of the Framework: Numerous sessions were held to familiarize nursing staff with the framework when it was first launched. Introduction to the framework is now routinely incorporated into the orientation of all new nurses who join the Region. The frame-work also gives the development of preceptors and change nurses. The major elements of the framework have been linked to the expected RN, LPN and RPN competencies articulated in job descriptions, and application of the framework in practice is not incorporated into nurse‘s ongoing professional development and continuing education plans. Further elaboration of frame work will be ongoing. For example use of the framework has exposed the Need to clarify some of its terms; such has ―insightful practice‖. Evaluation and Research: Now that the Professional Practice Framework has been articulated, it will be important to determine the effectiveness with which it is being implemented across the many sites and settings in this large regional health authority and measure its impact on practice and patient outcomes. Over the course of the next several years, specific implementation initiatives will be targeted for evaluation and research. An overchanging framework will be developed to guide the evaluation of specific initiatives. Answers will be sought to such questions as: What facilitated ―internalization‖ of the Professional Practice Framework? Did its implementation change nursing practice of select units? Did changes in nursing practice affect the roles of other members of the healthcare team? What difference, if any, did implementation of a Professional Practice Framework make in job satisfaction and patient outcomes? What went well in implementing the framework? What could have been done differently? Scope in Nursing Practice: Nursing is responsible for articulating and disseminating clear definitions of the roles nurses engage in, and the profession‘s scope of practice. National professional organisations bear the responsibility for defining nursing and nurses‘ roles that are consistent with accepted international definitions articulated by the International Council of Nurses, and relevant to their nation‘s health care needs. While nurses, through professional, labour relations and regulatory bodies, bear primary responsibility for defining, monitoring and periodically evaluating roles and scope of practice, the views of others in society should be sought and considered in defining scope of practice. 647
The scope of practice is not limited to specific tasks, functions or responsibilities but includes direct care giving and evaluation of its impact, advocating for patients and for health, supervising and delegating to others, leading, managing, teaching, undertaking research and developing health policy for health care systems. Furthermore, as the scope of practice is dynamic and responsive to health needs, development of knowledge, and technological advances, periodic review is required to ensure that it continues to be consistent with current health needs and supports improved health outcomes. National nurses associations (NNAs) have a responsibility to seek support for legislation which recognises the distinctive and autonomous nature of nursing practice, including a defined scope of practice. Background: The scope of practice is defined within a legislative regulatory framework, and communicates to others the roles, competencies (knowledge, skills and attitudes) and the professional accountability of the nurse. Nursing‘s authority comes from evidence-based knowledge related to its sphere of practice. However, nursing is also allied to other health professions through its collaborating, referring, and co-ordinating activities, and thus has developed a distinct as well as a shared body of knowledge and practice. The practice and competence of an individual nurse within the legal scope of practice is influenced by a variety of factors including education, experience, expertise and interests as well as the context of practice. Therefore, definitions of roles and scope of practice need to reflect what is distinctly nursing, while communicating the multidisciplinary and interdisciplinary nature of health care. Nurses require appropriate initial and ongoing education and training as well as lifelong learning to practice competently within their scope of practice. Therefore, nursing must ensure that nurse educators and nurses managing nursing services are experienced nurses with suitable qualifications and understanding of the competencies and conditions required to deliver quality nursing care in the current health care environment. To enable the profession to provide competent leadership, NNAs should be vigilant in assuring that nurses are prepared with the necessary competencies to function in leadership roles at all levels of the health system. NNAs are also responsible for ensuring that nurses are major participants in the planning and direction of nursing education, nursing services, regulatory bodies and other health related activities.Nursing is a dynamic profession that has evolved in response to changing needs, demands and resources of our society. The complexity of the health care delivery system today is such that the role and responsibility of the nurse within this system can change. Each registered nurse is responsible and accountable for making decisions and practicing in accordance with his/her educational background and experience in nursing within the statutory parameters of the Nurse Practice Act.
648
The Scope of Nursing Practice: Nursing, like other professions, is accountable for ensuring that its members act in the public interest and provide the unique service that has been designated to them by society. This process is called professional regulation. The profession of nursing regulates itself through defining practice, establishing an educational system, providing research to further develop the practice base and developing the standards of practice and a code of ethics. In turn, the state, through statues, attests to the public that registered nurses meet minimal standards for practice and prohibits unlicensed individuals from practicing as registered nurses. The legal boundaries of the scope of practice are determined by the definition of nursing found in the Nurse Practice Act (NPA) and provide the basis for interpreting the practice of the individual registered nurse. Since each state has legal authority for the regulation of nursing, the definition, and therefore the scope of nursing practice may vary from state to state. However, the purpose of the law remains consistent to protect the public. Nurse Practice Act: The Nurse Practice Act was enacted by the legislature to regulate the practice of nursing and to define the parameters of nursing practice for the purpose of protecting the public. The act does not address specific nursing duties that are proper to be performed by nurses, or hospital staffing patterns, labor practices or employment criteria. The Nurse Practice Act is designed to protect the public from incompetent nursing practice, not to protect nurses from discriminatory or questionable employment practices. Each nurse is responsible and accountable for making decisions and practicing in accordance with that individual's educational background and experience in nursing. Nursing Practice in Different Settings: Individual RNs Responsibility: The registered nurse is responsible and accountable, professionally and legally, for determining his/her professional scope of nursing practice. Since the role and responsibilities of nurses, and consequently the scope of nursing practice, is ever changing and increasing in complexity, it is important that the nurse makes decisions regarding his/her own scope of practice. The Nurse Manager & Nurse Executive's Responsibility: As a registered nurse, the nurse manager is responsible and accountable, professionally and legally, for determining his/her professional scope of practice. The nurse manger makes decisions regarding the roles and responsibilities for nurses within the institution or agency in order to provide quality care. The nurse executive, in a changing and complex health delivery system, is knowledgeable regarding changes in rules and regulations, accreditation standards and standards of care and practice, in addition to evaluation of the boundaries specified in the Nurse Practice Act. The nurse executive and/or the nurse manager facilitate changes to assure quality patient care outcomes and develop mechanisms that will promote the same. 649
Mobile Nursing Practic: In 1984 a need was seen to offer more extensive home health care for local residents who preferred to receive needed care in their own homes. This enabled many to reduce costs and remain in their homes, at least for a longer period of time. This organization became known as Mobile Health Care, Ltd. and was later changed to Mobile Nursing Services, Ltd. This was the areas‘ first private home health care delivery system. It was the first to offer such services at all times of the day and night. Previously such care was available only during regular business hours. Mobile Nursing Services has been a leader and innovator in the field of home health care and has transformed this important method of healthcare delivery in the southeast Iowa area. It is the largest and oldest home health care system in the area, except for public organizations, and it has had a favorable competitive effect on those, resulting in overall improved care for the area residents from a variety of public and private sources. Mobile introduced many innovations into the local home health care market and continues to do so. Mobile nursing services: These services provide home teaching and care for patients with varied needs and health problems. Patients discharged early from hospitals. Patients suffering from chronic and acute medical problems. Surgical Patients. Patients requiring IV therapy. The elderly. Respiratory patients. The seriously ill. Patients in need of medication management (including pain control). Hospice Concept. Ventilator Dependent. (Assistance) with Bathing, Dressing, Meals, Transportation, Light Housekeeping. Services may be covered by Medicare, Medicaid, private insurance, private payment, VA or other third party payers. Military Nursing Services: First World War: The Military Nursing Service has its origin from the Army Nursing Service formed in 1881 part of Royal Army. The Army nurses served in Flanders, the Mediterranean, the Balkans, the Middle East and onboard hospital ships. After, the war on 1st October1926, the Nursing Services was granted permanent status in Indian Army. This date is formally recognised as the formation day of Military Nursing Service, though in actual its origins occurred 45 five years before.
650
Second World War: With the outbreak of second world war, nurses once again found themselves serving all over the world. During the middle of the war in 1943, the Indian arm of the Nursing Services was separated through Indian Military Nursing Service Ordinance, 1943 and redesignated it, there by constituting the Military Nursing Service (MNS) in its present form. The Officers of the Military Nursing Service are governed by Indian Military Nursing Service Ordinance 1943 and Military Nursing Service Rules, 1944. The Section 5 of the ordinance provides that, all members of the Indian Military Nursing Service shall be of commissioned rank and shall be appointed as officers of the Indian Military Nursing Service by the Central Government by notification in the Official Gazette. The Nursing Service Officers are also subject to Army Act 1950, Army Rules 1954, Defence Service Regulations and various Government Orders, Army Instructions, Army Orders, issued from time to time. The Military Nursing Service stands out as one of the oldest services where women have contributed directly to the nation‘s war effort by providing care to the sick and wounded soldiers. This is also true for all the armed forces of the world. The army nurses have made a permanent place in every Nation‘s heart by nursing millions of sick and wounded soldiers back to health. The Officers of Military Nursing Service had distinguished them selves in the Second World War, through the care of the sick and wounded soldiers in India and also at many foreign theatres of war. Post independence, the Nursing Officers cared for the wounded soldiers in five major bloody conflicts with the neighboring countries. Rank Structure: The various ranks of the Military Nursing Service are listed below in descending order: Commissioned Officers. Major-General. Brigadier. Colonel. Lieutenant-Colonel. Major. Captain. Lieutenant. Presently there are no personnel below officer rank (PBOR) in Military Nursing Service as the other nursing personnel such as Nursing Assistants, Ambulance assistant; Stretcher Bearer etc are part of Army Medical Corps.
651
Tele-nursing: Refers to the use of Telecommunications and information technology for providing nursing services in health care whenever a large physical distance exists between patient and nurse, or between any numbers of nurses. As a field it is part of Tele-health, and has many points of contacts with other medical and non-medical applications, such as Tele-diagnosis, Tele-consultation, Telemonitoring, etc. Tele-nursing is achieving a large rate of growth in many countries, due to several factors: the preoccupation in driving down the costs of health care, an increase in the number of aging and chronically ill population, and the increase in coverage of health care to distant, rural, small or sparsely populated regions. Among its many benefits, Tele-nursing may help solve increasing shortages of nurses; to reduce distances and save travel time, and to keep patients out of hospital. A greater degree of job satisfaction has been registered among. Tele-nurses. Applications: One of the most distinctive Tele-nursing applications is home care., In normal home health care, one nurse is able to visit up to 5-7 patients per day. Using Tele-nursing, one nurse can ―visit‖ 12-16 patients in the same amount of time. [Needs source] A common application of Tele-nursing is also used by call centers operated by managed care organizations, which are staffed by registered nurses who act as case managers or perform patient triage, information and counseling as a means of regulating patient access and flow and decrease the use of emergency rooms. Tele-nursing can also involve other activities such as patient education, nursing Teleconsultations, examination of results of medical tests and exams, and assistance to physicians in the implementation of medical treatment protocols. The Nursing Robot: "Development of a Nursing Robot System" included the development of a mobile robot system (the Nursing Robot) to help physically handicapped people. Completed in 1986, the Nursing Robot was one of the first fully functioning mobile robots equipped with a manipulator arm. Also integrated were seven different sensor systems. The system was controlled by four networked onboard Sinclair Spectrum Computers and an off-board IBM-PC. This document describes the features of the mobile Nursing Robot System developed at the Technion. The Nursing Robot System comprises three major components: a self-propelled vehicle, a robotic arm mounted on it, and a communications post (workstation) next to the disabled person's bed. Onboard the mobile robot low-cost microcomputers are interconnected as a hierarchical network, in order to control a variety of activities: Sensor data processing, motion control, path-planning, communication, and others. The vehicle can move autonomously in a room with unexpected obstacles.
652
Nursing in Occupational Health: Occupational Health Nurses (OHN): Are registered nurses who independently observe and assess the worker's health status with respect to job tasks and hazards? Using their specialized experience and education, these registered nurses recognize and prevent health effects from hazardous exposures and treat workers' injuries/illnesses. Scope: Educationally prepared to recognize adverse health effects of occupational exposure and address methods for hazard abatement and control, OHNs bring their nursing expertise to all industries such as meat packing, manufacturing, construction as well as the health care industry. OHNs: Have special knowledge of workplace hazards and the relationship to the employee health status. Understand industrial hygiene principles of engineering controls, administrative controls, and personal protective equipment. Have knowledge of toxicology and epidemiology as related to the employee and the work site. OHN Activities: Observation and assessment of both the worker and the work environment. Interpretation and evaluation of the worker's medical and occupational history, subjective complaints, and physical examination, along with any laboratory values or other diagnostic screening tests, industrial hygiene and personal exposure monitoring values. Interpretation of medical diagnosis to workers and their employers. Appraisal of the work environment for potential exposures. Identification of abnormalities. Description of the worker's response to the exposures. Management of occupational and non-occupational illness and injury Documentation of the injury or illness. Academic Preparation: OHNs with varying degrees of academic preparation from entry level to PhD work in capacities commensurate with their experience and academic preparation: clinical nurse, clinical nurse manager, nurse manager, corporate nurse, nurse researcher, nurse educator and nurse consultant School health nurses: School nurses are primary care nurses for school children. They work with individual children, young people and families, schools and communities to improve health and tackle inequality. In addition they are recognized as contributing to raising education standards. A school nurse is a qualified, experienced professional and the only trained nurse working across health and education boundaries. They also provide the link between school, home and the community.
653
School health nurses responsibility School nurses have special responsibility for: Promoting healthy lifestyles and schools. Child and adolescent mental health. Chronic and complex health care needs in children and young people. Vulnerable children and young people. Activities of school health nurses: The school nurses work includes: Health assessments for children at entrance to school when required. Individual health interviews offered to young people aged 13-14 years. Immunisation programmes. Child protection. Health education. Space Nursing Society (SNS): Is an international space advocacy organization devoted to space nursing and the contribution to space exploration by Registered Nurses. SNS is an affiliated, non-profit special interest group associated with the National Space Society . The SNS provides a forum for the discussion and exploration of issues related to nursing in space and its impact upon the understanding of earthbound nursing through conference participation and its newsletter Expanding Horizons. The information being learned in the microgravity environment of space has tremendous applications for the bed-bound patient on earth. Bed rest is considered analogous to some of the reactions the astronauts have experienced in space, which include inner ear fluid shifts, loss of plasma volume, muscle atrophy, demineralization and calcium/bone loss. If one were to consider the issues of confined spaces, closed ecological systems with little personal space, and psychological-social interactions, there are many earth-bound counterparts that could benefit from what is being learned via space research. Legal Regulation: Nursing practice in Connecticut is regulated by Connecticut statutes. The professional nurse is responsible and accountable for making decisions that are based upon the individual's educational preparation and experience in nursing. Behaviors and activities of the nurse relating to the scope of practice that could lead to disciplinary action are: Performing acts beyond the authorized scope of practice for the level of nursing for which the individual is licensed. Assuming duties and responsibilities within the scope of nursing practice without adequate preparation or when competency has not been maintained. Failing to take appropriate action or to follow policies and procedures in the practice situation designed to safeguard the patient. Assigning or delegating unqualified persons to perform functions of licensed nurses contrary to the Nurse Practice Act or to the detriment of patient safety. Willfully or negligently failing to take appropriate action in safeguarding a patient or the public from incompetent practice performed by a registered professional nurse or a 654
licensed practical nurse. "Appropriate action" may include reporting to the State Board of Examiners for Nursing (SBEN). Connecticut State Board of Examiners for Nursing (SBEN) The SBEN was established in 1905 by the state government to protect the public's health and safety by overseeing certain aspects of the practice of nursing of licensed practical nurses, registered nurses and advanced practice registered nurses, but not certified nurse aides. The SBEN achieves this mission pursuant to Connecticut General Statutes Section 20-88 and 20-90 by advising the commissioner of public health about regulations for nursing programs and approving programs within schools of nursing and by adjudicating complaints filed against licensed practitioners and imposing sanctions when appropriate. The SBEN takes action against the licenses of those nurses who have exhibited unsafe nursing practice. In addition, the SBEN reviews and provides advisory guidance regarding scope of practice questions using the "Nursing Competency/ Scope of Practice Decision-- Making Model. The SBEN has the authority to suspend or revoke a license or discipline a nurse for misconduct, incompetence or negligence. The burden is upon the nurse, the licensee, to act at all times as a reasonable and prudent professional should act, in accordance with the prevalent professional standards. The SBEN can give direction before a given act is performed about whether it is permissible to perform that particular act. However, this direction must be specifically requested. A routine function of the SBEN is to respond to or comment upon practice questions. The majority of such requests are for clarification of a given activity with regard to the nurse's "proper" scope of practice. In specific instances specific guidance is given in a position statement. It is not a reasonable expectation that the SBEN can respond to each and every nurse's specific practice questions with position statements. Nurses need to recognize that, because they are individually licensed, they are liable for nursing judgment and action and obligated to make responsible practice decisions. The SBEN is authorized by the state to discipline nurses who are unable or unwilling to practice competently, but it has no authority over health facilities or other health care providers. Tends In Nursing Practice: Trends in nursing are closely tied to what is happening to healthcare in general. Trends are fascinating phenomena, but they do not exist in vacuums. Most are interrelated; one trend often spawns another. Although trends are more than fads, they are far from moneyback guarantees. We watch to anticipate the direction that a particular trend will take us, to remove the element of surprise. When we look back on trends, however, some will have heralded permanent changes, but others might have been no more than blips on the radar screen.
655
Broadening Focus: The focus of nursing has broadened from the care of the ill person to the care of the people in illness and from care of only the patient to care of the client, the family, and in some instance the community. In the past, nursing, like medicine was oriented towards disease and illness. Today, there is increasing recognition of peoples need for health care as distinct from illness care and of the nurses‘ independent functions in this area. Another aspect of the broader nursing focus to the movement of nursing practice into the community. In a sense, there is a return to the beginning of nursing, that is before it becomes a recognized occupation. Through out much of this century however nurses worked only in institution, increasingly nursing services are provided in community often in homes and clinics. The nursing activity not only assists those who are ill but also helps those who are healthy to maintain or continue their health. Scientific basis: In the past nursing largely was either intuitive or relied on experience or observation rather than on research. Through trail and error the individual nurses discovered with measures would assist the client and many nurses became highly skilled in providing care through experience. Technology: Technology or mechanization is being applied in the health field extensively. Certain areas of a hospital are more technologic than others. Nurses find themselves in the midst of this rapidly changing, increasingly technologic environment in hospital and in client‘s homes. Indicators of increasing technology include:a. The proliferation of technologic equipment used in case of clients in hospitals and homes. b. The increasing home and self care equipment. c. Use of computers in many areas of health care. Many nurses feel they need more education to obtain the knowledge and skills necessary to use the new technology. High technology has enabled nurses to gather client assessment data through non-invasive techniques (E.g. pulse oxymetry) rather than, through the costly invasive procedure. Renewed focusing caring: The increasing use of technology in hospitals and homes has created an increasing need to humanize. Nursing has traditionally been a caring and humanizing profession. Indicators of this trend include:a. The increasing number of professionals, articles and books about balancing of caring and technical skills. b. Many studies regarding caring as an aspect of nursing. c. Increasing recognition in nursing of needs of clients in technology and environment.
656
Expansion of employment opportunities: Nursing practice trends include a growing variety of employment setting in which nurses have greater independence, autonomy, and respect as member of the health care team. Nursing roles continue to expand and develop, broadening the focus of nursing care and providing a more holistic and all-encompassing domain. Nursing therapies are not only drawing from traditional nursing and medicine, spiritual and emotional realms, but also expanding into alternative therapies such as healing touch, massage therapy and use of natural herbs and vitamins. Nursing’s public perception: Any member of society who has been ill, hospitalized or visited an emergency department has experienced nursing campaign noted ―everybody needs a nurse‖. The Johnson and Johnson foundation has developed compelling, attention getting media campaign on the nursing profession. These media clips show nursing practice, and the nurses featured in the advertisement and described their satisfaction in the profession. Nursing is a pivotal health care profession, as frontline health care providers, nurses‘ practice in all health care settings and constitute the largest number of professionals. Nurses are essential to provide skilled, specialized, knowledgeable care, to improve the health status of the public, and to ensure safe, effective quality care. In addition, the American public rated nurses high in honesty and ethics in their professional role. Nursing’s impact on politics and health policy: The ability to influence or persuade an individual holding a government office to exert the power of that office to affect a decide outcome is known as political power or influence. Nurse‘s involvement in politics is receiving greater emphasis in nursing curricula, professional organizations, and health care settings. Professional nursing organizations have employed lobbyists to urge State legislatures and the US Congress to improve the quality of health care. The ANA works for the improvement of health standards and the availability of health care services for all people. Fosters high standards of nursing, stimulates and promotes the professional developments of nurses, and advances their economic and general welfare. The purposes are unrestricted by considerations of nationality, race, creed, lifestyle, colour, sex or age. The ANA employees RNs as lobbyists at the federal level and State nursing organizations also hire lobbyists and legislative specialties to work on State nursing issues and assist with federal efforts. Lobbyists working on behalf of nursing are employed in Washington DC by professional organizations such as the American Federation of Teachers, NLN, and American College of Nurse-Midwives, American Public Health Association and AACN. This groups aim to remove financial barrier to health care, increase the quality of nursing care available, to increase economic rewards to nurses, expand professional nursing roles. In addition, individual nurses can influence policy decisions at all governmental levels. If nurses become serious students of social needs, activist in influencing policies to meet those needs and generous contributors of time and money to nursing and their organizations and to candidates working for universal good health care.
657
Nurses are becoming more involved in health care reform. Nursing‘s Agenda for Health Care Reform Supports the creation of health care system that ensured access, quality and services at affordable costs. The plan for reform focuses on primary health care service and promotions, restorations and maintenance of health. Healthy people 2010 are the document for public health policy for the new millennium. It outlines goals for vulnerable populations such as low income groups, minorities, persons with disabilities. Political activism and commitment are a part of professionalism; however politics are an important aspect of the delivery of health care. Therefore the nurses should view politics as a reality that includes the arts of influence, compromise and social interactions. Nurses have been involved in a different sort of politics in schools of nursing and in health care setting. When seeking more additional resource, more self directions accountability with authority. The skills gained in such experiences can be transferred to the politic of health care policy making. As long as nurses maintained involvement in health care policy and practice, outsiders can‘t attempt to impose their will on nursing and nursing practice. Nursing should have its own voice in decision made in these and numerous other areas affecting the practice and quality of nursing care. All though nurses have often successfully prevented infringement on the professions self governance, the future of nursing requires that nurses individually and collectively seek a greater influence on health care policies affecting nursing practice. Changing trends in nursing: Nursing has originated from the word ‗nurturing‘, which means nourishing, helping in growth and development of a human being. In the past, nursing was family-based work. Modern nursing began in the 19th century under the leadership of Florence Nightingale. The aim of nursing was only to promote the recovery of patients. Even now, the central concern of nursing is ‗nurturing the human beings‘. The present day nurse provides care for the people in health and illness. Nursing is one of the health services, which contributes to well-being of an individual, family and community. Therefore, nursing is defined as a humanistic science dedicated to maintain and promote health, preventing illness, care for and rehabilitation of the sick and disabled persons. Nursing process includes doing, thinking and interaction component. It is mainly and basically a problem-solving approach of nursing cares. The nursing process consists of four steps- Assessment, Planning, Implementation and Evaluation. Each step of a nursing process leads to the next one, which makes it a continuing cyclic process. Modern Trends in nursing practice: The public perception of alternative, complimentary treatment methods has been changing over the past few decades. In the late 1960‘s and early 1970‘s ―Natural‖ ―New Age‖, ―Self Help Movements‖ begin to attract followers, first among consumers and later among health care practitioners. During that time provide, there was a growing trend towards rejection of traditional medicine because of it‘s perceive invasiveness, painfulness, cost and ineffectiveness. A rekindled interest in Eastern religions, lifestyle 658
and medicine has flueled the development of contemporary holistic, alternative/ complementary modalities. Clients are seeking out alternative/ complementary therapies because most such therapies are non-invasive, holistic and in many instances less expansive then going to a physician. In 1993 a landmark survey found that 1/3 of the US population had used some nontraditional alternative methods of treatments in addition to the standard medical treatment. In 1992 the US Government established an Office of Alternative Medicines (OAM) at the National Institute of Health. ―One of the reasons for the OAM‘s creation was the Federal Governments recognition that US citizens are persuing alternative methods of health care with unpredicted enthusiasm‖. In 1992, the OAM was allocated 2million to investigate the use of non-traditional treatment methods. Congress increased the OAMs budget to 20 million for the year 1998. A few therapies investigated by the OAM- 1995 include: Biofeedback to control pain. Acupuncture to relieve depression. Imagery to control asthma. Ayurvedic medicine to treat Parkinson‘s disease. Music therapy to treat brain injured clients and Shark cartilage to treat cancer. Role of professional nurse: The following nurse roles are ways of describing the nurse‘s activities in practice. Each roll is described as a separate entity for the state of clarity. However the roll is not in actuality exclusive of one another. In practices, several roll often coincide. 1.) Care provider: The goal of nurse in this roll is to convey understanding about what is important and to provide care. The nurse supports the client by attitude and actions that show concern for the client welfare and acceptance of the client as a person, not merely a mechanical being Caring is central to most nursing intervention and an essential attribute of the expert nurse. 2.) Communicator/helper: Communications shapes the relationships between nurses and clients, nurses and support persons, and nurses and colleagues. Communications facilitates all nursing actions. The nurse communicates to other health care personnel the nursing interventions planned and implemented for each client. Nurses communicates pertinent information verbally- at- change of shift reports, when clients are shifted to another unit, at clients rounds, and when clients are discharged to another health care agency.
659
3.) Teacher: It is an interactive process between a teacher and one or more learners in which specific learning objectives or desired behavior changes are achieved .the focus of the behavior change is acquiring a new knowledge or technical skills. 4.) Counselor: It is the process of helping the client to recognize and cope with stressful psychologic or social problems, to develop improved interpersonal relationships, and to promote personal growth. It involves providing emotional, intellectual and psychologic support. The nurse focuses on helping the person develop new attitudes, feelings and behaviors rather then on promoting intellectual growth The nurse encourages the client to look at alternative behaviors, recognize the choices, and develop a sense of control. 5.) Client Advocate: Advocacy involves concern for and defined actions in behalf of another person or organizing to bring about a change. A ―client advocate‖ is an advocate of client‘ right. It involves promoting what is best for the client, ensuring that the client‘ needs are met, and protecting the client‘s right. 6.) Change agent: Is a person or group who initiates changes or who assists others in making modifications in them selves or in the system. 7.) Leader: Nursing leadership is defined as a mutual process of interpersonal influence through nurse helps client make decision in establishing and achieving goals to improve the clients‘ wellbeing. To improve the health status and potential of individuals or families Increasing the effectiveness and level of satisfaction among the professional colleagues providing care. 8.) Manager: Management is planning, giving direction, developing staff, monitoring operations, giving rewards fairly and representing both staff members and administrations as needed. The nurse manages the nursing care of individuals, groups, families, and communities. The manager delegates nursing activities to ancillary workers and other nurses and supervises and evaluates their performance. 9.) Researcher: Nurse who will engage in research, there is a growing expectation that all nurses will be able to critically appraise research reports and will utilize of scientific studies as a basis for making decisions in their work.
660
10.) Expanded nursing roles: An expanded role is one that a nurse assumes by virtue of education and experience. The nurse who assumes an expanded role has increased responsibility and, usually greater autonomy. Nurses are assuming expanded roles in both hospitals and community settings. 11.) Nurse Generalist: The ANA conducts nurse generalists certification programs that issue certificates in eleven areas: General nursing practice, medical surgical nursing, gerontologic nursing, pediatric nursing , perenatal nursing, college health nursing , school nursing , community health nursing , psychiatric & mental health nursing , nursing continuing education & stall Development & home Health Nursing . 12.) Nurse Clinician: The Clinician‘s Provide bed side or direct Care in a speciality area. They may or may not have advanced educational preparation. 13.) Nurse Practitioner: The role of nurse practitioner is an extension of the nurses basic care giving role .it prepares nurses for an expanded role in the provision of primary care. The nurse practitioner may be generalists. (Eg : Family nurse practitioners) or specialists.( eg : Geriatric Nurse Practitioners ) Nurse practitioner in a community employed in health maintenance organizations, health centers, schools & Physicians Office. They are usually skilled at making nursing assessment ,performing physical assessments , counseling , teaching & Treating minor , self limiting illnesses , long term illnesses . The nurse practitioners in hospitals are often employed in speciality areas. eg: geriatric nursing . 14.) Nurse Specialist: The nurse specialist has advanced knowledge & skill In a particular area of nursing This nurses practice in hospitals or communities. In hospitals such nurses give direct client care, advice other nurses & co-ordinate nursing given by others. The clinical nurse specialists are a role model & are expected to keep abreast of new developments in the field.
661
Summary and conclusion: Each nurse must determine his/her own individual scope of practice. To determine one's scope of practice, the nurse must understand the Nurse Practice Act and assess his/her own evolving set of competencies. A nurse's scope of practice will change over time, with additional experience and education. Determining scope of practice is an obligation and responsibility jointly shared by individual nurses, nurse managers, nurse executives and educators, as well as the regulatory agencies and professional organizations. This article is intended to provide nurses with information and tools to assist them in determining their scope of practice. The process of developing a Professional Practice Framework for the Calgary Health Region demanded considerable time and effort on the part of a multitude of nurses. The resolve to reflect accurately the language of nurses in developing the framework was vital to defining professional practice in a manner than promoted ownership of the final product by nurses in the Region. It will now be important to examine the extent to which elaboration of this framework helps nurses achieve increased meaning and continually string to attain higher levels of excellence in their work. It is hoped that the development of an explicit model to guide practice will ultimate help nurses feel pride ix their profession and value the tremendous contribution.
662
BIBLIOGRAPHY: 1. Potter & Perry, Fundamentals of Nursing, 5th Edition, Mosbys Publications, Page no 22. 2. Patricia A. Potter, Fundamentals of Nursing, 3rd Edition Mosbys Publication, Page no 29 – 31. 3. Lois White, Fundamentals Of Nursing, Mosbys Publication, Page no: 85, 224. 4. Kozier , Fundamentals Of Nursing , 5th Edition , Page no :18 ~ 21 , 40 , 41,
663
SCOPE Introduction: Nursing practise today is composed of a wide variety of roles and responsibilities necessary to meet the health care needs of the society. Nurses are the front line professional of health care. Nurses of a skilled care to those recuperating from illness or injury, advocate for patient right, support patient at critical times. The framework provides principles which should be used to review, outline and expand the parameters of practise for nurses. It is appropriate for nursing practice should develop to meet the ever changing needs of the population and the health service. General Objectives: On completion of the class the group will have in depth knowledge regarding the scope and trends in nursing practise. Specific Objectives: After completion of the class, the group will be able to: Define scope of nursing practice. Enlist the principles of nursing practice. State the values of scope of nursing practice. Understanding key components of nursing practice. Enumerate the trends of nursing practice. Terminologies: Scope : The opportunities or possibilities for doing something. Trend : A general direction in which something is developing or Changing. Autonomy : Freedom of action. Accountability : Responsible for ones actions and expected to explain them Delegate : A person sent to represent others. Delegation : An action of delegating. Competence : The quality of being competent. Holistic : Treating the whole person rather than just the symptoms of Diseases. Scope of Nursing Practise: Definition: The range of practise is the range of roles, functions, responsibilities and activities which a registered nurse is educated, competent and has the authority to perform. This definition of scope of nursing practise must be understood in the context of the following definition of nursing, which is based on the definitions provided by the WHO 1996 and ICN 1987. Nursing is both an art and science. It requires the understanding and application of specific knowledge and skills, and it draws on knowledge and techniques derived from the humanities and the physical, social, medical and biological sciences. (WHO1996p.4) Principles: The following are the basis for making decisions with regard to the scope of practise for an individual nurse: The primary motivation for expansion of practise must be the best interest of patients/clients and the promotion and maintenance for the best quality health service for the population. 664
Expansion of the practice must be made in the context of the definitions of nursing and the values that underpin nursing practise. Expansion of practise must only be made with due consideration to legislation, national policy, local policy and guidelines. In determining his or her scope of practise the nurse/midwife must make a judgement as to whether he or she is competent to carry out the role function The nurse /midwife must take measures to develop and maintain the competence necessary for professional practise. Expansion of the practise must be based on appropriate assessment, planning, communication and evaluation. The nurse who is delegating a particular role/function (the delegator)is accountable for the decision to delegate. This means that the delegator is accountable for ensuring that the delegated role/function is appropriate and that support and recourses are available to the person to whom it has been delegated. The individual nurse is accountable for his/her practise. This means that he/she is accountable for decisions he/she makes in determining his/her scope of practise. This included decisions to expand or not to expand his/her practise. Values: The following values are mentioned below: In making decisions about an individual nurse‘s scope of practise, the best interest of the patient /client and the importance of promoting and maintaining the highest standards of quality in the health services should be foremost. Nursing care should be delivered in a way that respects the uniqueness and dignity of each patient client/client regardless of culture and religion. Fundamental nursing practise is the therapeutic relationship between the nurse and the patient/client that is based on trust, understanding, and support and serves to empower the patient/client to make life choices. Key Components: The key determining factors that must be taken into account in deciding on the scope of nursing these include: Competency. Accountability and autonomy. Continuing professional development. Support for professional nursing practice. Delegation. Competency: Competence is the ability of the registered nurse or registered midwife to practise safely and effectively fulfilling his or her responsibility with her scope of practise. In determining with her scope of practise the nurse midwife must make a judgement as to whether she or she is competent to carry out a particular role or function A competent professional nurse or midwife function or even to be able to practise at a specific level of skills. A competent professional nurse or midwives possess many attributes. These include practical and technical skills, communication and interpersonal skills, organizational and managerial skills to adopt problem solving approach. 665
Accountability and Autonomy: Accountability is ―the fulfilment of a formal obligation to disclose to referent others the purposes, principles, procedures, relationships, results, income and expenditures for which one has authority. Authority is the legitimate power to fulfil a responsibility. Accountability means being answerable for the decisions made in the course of one‘s professional practise. A nurse must be prepared to make the rationale for decisions to make and to justify such decisions. Accountability cannot be achieved unless the nurse has an autonomy to practise Nurses are autonomous in the practise of nursing. Continuing Professional Development: It encompasses experience, activities and process that contribute towards the development of a nurse or a midwife as a health care professional. Continuing education is a vital component of continuing professional development and takes place after the completion of the pre-registration education programme for nurses. It consists of planned learning experiences that are designed to augment the knowledge, skills and attitudes of a RN or RM for the enhancement of nursing practise, patient care. Education, administration and research. It is essential to acquire the new knowledge and competence which will enable her to practise effectively. Health care organization has the responsibility to assess the professional development needs of their staff and to provide appropriate support for the staff to enable them to practise to high standards of nursing care. Supporting For Professional Nursing Practise: To practise competently and to realise their potential in the patient care, certain support need to be in place. Local and national guidelines, policies and protocols are the supporting needs. Nursing managers need to ensure that there are systems in place that will provide support for nurses and midwifes in determining and expanding their scope of practise. Delegation: It is the transfer of authority by a nurse or midwife to another person to perform a particular role or function. The nurse who is delegating is accountable for the decision to delegate. The delegator is accountable for ensuring that the delegated role is appropriate and that support and resources are available to the person to whom the role has been delegated. Principles: The nurse must ensure that the primary motivation for delegation is to serve the interests to the patients/clients The nurse must take the level of experience, competence, role and the scope of practise of the person to whom the role/function is being delegated into account. The nurse must not delegate to junior colleagues. 666
The nurse must communicate the role in a manner understandable to the person to whom it is been delegated. Trends in Nursing Practise: 1. Case method: This is the oldest models of nursing care delivery where one nurse provided all the care needed by a particular client. Although she would accompany the client to the hospital if necessary. She provides care in the home and did many household duties. As time changed this model became so very impractical. 2. Functional Nursing: It is a task oriented model where distinct duties are assigned to specific personnel for e.g. one takes all the vital signs and other does all the dressing and so on. Tasks are divided and client sees several people during the shift. Although efficient it fragments care and is confusing to the client. 3. Team nursing: It emerged to accommodate the staff with varying level of education and skill. Here team is made up of an RN team leader. Other RN, LP‘s and nursing assistants who provide care to group of clients. The leader directs the care provided by her juniors and works with them in various capacities. 4. Total care: It refers to assignments in which a nurse assumes all the care for small group of clients. This method focuses more on the client as whole rather than the collection og nursing tasks that need to be accomplished. It is often practised in the ICU. 5. Primary nursing: Here an RN assumes 24 hrs accountability for the client care and for the nursing care of assigned client during his or her shift. The advantage is that the clients are assured of having a care given who sees to all of his or her need and who provides holistic and comprehensive care. 6. Patient focussed care: An updated version of team nursing and primary care is called patient focused care where an RN is partnered with one or more assistive personnel to take care of a group of clients. The RN may work with an assistant, respiratory therapist. The RN may have a role in resources management and may be held accountable for outcomes of nursing care such as skin breakdown or early ambulation. 7. Ambulatory care centres: Some office settings have broadened to include diagnostic and treatment facilities such as laboratory, radiology service, sometimes surgery. They are often operated by large health care systems such as corporation who has hospital and other facilities. This type of setting is popular because surgeries here are not burdened with high built in cost associated with the hospital settings. 8. Expansion of employment opportunities: Nursing practise trends include a growing variety of employment settings in which nurses have greater independence, autonomy and respect as the members of the health care team. Nursing roles continues to expand and develop, broadening the focus of nursing care and providing a more holistic and all –encompassing domain. Nursing therapies are 667
expanding into alternative therapies such as healing touch, massage therapy and use of natural herbs. 9. Nursing informatics: It is a nursing speciality integrating nursing science, computer science, information science in identifying, collecting, processing and managing data and information to support nursing administration, research and expansion of knowledge. Nursing informatics studies the structure, and the processing of nursing information to arrive at clinical decision and to build systems to support. 10. Standardised nursing terminologies: The demand of current health care systems is challenging the nursing profession to define its practise and the impact it has on the health and the health care of an individual‘s families and communities. Nursing has moved towards standardising nursing terminology. It is used to clearly define and evaluate nursing care. They can promote continuity of patient care and provide data can support credibility of the profession. ANA recognised nursing terminologies such as: NANDA Nursing diagnoses definitions and classifications. Nursing intervention classification (NIC). Nursing outcomes classification (NOC). Clinical care classification (CCC). Systematised nomenclature of medicine clinical terminology (SNOMED CT). 11. Health care informatics: The current erratic and inconsistent use of paper records and computers to document, store and retrieve patient care information is undergoing a major upheaval as federal initiatives promote the development of uniform electronic health record. An electronic health record is computerised record of all the health information related to an individual that can be electronically accessed by variety of health care providers. 12. Evidence based practice : Nurses are faced with the challenge of providing safe, effective care. One way to achieve this goal is to provide evidence based practise. Evidence based clinical practise is an approach to health in which the clinician uses current research to help guide client care decisions. The practise of evidence based care means integrating individual clinical expertise with best available from systemic records. 13. Hospice services: Hospice began in England. Hospice means shelter for those on a difficult journey. These services occur in clients home or in special facilities to the terminally ill. CONCLUSION: The health care services and the work trends of nurses and midwives are undergoing continuous change, driven by the demand for a consumer responsive service that is cost effective and response to the changing democratic population. Change in the overall scope of practise of the profession to include areas of practise that have not been within the remit of nurses and midwives.
668
EXTENDED AND EXPANDED ROLE OF THE NURSE Introduction: During the past five decades the nursing profession made significant progress towards developing a body of scientific knowledge and establishing the credibility of nursing science. Nursing practice changes in response to consumer demands and accessibility and involvement in decision making, new technology changes in health care delivery systems and policy. Nursing Roles: Role meaning: Role is a set of expected behaviors associated with a person‘s status or position and it includes behavior, rights and responsibility. Predominant Nursing Roles: Nurses assume a number of roles when they provide care to the client. Contemporary nursing requires that the nurse possess knowledge and skills in a variety of areas. In the past the principle role of a nurse was to provide care and comfort. But changes in nursing have expanded the role to include increased emphasis on health promotion and illness prevention as well as a holistic approach. The roles are:1. Health promoter and care giver. 2. Counselor. 3. Learner and teacher. 4. Protector and client advocate. 5. Resource person. 6. Communicator. 7. Leader and manager. 8. Case manager. 9. Resource consumer. 10. Rehabilitator. 11. Clinical decision maker. 12. Political advocate. 13. Colleague and collaborator. 1.) Health Promoter and Care Giver: Health promotion is an important aspect of nursing practice. It is a way of thinking that revolves around philosophy of wholeness, wellness and well being. Many people are aware of the life style and illness and are developing health promoting habits. The role of the nurse in health promotion is to work these people for the process of assessing and evaluating health. Care giver role includes those activities that assist the client physically and psychologically while preserving client‘s dignity. Nurse‘s actions may involve full or partial care for the client and supportive educative care to assist clients in attaining highest possible levels of health and wellness specific activities of the care giver include feeding bathing and administering medical care. 669
2.) Counselor: When acting as a counselor the nurse assist the clients with problem identification and resolution. Counseling is done to help clients increase their coping skills. Effective counseling is holistic in that it addresses individual‘s emotional, cognitive, spiritual dimensions. 3.) Learner and Teacher: Nurses have both learning and teaching responsibilities. We must continue to learn so that we can maintain our knowledge and skills amidst the many changes in health care. Teaching is an intrinsic part of nursing. The nurse views each interaction as an opportunity for education. As a teacher the nurse helps the client learn about their health and the health care procedures they need to perform to restore or to maintain the health. Nurses also teach unlicensed assertive personal to whom they delegate care and they share their expertise with other nurses and health professional. 4.) Protector and Client Advocate: As a protector the nurse help to maintain a safe environment for the client and takes steps to prevent injury and protect the client form possible adverse effects of diagnostics and treatment measures. A client advocate is a person who speaks up for or acts on behalf of the client. In the role of client advocate, the nurse protects the client‘s human and legal rights and provides assistance in asserting those rights if need arise. The nurse may also defend clients rights in a general way by speaking out against policies or actions that endanger clients well being or conflict with their rights. 5.) Change Agen: Nurse acts as a change agent when assisting with clients to make modifications in their own behavior. Nurses also act to make changes in a system such as clinical care if not helping client return to health. Technological changes, changes of the population, and medication are few of the changes that nurses deal with daily. 6.) Communicator: Communication is integral to all nursing roles. Nurses communicate with the client, support person, other health professionals and people in the community. In the role of the communicator nurses identify the patients‘ problems and then communicate these verbally or in writing to other members of the health team. The nurse must be able to communicate clearly and accurately in order for clients health care needs to be met. 7.) Leader and Manager: Today‘s professional nurses assume leadership and management responsibilities regardless of the activity in which they are involved. A leader influences others to work together to accomplish a specific goal. The leader role can be involved in different levels—individual, client, family, groups of clients, colleagues or the community. As a manager the nurse manages the nursing care of the individual‘s families and community. The nurse manager also delegates‘ nursing activates to auxiliary workers and other nurses supervisors and evaluate their performance.
670
8.) Case Manager: Nurse case manger work with the multidisciplinary health care team to ensure the effectiveness of the case management plan and to monitor outcomes. Each agency unit specifies the role of the nurse case manager. Regardless of setting case mangers help ensure that care is oriented to the client, while controlling costs. 9.) Research Consumer: Nurses often use research to improve client care in nursing. According to ANA position statement on education for participating in nurses‘ research (1994) all nurses share a commitment to the advancement of nursing science. Nurses in clinical practice identify the need for investigation and collaborate with nurse researcher who designs studies to address the problem and analyze data and clinician will determine appropriate application of those findings to practice. 1O.) Rehabilitator: Rehabilitation is the process by which the individual returns to maximum functioning after illness, accidents or disabling events. Rehabilitative and restorative activities range from teaching client to with crutches to helping client cope with lifestyle changes associated with chronic illness. 11.) Clinical Decision Maker: To provide effective care the nurses uses critical thinking skills through out the nursing process. Before understanding any nursing actions the nurse plans the action by deciding the best approach for the client. The nurse makes these decisions alone or in collaboration with family and in consultation with other health care professionals. 12.) Political Advocate: Nurses are actively participating in political process to promote change within the profession and to influence policy making regarding nursing and other health care policy issues. 13.) Colleague and Collaborator: Changing models of health care have created a need for modification of traditional roles. Collaborating among health care professionals involves recognition of expertise of others within and outside ones profession and referral to those providers when appropriate. Collaboration also involves some shared function and common focus on the same overall mission. Extended V/S Expanded Roles In Nursing: Extended roles Expanded roles Along with the contemporary roles in Along with the practice of extended roles nursing the nurse chooses the field or the nurse gains expertise in a special field branch of nursing science that suits the and acquires knowledge and skills to interest most and practices them. fulfills the criteria of experts to become an expert and expand from the basic health care, care giving role to more avenues of health care. The qualifications remain basic nursing a Along with the basic qualifications diploma or BSc nursing, advanced degrees or training or specialization in a particular field or 671
branch of nursing science. Restricted avenues because of lack of Explores various avenues of health care credited expertise. because of credited expertise Focused more on general nursing Focused on specialization strategies Extended Care Facilities: Extended care facilities formerly called nursing homes are more often multilevel campuses that include independent living quarters for seniors and assisted living facilities skilled nursing facilities and extended care facilities that provide care to clients of all ages who require rehabilitation or custodial care. An extended care facility is an institution providing intermediate and long term medical, nursing or custodial care for clients recovering from acute illness or clients with chronic illness or disabilities. Extended care facilities are becoming the more popular means for managing the health care needs of clients who require additional care but do not meet the criteria for remaining in hospital nurses in extended care facilities assist clients with their daily activities, provide care when necessary and coordinate rehabilitation services. Extended Role Of The Nurse: Nurses in extended care facilities assist clients with their daily activities provide care when necessary and coordinate rehabilitation activities. These nurses has increased responsibilities and autonomy and they are supposed to provide care in variety of settings such as hospital, community etc. 1.) Nurse Educator: The nurse educators are employed in nursing programs at educational institutions and in hospital staff development department of health care agencies and client education departments. A nurse educator usually has a baccalaureate degree or more advanced preparation. Faculty members in a school prepares students function as a nurse and are responsible for teaching current nursing practice theory and necessary skills in laboratories and clinical settings. Nurse educators in staff development department provide educational programs for nurses within their institute. As a nurse educator in client education department she/he teaches ill or disabled client and families to provide care in home. 2.) Critical Care Nurse: Critical care has progressed from a ―do the best you can‖ approach into a specialty based on a solid body of scientific knowledge and intricate skills. The critical care nurse uses primary nursing delivery system which allows a certain degree of independence and also serves as a full fledged team member in patient management. Qualification of critical care nurses are basic BSc degree or diploma in nursing and advanced preparation in critical care nursing. Functions include: Monitoring balloon angioplasty, pacemaker, hemodynamic, intra aortic balloon pumping, bedside hemodialysis, advanced neurological and surgical procedures. Teaching physicians—primarily interns and residents in teaching hospitals about caring for critically ill patient. Help design products and techniques for practice. Manages patient‘s total care. 672
Performs defibrillation. Interprets diagnostic tests. 3.) Nurse Administrator: The nurse administrator manages client care, including delivery of nursing service. The functions of nursing administrator include budgeting, staffing and planning programs. The educational preparation for the nurse administrator is at least a baccalaureate degree in nursing and frequently a masters or doctoral degree. 4.) Nurse Practitioner: Nurse practitioners are currently recognized as a critical component of health care reform. They are employed in health care agencies or community based settings. They usually deal with non emergency, acute or chronic illness and provide primary ambulatory care. 5.) Nurse Midwife: An RN who has completed a course in midwifery and is certified by the corresponding national council can be a nurse midwife. The nurse midwife gives perinatal care for the mothers. They also conduct routine pap smear, family planning and routine breast examinations. 6.) Community Health Nurse: Community health nurse functions within the communal framework. And serves the health needs of the portion of public assigned and delivers care to the community as a whole. The goal of the community health nurse is to improve health of the community as a whole by identifying 7.) Occupational Health Nurse: It is a branch of public health nursing. The occupational health nurse work in traditional manufacturing, industry service, construction sites and government settings The roles include: worker/ workplace assessment and surveillance, primary care, case management, counseling, health promoting and protection, research, administration and management, Community orientation, Legal and ethical monitoring. 8.)Psychiatric Nurse It is a branch of nursing that deals with mentally challenged and mentally disturbed clients and their needs, in daily life as well as in the social life. The role includes educator, surrogate, counseling, psychotherapist, and advocate. 9.) Medical Surgical Nurse: It is a branch of medicine that deals with the over all medical and surgical needs of the client and the functions include assessment of the problem help in diagnosis, treatment, administration of medication, assistance in ADL and so on. Expanded Role Of Nurses: Because of increasing educational opportunities for nurses, the growth of nursing as a profesion and a greater concern for job enrichment, the nursing profession offers expanded role and different kinds of career opportunities. The expanded roles include the following. 1. Advanced Nurse Practioner. 2. Clinical nurse specialist. 3. Nurse anesthetist. 4. Nurse researcher. 673
5. Nurse educator. 6. Nurse entrepreneur. 7. Acute care nurse practioner. 8. Operating home nurse. 9. Professional nurse care manager. 10. Rehabilitation nurse. 11. Nurse analyst. 12. Travel nurse. 13. Nurse oncologist. 14. Sport nursing. 15. Nurse as authors. 16. Nurse liaison. 17. Space nursing. 18. Hospice nurse. 19. School health nurse. 20. Tele nursing. 21. Cruise ship/ resort nurse 22. Attorney. 23. Disaster/ bioterrorism nurse. 24. Epidemiology nurse. 25. Ethicist. 1.) Advanced Nurse Practitioner: A nurse who has an advanced education and is a graduate of a nurse practitioner program are employed in health care agencies or in community settings and deals with non emergency acute or chronic illness and provide primary ambulatory care. Job responsibility include: Taking client history. Conducting physical examinations. Ordering performing and interpreting diagnostic tests. Prescribing pharmacologic agents. Treatment and therapies for the management of client‘s condition. Providing primary care. Consultant for individuals, families and communities. The major nurse practitioner categories are: Adult nurse practitioners—are who provides primary ambulatory care to adults with a non emergency, acute or chronic illness and some setting tertiary care. Family nurse practitioners provide primary ambulatory care for families usually in collaboration with family care physician. Pediatric nurse practitioner provides care to infants and children. An obstetric and gynecology nurse practitioner provides care to women seeking obstetrical and gynecological health care and conducts delivery independently. Geriatric nurse practitioner provides ambulatory or impatient care to older adults. Their activities include interventions for health maintenance, illness prevention or health restoration. 674
2.) Nurse Clinician/ Clinical Nurse Specialist : The clinical nurse specialist has a master‘s degree in nursing and expertise in a specialized area of practice. The CNS may work in primary care, acute care, restorative care and community based settings. The CNS function as client care provider, educator, and consultant, and researcher, manager, to plan and improve the quality of care provided to the client and family. 3.) Nurse Anesthetist: A nurse anesthetist is an RN who received advanced training in an accelerated program of anesthesiology. Functions Carries preoperative visits and assessments. Administration of general anesthetic agent for surgery under supervision of anesthetist. Assessment of post operative status of client. 4.) Nurse Researcher: Minimum educational qualification is a doctorate, with at least a masters degree in nursing. The nurse researcher investigates problems to improve nursing care and to further define and expand the scope of nursing. They may be employed in an academic setting, hospital or independent professional or community service agencies. 5.) Advanced Nurse Educator: The nurse educates usually a baccalaureate degree or more advanced preparation and frequently expertise in particular area of practice. 6.) Acute Care Nurse Practitioner: An acute care nurse practitioner functions in settings where critically ill patients reside, this type nurse provide special expertise. The certification includes physiology, advanced assessment, advanced Pathophysiology, pharmacology and advanced therapeutics. 7.) Nurse Entrepreneur: An entrepreneur is an individual who organize operates and assumes the risk for business ventures. Such business includes independent nursing practice, consultant services etc. the nurse may be involved in education consultation research etc. 8.) Operating Room Nurse: When patients are admitted before and after surgery, the operating room nurse monitors the patient‘s progress from the time he/she enters the operating room until he/she is dismissed to the attending staff nurse. She also performs preoperative assessment, prepares the patient for surgery, set up for surgery, assists the surgeon during the procedure and manages patient recovery. 9.) Professional Nurse Case Manager: The nurse case manager assess the patient and develops care according to expected out comes in terms of cost and quality. 10.) Rehabilitation Nurse: The most important role of rehabilitation nurse is education. She teaches the client to perform self assessment, make decisions about beginning continuing self care measures. Perform every day activities and evaluate the progress and recovery.
675
11.) Travel Nursing: Travel nursing and the Travel Nursing Industry developed in response to the nursing shortage in which nurses are relocated for short-term nursing positions. Most nurses enjoy travel nursing for 3 reasons: Visiting many different locations. Free benefits. Higher salary with bonuses. 12.) Nurse Oncologist: Advance oncology nursing practice is defined as the practice of expert competency and leadership in the provisional care to individuals with an actual or potential diagnosis to cancer. 13.) Nurse Informatics/Nursing Analyst: The nursing analyst works within the management team to ensure high quality of performance, compliance and technical support to both the management and the nursing staff. The nursing analyst is involved in data analysis and interpretation with regards to effectiveness and efficiency of data collection, entry and use within the various areas of the hospital or healthcare facility. A nursing analyst must have a strong statistical background and be able to interpret data in a logical and organized manner. The nursing analyst must be able to work on multiple projects at one time, focus on details as well as the overall project, as well as stay on deadlines and timelines for preparing and presenting information to management sources or stakeholders. The nursing analyst may be required to actually present the material orally or in written form or may be required to create PowerPoint or other presentations to display the required information. Excellent computer skills and a good working knowledge of data analysis and display are critical. Some of the programs that the nursing analyst may use include Crystal Report, Oracle, SQL, PowerPoint or Desktop Publisher. In addition the nursing analyst should be able to complete public speaking activities as required. The nursing analyst may also be required to assist in setting benchmarks and standards for the various projects based on actual data and healthcare regulations and requirements. An ability to analyze data is critical to effectively make recommendations for standards and policy and procedural changes. Understanding the realities of the job is very important for the nursing analyst. Career Requirements: The minimum requirement for a nursing analyst is a Bachelor in Nursing. Many hospital or healthcare facilities require a Master level training in medical informatics, healthcare management or quality management. In addition the nursing analyst will have to have experience working in the same type of hospital or healthcare facility that they are apply for a nursing analyst position in. Experience with statistic analysis and data management is considered beneficial as is a strong computer background and a familiarity with various medical and data programs. 14.) Sport Nursing: Helping humans stay healthy and prevent disease is one of the main thrusts behind an emerging trend that combines nursing with some aspect of fitness or sports. Although the nursing profession has yet to officially develop a specialty in ―fitness nursing‖ or ―sports 676
nursing‖ on either the professional or academic level, a growing number of nurses are becoming involved in these areas. The connection between physical fitness, wellness and disease prevention is well documented. As a result, hospitals and HMOs around the country have begun opening fitness centers and offering wellness programs with information on nutrition, stress management and exercise. Many corporate employers, meanwhile, have begun offering on-site fitness programs and wellness centers for their employees. In addition to these practice settings, nurses can also find job opportunities working for professional sports teams, college and university athletic departments, and hospitals, clinics and orthopedic practices that have sports medicine or sports injury programs. Some nurses are involved in sports medicine on a full-time basis while others work on a part-time, contract basis for sports teams For example, some nurses work for professional football teams each summer, evaluating the health and fitness of players who are either preparing for another season or trying to make the team for the first time. Other nurses work professional baseball games, either sitting in the dugout to help injured players or treating injured fans at the first-aid stations. 15.) Hospice Nurse/ Palliative Nurse: The focus of hospice care is on comprehensive physical, psychosocial, emotional, and spiritual care to terminally ill persons and their families. Hospice providers promote quality of life by protecting patients from burdensome interventions and providing care at home, whenever possibly, instead of the hospital. The care that both hospice and palliative care nurses provide is essentially the same as demonstrated by the Hospice and Palliative Nurses Role Delineation Study. However, hospice and palliative care nurses differ in their preparation and practice settings. Roles: Hospice and palliative care nurses work in collaboration with other health providers (such as physicians, social workers, or chaplains) within the context of an interdisciplinary team. Composed of highly qualified, specially trained professionals and volunteers, the team blends their strengths together to anticipate and meet the needs of the patient and family facing terminal illness and bereavement. Hospice and palliative nurses distinguish themselves from their colleagues in other nursing specialty practices by their unwavering focus on end-of-life care. Hospice and palliative care includes 24-hour nursing availability, management of pain and other symptoms, and family support. By providing expert management of pain and other symptoms combined with compassionate listening and counseling skills, hospice and palliative nurse promote the highest quality of life for the patient and family. Regardless of the setting, hospice and palliative nurses strive to achieve an understanding of specific end-of-life issues from the perspective of each patient and his or her family. To accomplish this, nurses collaborate in a cultural assessment of the patient and family and provide culturally sensitive care. Hospice and palliative nursing is not only practiced at the bedside. Nurses, consistent with their individual educational preparation, experience and roles, promote the highest standards of end-of-lie care through community and professional education, participation 677
in demonstration grants, and in end-of-life research. As society‘s needs change and awareness of the issues surrounding the end of life increases, nurses are called to advocate for the terminally ill and their families through public policy forums, including the legislative process. Education: Hospice and palliative nurses are registered nurses prepared at the associatedegree, baccalaureate-degree, and/or master‘s-degree level (there are currently two master‘s degree programs that focus on hospice/palliative care – New York University (New York, NY) and Ursuline College (Pepper Pike, OH). A small percentage of hospice and palliative nurses hold a doctoral degree. Nurse liaison The Nurse Liaison's role is multifaceted. They are the vital link between the potential patient and the rehabilitation facility. In this capacity, the transition between an acute hospitalization and rehabilitation is made as smooth as possible for the patient. The Nurse Liaison explains to the potential patient and his/her family members what to expect during the rehabilitation stay. This explanation is usually given during the assessment of the potential patient. The Nurse Liaison performs the assessment at the request of the attending physician. This information, once obtained, is then submitted to the Physiatrist and the Admissions staff for review. The major role in liaison nursing is enhancement of delivery of psychological nursing care and effective management. Also serves as a catalyst in negotiations with staff and clients. The Nurse Liaison is an RN/LPN currently licensed in the state of Tennessee. He/she has three or more years of diverse clinical experience, sound clinical judgment, and excellent assessment skills. 16. Space Nursing: Space nurses provide a on the ground monitoring and a full range of health services to astronauts, who are screened to determine if they meet the NASA health requirements and in some cases, military stipulations. It is very crucial for mission safety and service eligibility. A dispensary staffed by nurses is included in NASA‘s long term plans, which call for larger space stations and a permanent lunar base. Flight medicine nurses also coordinate dietary and fitness services; clinic nurse staff a sick call service for astronauts to use before and after flight. Space nurse society members now meet yearly at conferences to exchange ideas share research findings, and discuss application of research findings, and application of nursing methods used on earth in space settings. The members are with a basic nursing degree and a doctorate or masters in any discipline of nursing. The skills needed are excellent communication skills; interest and knowledge of aerospace industry and challenges, mental health skills, innovation and creativity, knowledge of physics and engineering 17.) Tele Nursing: This refers to the use of telecommunications and information technology for providing nursing services in health care whenever a large physical distance exists between patient and nurse, or between any numbers of nurses. As a field it is part of telehealth, and has many points of contacts with other medical and non-medical applications, such as telediagnosis, teleconsultation, telemonitoring, etc. 678
Telenursing is achieving a large rate of growth in many countries, due to several factors: the preoccupation in driving down the costs of health care, an increase in the number of aging and chronically ill population, and the increase in coverage of health care to distant, rural, small or sparsely populated regions. Among its many benefits, telenursing may help solve increasing shortages of nurses; to reduce distances and save travel time, and to keep patients out of hospital. A greater degree of job satisfaction has been registered among telenurses 18.) School Health Nurse: The role of the nurse is to support the educational process by helping students keep healthy and by teaching students and teacher‘s preventive practices. The responsibilities include first aid, screening follow up, control of communicable diseases, immunization, teaching health classes, transmitting knowledge regarding healthy behaviors, conducting health related studies, referral services. 19.) Cruise Ship/ Resort Nurse: These nurses work on ships or resorts to provide emergency and general care to passengers/ vacationers, should it be required. These nurses also serve as part of the occupational health team of the crew who live in the ship for 6 to 8 months of time, or the staff at resorts. Responsibilities include providing patient care in the health centre and dealing with onsite emergencies. the requirements are A registration with a minimum of 2 years of experience in recent hospital required. Experience with cardiac care, trauma, and internal medicine is desirable. They must possess excellent interpersonal skills, enjoy travelling and be very flexible with time, strong health assessment skills, possess a valid passport and able to tackle minor illnesses 20.) Attorney: Nurse attorneys engage in a range of legal activities including the following, providing legal consult, prosecute, defend cases; may represent individuals, patients, hospitals health professionals or institutions, provide depositions and court testimony, engage in legal research , define standards of care, serve as quality-of-care experts for hospitals and other health care institutions, review cases, define applicable standards of care, organize records, research the literature, provide behind the screen or up front consultations, interview clients and witnesses, prepare exhibits, prepare questions for depositions and court. A register nurse with a law degree fulfills the criteria. 21.) Disaster/ Bioterrorism Nurse: These nurses‘ works in disaster areas that are the result of bioterrorist attack or in situations caused by natural disaster, war or poverty, Red Cross nurses are often part of this wing of nurses. A basic degree in nursing is needed and should be the member of a society like Red Cross. The skills include: emergency room and critical care experience, experience with local disaster action teams, management skills, ability to meet the needs of the people in high crisis situations. Knowledge of disaster preparedness and basic first aid. 22.) Nurse as Authors: An RN who works in any area of writing, this written material may be used in research education, training, sales and marketing, and other mediums and communication forums. Nursing knowledge must be disseminated as widely as possible to nursing practice and keep pace with the health needs of the community. The quality of journals which publish, 679
materials concerning nursing issues depends on quality of material submitted. It‘s the responsibility of nurses to attempt to publish any new knowledge they gain. 23.) Epidemiology Nurse: A nurse epidemiologist investigates trends in groups or aggregates and studies the occurrence of diseases and injuries. The information is gathered from census data and statistics and reportable disease records. They identify population at risk monitor the progress of disease, specify areas of health care need, determine priorities and size and scope of programs and evaluate their impact. They don‘t provide direct nursing care, but they do research and publish the latest trends in health care. Masters degree in community health or PhD preferred. 24.) Ethicist: A nurse who knows about legal/moral/ethical issues and provides services for patients and families is called nurse ethicist. The nurse may work with an ethicist team to develop a detailed investigative plan to answer question raised by an ethics violation allegation or resolve clinical dilemmas. The criteria are a master‘s degree in bioethics or related field along with a registered nurse certificate. Healthy Student Nurse: Expands The Profession: To prepare an enlightened nurse for tomorrow, the latest advancements in technology and various avenues of health care should be brought to the notice of the students perusing the career of nursing. Seldom do they know about the vast scope of the profession and be satisfied with the clinical nurse or a basic educator. According to a study conducted by Partners Chief Nursing council of Boston, America in 2002. Surveyors conducted 400 telephone interviews of people in two target groups teenage students in 7th through 11th grades & and adults aged 18 to 39 who said they had considered switching careers among the samples 75% female and 25% male. Their attitude towards nursing are listed in the table below:66% students & 73% adults Nurses need to have solid understanding of medical technology. 59% of students & 73% of adults Nurses have to react quickly to situations in a fast paced environment. 59% students & 73% of adults Nurses are professionals who need to be skilled in latest medical technology 40% of students & 38% of adults Nurses work closely with doctors to make important decisions of patient care. Thus it is evident that the view of the nurse as learner and associate is all that was and is exiting. Does today‘s nursing education in India prepare our nursing graduates to meet a brighter tomorrow? For this a holistic model preparation is needed. So training should focus on physical, social, mental, emotional, spiritual and intellectual strengthening of each Indian student to compete in the global market. Major global crisis in nursing today are; position lying vacant due to inadequate number of qualified professional, steady brain drain due to unattractiveness in the job environment and poor payment in out country and man money, material shortage for training.
680
CONCLUSION: There are more roles of nurses and nursing avenues, some explored and some unexplored. To achieve positive patient outcomes, institutions are standing to provide care in a timely cost effective manner. The future of nursing is brighter than ever. Because of the never ending changes and the broadening of new avenues more health care jobs will result. Professional nursing has to be viewed as a cost effective way to provide care to the clients. So according to the advancement of technologies and increased health problems nurses has to be prepared to deal with all these technologies and health problems.
681
BIBLIOGRAPHY: Books:a. Barabara cherry and Jacob susan R; contemporary nursing issues, trends and management;2nd edition;2002; mosby, usa;page number 561-558,543-544 b. Hameric, spross and hanson: advanced practice nursing-and integrated approach;1st edition; W B Saunders company; page number 555-569 c. P A Potter and A G Perry, fundamentals of nursing; 4th edition ;1997; mosby company; Toronto; page number 223-225 d. Carol Taylor, carol lillis; fundementals of nursing, the art and science opf nursing care; 5th edition; 2005; Lippincott William and willkins company page number 441-501. e. Claudia M smith, France A maurer; community health jursing theory and practice;1995; W B Saunders company philedelphia; page number 40-41 f. Martia Stanhope, jeanelle Lancaster, community and public health nursing; 5th edition; Mosby Toronto. Page number 932-942 g. Catheline koeing vlais, janites hayes barbera, kozier, glenora erd,; professional nursing practice concepts and perspectives ;4th edition;2002; prenticehall; New Jersy; page number 20-22 109-209 Journals:h. Sr (prof) Gilbert, Healthy student nurse : brighter tomorrow; The nursing journal of India Vol XCVIII page 101-102 i. Deepika C Khakha , independent nurse practitioner in mental health nursing, the nursing journal of India VOL LXXXXII page 81-82 Online reference:j. http://www.biohealthmatics.com/careers/PID00603.aspx k. http://www.nsna.org/pubs/imprint/jan06/Jan06_FeatureBrown_Andereson.pdf l. http://en.wikipedia.org/wiki/Travel_nursing m. http://www.minoritynurse.com/features/nurse_emp/03-03-05a.html n. http://www.nursingspectrum.com/StudentsCorner/CareersInNursing/Specialties/RHN .htm o. http://www.nursesource.org/hospice.html
682
Extended Role Of Nursing: Meaning: Extended role of a nurse is the responsibility assumed by a nurse beyond the traditional role i.e; outside the practice. It is the scope of nursing services outside the hospital. Roles and Functions Of Nurse: i) Care Giver. ii) Manager. iii) Advocate. iv) Counselor. v) Educator. vi) Consultant. vii) Researcher. viii) Collaborator. ix) School Health Nurse. x) Occupational Health Nurse. xi) Parish Nurse. xii) Public Health Nurse. xiii) Private Health Nurse. xiv) Home Care Nurse. xv) Hospice Nurse. xvi) Rehabilitation Nurse. xvii) Office Nurse. xviii) Nurse Epidemiologist. xix) Military Nurse. xx) Aerospace Nurse. xxi) Telenurse. xxii) Disaster Nursing. xxiii) Forensic Nurse. xxiv) Prison Nurse. xxv) Peace Corps Nurse. 1) Care Giver: Care giving role is a primary role of the nurse. The provision of care to clients combines both the arts & science of nursing which helps clients regain health through healing process. Healing is more than just curing a specific disease, although treatment skills that promote physical health are important to caregivers. the nurse adders the holistic health care needs of the client , including measures to restore emotional, spiritual & social well being. The caregiver helps the client & families set goals & meet those goals with a minimal cost of time & energy. II) Manager: As a manager, the nurse coordinates the activities of other members of the health care team, such as nutrionists & physical therapists, when managing care for a group of clients. Nurses must also manage their own time & resources of the practice setting when providing care to several clients. As a clinical decision maker, the nurse uses critical thinking skills throughout the nursing process to provide effective care. Before giving care, the nurse should plan the action by deciding the best approach for each client. The 683
nurse makes these decisions alone or in collaborates and consults with each other health care professionals. III) Protector and Advocate: As protector, the nurse helps to maintain a safe environment for the client and takes steps to prevent injury and protect client from possible adverse effects of diagnostic or treatment measures. Conforming that a client does not have an allergy to a medication and providing immunization. As advocate, nurse protects the client human and legal rights and provides assistance in asserting those rights if the need arises. The task of an advocate is to be a supporter and source of information for the patient and the patients significant others. Eg: Nurse may provide additional information for a client who is trying to decide whether or not to accept a treatment or the nurse may assist with communication with in the family. IV) Counselor: In the role of a counselor, nurse help to explore feelings and attitudes about wellness & illness with patients and their families. It involves providing emotional, intellectual and psychological support. In contrast to a psychotherapist, the nurse counsels primarily healthy individuals with normal adjustment difficulties. The nurse encourages the client to look at alternative behaviors, recognize the choices and develop a sense of control, Counseling can be provided on a one – to – one basis or in groups. Counseling requires therapeutic communication skills. She should be a skilled leader able to analyses a situation, synthesize information & experiences & evaluate the progress & productivity of the individual or group. The nurse must also be willing to model & teach desired behaviors, to be sincere when dealing with people. V) Educator: As an educator, the nurse explains to client‘s concepts and factors about health, demonstrates procedures such as self – care activities, determines that the client fully understands reinforces learning or client behavior and evaluates the client‘s progress in learning. The teaching process has four components - assessing, planning, implementing & evaluating – which can be viewed as parallel to nursing process. In assessment phase, the nurse determines the clients learning needs and readiness to learn. During planning, the nurse sets specific learning goals & teaching strategies. During implementation, the nurse enacts teaching strategies and during evaluation measures learning. Some client teaching can be un planned & informal. Eg: Nurse responds to a question about a health issues in casual conversation. Other teaching activities may be planned & formal. Eg: Self administration of insulin injection. The nurse uses h methods that match client capabilities & needs & incorporates other resources, such as the family. VI) Communicator: The role of communicator is central to all nursing roles and activities. Nursing involves communication with clients, families, other nurses and health care professionals, resource persons and the community. Without any clear communication, it is impossible to give care effectively, make decision with clients and families, and protect clients from threats to well being, coordinate and manage client care, assist the client in rehabilitation, offer 684
comfort or teach. Quality of communication is a critical factor in meeting the needs of individuals, families and communities. Communication facilitates all nursing actions. The nurse communicates to other health care personnel‘s the nursing interventions planned and implemented for each client and should document them on client record. This type pf communication needs to be concise, cleared and relevant VII) Rehabilitator: Rehabilitation is the process by which individuals return to maximum levels of functioning after illness, accidents or other disability events. Usually, client experience physical or emotional impairment that change their lives, and the nurse helps them to adapt as fully as possible by using her knowledge and skills of many concepts when she learned. Rehabilitation activities range from teaching client to walk with crutches to helping clients to cope with life style changes of an associated with chronic illness. VIII) Collaborator: Many professions make up the team involved in the care of each client. Besides nurse, there also can be physical therapists, occupational therapists, medical social workers, home health aids, recreational therapists, volunteers and nutritionist. Nurse collaborates with other team members when providing care to a client. Quality care is given when nurse and team members work together in planning for the patient‘s care management. A nurse can be a good collaborator when she is knowledgeable, a good planner when providing patient care, and a good communicator of each patient‘s assessment and need to work well with patients, families and health care members. IX) School Heath Nurse: School nursing is a specialized practice of professional nursing that facilitates the well being, academic success and life long achievements of students. School heath services have the goal of supporting educational success by enhancing health. Effective school health services are comprehensive programmes that integrate health promotion principles through out school‘s curriculum. A school nurse develops programmes that foster children‘s growth, positive life skills for successful coping and acquisition of knowledge and skills for self care and thereby reinforce positive health attitudes. Functions: Direct caregiver: the school nurse is expected to give immediate nursing care to the ill or injured child or the school staff members Case finder: The school health nurse identifies as early as possible children at risk for physical, behavioral, social or academic problems. Case Manager: Helps to coordinate the health care for children, with complex health problems Consultant: Provides professional information about proposed changes in school environment and their impact on the health of the children Counselor: The school health nurse must be trust worthy person to whom children can go if they are in trouble or they need some one to talk to. Researcher: The nurse makes sure that the nursing care is based on evidence based practice. Health Educator: The nurse provides health education regarding proper nutrition or safety information, personal hygiene to children and also to their parents. 685
X) Occupational Health Services: Occupational and environmental health nursing is the specialty practice that provides for and delivers health and safety programmes and services to workers, worker populations and community groups. The practice focuses on promotion and restoration of health, prevention of illness and injury and protection from work related and environmental hazards. Functions: Direct Nursing Care: This care encompasses primary, secondary and tertiary prevention with nursing intervention from assessment to rehabilitation Eg: Physical assessment, screening, emergency care etc. Case Management: Occupational health nurse acts as gate keepers for health services, rehabilitation, return – to – work and recommending treatment plans that ensure quality and efficacy while controlling costs and monitor care outcomes. Counseling and Crisis Intervention: Besides counseling workers about work related illness and injuries occupational nurse counsels for issues such as substance abuse and emotional or family problems and work place stressors? Health Promotion: Occupational health teach skills and develop health education programmes specially on smoking cessation, exercise, nutrition, weight control, stress management, control of chronic illnesses etc Legal And Regulatory Compliance: Occupational health nurse provides knowledge regarding various occupational legislation and she works with employers on compliance with regulations and laws affecting the work place Worker and Work Place Hazard Detection: Occupational health nurse monitors the health status of worker populations by conducting research on the effects on work place exposures, gathering health and hazard data and using the data to prevent the injuries and illnesses. According to a study, occupational research is seen as more complex issue in India, which includes child labor, poor industrial legislation and vast informal sector and balance between modern industrial exposures and health risk of traditional sectors. XI) Parish Nurse: Parish nurse is the most commonly used term for the professional advanced nurse practice role that gather in churches, cathedrals, temples, or mosques and acknowledge common faith traditions. Parish nurse in church has been referred to as congregational health minister, an emergency church nurse, a faith community nurse or a health minister‘s nurse. Parish nurse respond to health and wellness needs within the context of populations of faith communities and are partners with the church in fulfilling the mission of health ministry. Functions: Provider of spiritual care: Spiritual care is the core of the parish nurse practice and central to the healing process Health Counselor: Health counselor explains clarifies and interprets for the client the language of health care. She discusses health risk appraisals, plan for healthier life styles, provides support and guidance related to numerous acute and chronic, actual and potential health problems and performs spiritual assessment. 686
Health Advocate: As an advocate, parish nurse guides persons successfully for problem solving and care options. Health Educator: As an educator, serves to gain knowledge in order to make best choices for maintaining health, lowering health risks, preventing illness and managing diseases already present. Facilitator of Support Groups: Facilitating the support necessary for those encountering loss or other changes is an important part of whole person health journey. Equipping congregations with the tools of support i.e.; coaching and facilitation, assures sustainability. Trainer of Volunteers: Many volunteers need additional preparation in order to be effective. The parish nurses facilitate varied trainings necessary for a variety of ministries. Liaison to community resources and referral agent: Knowing community and services available within the community and establishing relationships is an important aspect of parish nurse. XII) Public Health Nurse: Public Health Nurse (PHN) is a registered nurse with special training in community health. The PHN works special training in a specific geographic area & help the client & the family with health concerns and parenting and lifestyle issues. PHN should be knowledgeable about the resources in her immunity. Function: Health Advocate: As an advocate, public health nurse collects monitors & analyse data & discuss with the client which services & analyses data & discuss with the client which services are needed. She also promotes healthy behavior, safe, water, air & sanitation. The client can be either an individual, a family, a community or a population Care Manger: Public health nurses use the nursing process of assessing, planning, implementing & evaluating outcomes to meet client‘s needs at the least cost. Referral Resource: The nurse educates clients to unable them to use the resources and to learn self-care. Nurses refer to other services in the area, & the other services refer to public health. Nurse for care & follow-up Health Educator: As an educator, the public health nurse identifies community needs & develops & implements educational activities aimed at changing behavior. Direct Primary Caregivers: Public health nurse provides primary care is determined by community assessment & is usually in response to an identified gap that the private sector is unable to respond to, coupled with an assessment of the impact of the gap in services on the health of the population. The direct care services are available in the community for at risk-populations by working with the community to develop programs that will meet the needs of that population eg: Free or low cost immunization for target groups. Communicable Disease Control: Public health nursing skills are necessary for education, prevention, surveillance, & outbreak investigations of communicable disease in community. Disaster Preparedness: Nurse provides education that will prepare communities to cope with disaster, professional triage of for local shelters, conducting communicable disease surveillance, working with environmental health specialists to ensure safe food 687
and water for disaster victims and emergency workers and serving on the local emergency planning comity. XIII) Private Duty Nurse: Private duty nurse is a registered nurse or a licesenced practical nurse that provide nursing services to patients at home or any other setting in accordance with physician orders. Patients may receive continues nursing services beyond the scope of care available from certified home health care agencies (CHHAS). Patients may need only intermittent nursing services which are normally provided with CHHAS which are unavailable at the time the patients needs them. XIV) Home Care Nurse: Home care nurse is a nurse who provides periodic care to patients with in their home environment as ordered by the physician. It includes health maintence, education, illness prevention, diagnosis and treatment of disease. Palliation and rehabilitation. It is component of a continuum of comprehensive health care where by health services are provided to individuals and families in their home to promote, maintain or restore health, or to maximize the level of independence while minimizing the effects of disability and illness. Home care can be restorative care or acute care depending upon the client condition. Home care nurse acts as referral agent for clients who are discharged from acute care settings such as hospitals or mental health facilities for continued care & follow up. In community have care nurse, conducts home visits where nurse can view clients in perspective and thus can understand them better, capitalize on their resources and tailor health services to meet their needs. XV) Hospice Nurse: Hospice nurse is one who provides a family centered care and allows clients to live and remain at homes with comfort, independence and dignity, while alleviating the strains caused by terminal phase. The nurse provides care and support for the client and family during the terminal phase or at the time of death. Hospice care can be given in patients have, a hospital, nursing home or private hospice facility. Functions: Pain & symptoms control: The nurse helps the patient to achieve comfort and allows remaining in the control in life by managing to ensure that the patient is free of pain and symptoms as much as possible. Spiritual Care: Spiritual care is individualized to meet patients and their families need and to include helping the patient to look at what death means to them Home Care and impatient Care: The nurse stay involved in treatment of the patient and with the family, resuming in – home care when appropriate. Family Conferences: The nurse provides a chance to share feelings, talk about expectations, and learn about death and the process of dying. Family members can find great support and stress relief through family conferences. Co-ordination of care: There should be coordination and supervision of care 7 days a week, 24 hrs a day between the interdisciplinary team. The interdisciplinary team includes doctor, nurses, social workers, councilors, pharmacist, and clerks etc who provide physical, social and emotional support to the client. 688
Bereavement Care: Bereavement is the time of mourning following a loss. The provides support to the family members through visits, phone calls, letters and through support groups. XVI) Rehabilitation Nurse: Rehabilitation nurse is a nurse who specializes in assisting persons with disabilities and chronic illness to attain optimal function, health and adapt to an altered life style. Rehabilitation nurse can practice in hospitals, impatient rehabilitation center, outpatient rehabilitation centers, long term care facilities, community and home health settings, insurance companies, private practice. Functions: Assists patients in their move towards independence by setting realistic goals They work as a part of multidisciplinary team and often co-odinate patient care and team activities Rehabilitation nurse provides care that helps to restore and maintain functions and prevent complications Provides patient and family education, counseling and case management. Serves as a patient and family advocate and participates in social that helps improve the practice of rehabilitation. XVII) Office Nurse: Office nurse is also called as clinic nurse. Office nurse provides patient care along with physician in settings such as, physician officers, surgi centers and medical office buildings. The main focus is on diagnosis and treatment of specific illness rather than health promotion. But now the patient enrole to have regular physical examination. Functions: Identifies trends in the types of problems client present and treating them. Provides health promotion activities by health education and health counseling. Acts as problem solver who helps with referral questions Performs clerical duties like managing the flow of clients through the office and dealings with physician concerned. Is an important bridge between physician and population of clients Supervision of secretarial and medical assistance staff and medical record personnel. XVIII) Nurse Epidemiologist: Nurse epidemiologist
689
COLLABORATION ISSUES AND MODELS WITHIN AND OUTSIDE NURSING Introduction: Changing models of health care have created a need for modification of traditional roles. Nurses and physicians have been especially affected by these changes and work more collaboratively as colleagues. According to American Nurses Association (ANA) 1995: The boundaries of each h3ealth care professionals constantly changing, and members of various professional co-operate by exchanging knowledge and ideas about how to deliver high-quality health care collaboration among health care professionals involves recognition of the expertise of others within and outside one‘s profession and referral to those providers when appropriate. Collaboration also involves some shared functions and common focus on the same over all missions. Recently however the health care system has moved toward more collaborative efforts and initiatives in which providers and clients become partner in the care. Definition of Collaboration: Collaboration means a collegial working relationship with another health care provider in the provision of (to supply) patient care, collaborative practice requires (many include)the discussion of patient diagnosis and cooperation in the management and delivery of care .each collaborator is available to the other for consultation either in person or by communication device, but need not be physically present on the premises at the time actions are performed. The patient designated health care provider is responsible for the over all direction and management of patient care (ANA, 1992). Collaborative Health Care: Virginia Henderson(1991,p44)on e of the pioneers of nursing ,defines collaborative care as ―a partnership relationship between doctors ,nurses and other health care providers with patients and their families‖ .It is a process by which health care professionals work together with clients to achieve quality health care outcomes. Mutual respect and a true sharing of both power and control are essential elements .Ideally collaboration becomes a dynamic, interactive process in which clients (individual, groups, communities)confer with physicians, nurses and other health care providers to meet their health objectives .more recently published executive Summary from (ANA1998)relished in nursing trends and issues described collaboration as intrinsic to nursing as follows, Nurses and physicians working together and indigently assessing,diagnosing,caring for consumers by preparing patients histories conducting physical and psychosocial assessments, and reviving and discussing their cases with other health professionals to determine the changing health status of each clients. To provide effective and comprehensive care, nurses, physicians, and other heath care professionals must collaborate with each other. No group can claim total authority over the other. The different areas of professional competence exhibited by each profession, when combined, provide a continuum of care that the consumer has come to expect.
690
Collaborative Practice Models Propose To Achieve The Following Objectives: 1) Provide client- directed and centered care using multi deciplinary, integrated, participative framework. 2) Enhance continuity across the continuum of care, from wellness and prevention, pre hospitalization through an acute episode of illness to transfer or discharge and recovery or rehabilitation. 3) Improves clients and family satisfaction with care. 4) Provide quality, cost-effective, research-based care that is outcome driven. 5) Promote mutual respect, communication and understanding between client(s) and members of health care team. 6) Create synergy among clients and providers, in which the sum of their efforts is greater than the parts. 7) Provide opportunity to address and solve system related to issue and problem. 8) Develop interdependedt relationships and understanding among providers and clients. Continuum of Health:
A continuum of collaboration begins with parallel communication, where by everyone is communicating with the client independently and asking the same question. Parallel functioning may have more co-ordinated communication, but each professional has separate intervention and a separate plan of care. Information exchange involves planed communication, but decision making is unilateral, involving little, if any, collegiality. Coordination and consultation represent mid range levels of collaboration seeking to maximize the efficacy of the resources. Home management and referral represent the upper levels of collaboration, where provide us retain responsibility and accountability for their own aspects of care and patience are directed to other providers when the problem is beyond their expertise.
691
Characteristics Of Effective Collaboration Include: Common purpose and goals identified at the outset. Clinical competence of each provider. Interpersonal competence. Humor. Trust. Valuing and respecting diverse, complementary knowledge. The Nurse as a Collaborator: With client: o Acknowledges supports and encourages client‘s active involvement in health care decision. o Encourages a sense of client autonomy and an equal position with other members of the health care team. o Help clients set mutually agreed upon goals and objectives for health care. o Provides client consultation in a collaborative fashion. With peers: o Shares personal expertise with other nurses and elicits the expertise of others to ensure quality client care. o Develops a sense of trust and mutual respect with peers that regimes their unique contributions. With other health care prifessionals: o Recognizes the contribution that each member of the interdisciplinary team can make by virtue of his or her expertise and view of the situation. o Listens to each individual‘s view. o Shares health care responsibilities in exploring options, setting goals, and making decisions with clients and families. o Participates in collaborative interdisciplinary research to increase knowledge of a clinical problem or situation. With professional nursing organizations: o Seeks out opportunities to collaborate with and within organizations. o Serves on committees in state (or provincial),national and international nursing organizations or specialty groups. o Supports professional organizational in political action to create solutions for professional and health care concern With legislator: o OFFERS experts opinions on legislative initiatives related to health care. o Collaborative with health care providers and consumers on health care legislation to best serve the needs of the public. Benefits of Collaborative Care: A collaborative approach to health care ideally benefits clients ,professionals ,and health care delivery system .care becomes client centered and most important client directed .clients become informed consumers and actively participate with the health care team in the decision making process. When clients are empowered to participate actively and professionals share mutually set goals with clients. Everyone including the organization and health care system ultimately benefits. When quality improves adherence to 692
therapeutic regimens increases, lengths of stay decreases and overall cost to the system decline. When professional interdependence develops collegial relationship emerges and overall satisfaction increases. The work environment becomes more supportive and acknowledges the contributions of each team member ―Because authority is shared, thus effort results in more integrated and comprehensive care, as well as shared control of cost and liability.‖ Competencies Basic to Collaboration: Key features necessary for collaboration include effective communication skills, mutual respect, and trust, giving and receiving feedback, decision making, and conflict management. Communication Skills: Communication style is very important in successful collaboration. Norton‘s theory of communicator style (1983) defines style as the manner in which one communicates and includes the way in which one indicates, therefore, what is said and how it is said are both important. Three communicator styles have been used in a nursing study of collaboration styles as they relate to degree of collaboration and improved quality of care. Using attentive style and avoiding contentious and dominant styles made a significant difference in nurse, physician collaboration, positive patient outcomes and nurse satisfaction. The researchers assert that attentive style can be taught by modeling the behavior of obvious listening such as making eye contact while communicating and refraining from participating in other activities that interrupt communication while someone is trying it communicate. Verbal feedback and repeating back offers the opportunity to reflect on what was said and correct misunderstanding. Developing a non-contentious style means developing judgment in recognizing when it is necessary to stop a conversation an insist on clarification because it is an important point and when it is better to ignore a comment that is disagreed with because it is not essential to goal. Developing a non-dominant style involves controlling one‘s behavior of monopolizing the conversation or speaking so forcefully that feel pushed back and unwilling to respond. Role playing followed by discussion and role-modeling have been identified as effective strategies for developing positive communicator styles. Mutual Respect and Trust: Mutual respect occurs when two or more people show or feel honor or esteem towards one another. Trust occurs when a person is confident in the action of another person. Both mutual respect and trust imply a mutual process and outcome. They must be expressed both verbally and non-verbally. Sometimes professionals may verbalize respect or trust of others but demonstrate by their actions a lack of trust and respect. Giving and Receiving Feedbacks: One of the most difficult challenges for professionals is giving and receiving timely, relevant and helpful feedback to and from each other and their clients. When professional work closely together, it may be appropriate to address attitude or actions that affect the collaborative relationship. Feedback may be affected by each person‘s perception. 693
Personal space, roles, relationships, self esteem, confidence, believes, emotions, environment and time, giving and receiving feedback helps individuals acquire self awareness while assisting the collaborative team to develop an understanding and effective working relationship. Decision Making: The decision making process at the team level involves shared responsibilities for outcome. The team must follow each step of decision making process, beginning with a clear definition of problem. Team decision making must be directed at the objectives of the specific effort factors that enhance the process include mutual respect and constructive and timely feedback. An important aspect of decision making is interdisciplinary team focusing on the client‘s priority needs and organizing interventions accordingly. The discipline best able to address the client‘s need is given priority in planning and is responsible for providing its interventions in a timely manner. For example, Nurses, by nature of their holistic practice, are often able to help the team, identify priorities and area requiring for further attention. Conflict Management: Role conflict can occur in any situation where individuals work together. Role conflict arises when people are called on to carry out roles that have opposing or incompatible expectations. In an interpersonal conflict, different people have different expectations about a particular role. Inter Role Conflict exists when the expectations of a person or group differ from the expectation of another or group. Any one of these conflict can affect inter disciplinary collaboration. There Are Five Stages Of Conflict: Latent conflict is always present when there is a complex organization or when goals are differentiated and may come in to conflict. Perceived conflict is when awareness begins. The conflict may or may not progress beyond a latent or perceived level. When it does progress, felt conflict occurs and hostilities anxieties and stress erupt over conflict results when the conflict is acted out and battle line are drawn. Conflict aftermath comes about with a resolution and it may or may not be optimal. The results may range from full co-operation to active or passive resistance. Although the conflict is resolved, the behavior may still affect. There may be difficult letting go once there is resolution. The conflict may be interpersonal between or among individual, or the conflict may involve groups. Intergroup conflicts may occur between nurses and laboratory personnel or between nurses and physicians. For example, intergroup conflict may occur within a group such as when nurses on a care unit disagree about policies governing practice, such as a plan or policy for floating Trade off to get a final agreement that is as close as possible to one‘s optimal position. Smoothing over is a short term resolution focused on minimizing the felt conflict without resolving it. With this approach felt conflict is likely to remerge to another unit.
694
Problem solving or confrontation can be applied through open discussion and a through investigation of the dimension of the conflicts. Negotiation or bargaining: entails identifying one‘s bottom line as well as one‘s optimal result and then making Avoidance may be used when one side makes that decision to cease discussion and withdraw. Forcing uses power or influence to improve a performance this often involves going over someone‘s head and using a higher authority to enforce resolution. Factors leading to the need for increased collegiality and collaboration: World wide there are a number of significant influence on health and health care that will require international collaboration. The World Health Organization (WHO) sets an objective that they hoped all people would achieve by the year 2000, a level of health that would permit them to lead socially and economically productive lives. A number of factors influence the provision of health care: They are:Consumer Wants and Needs: Health care consumers are demanding comprehensive, holistic and compassionate health care that is also affordable. Clients expect that health care providers will view each person as a bio psycho social whole and respond to his or her individual needs. They want expert, humanistic care that integrate that available technology and provides information and services related to health promotion and illness prevention. Today‘s health care consumers have greater knowledge about their health than in previous years and they are increasingly influencing health care delivery. Previously people expected a physician to make decisions about their care: today however consumers expect to be involved in making any decision. Consumers have also aware of how life style affects health. They are willingly participating in health promotion activities. They are beginning to view health care professionals as recourse to guide these activities. Self Help Initivative: Responsibility for the self is a major belif-underliying, holistic health that recognize the inter dependent of body, mind, and spirit. Increasing people are adopting the view that the self empowered with the ability to create are maintaining health or disease. Today many individuals eek answer for acute and chronic health problems through non traditional approaches to health care. Alternative medicine and support groups are among two of the most popular self-help choice. The most commonly used therapies of relaxation techniques, chiropractic treatment, massage, imagery, spiritual, healing, weight los programs and herbal medicine. Alcoholic Anonymous (AA), which formed in 1935, serves as a model for many of these groups. The national self-help clearing house in the United State provides information on current support groups and guidelines about how to start a self-help group. Changing Demographic and Epidemiology: It is predicted that by the year 2020, there will be more than 50 million adults over the age of 65 years living in the united state .the growing number of older adults, combined with The fact that the average older adult has three or more chronic conditions, will greatly influence the health care system and the insurers in the future. 695
Closely related to the major epidemiology influence posted by chronic illness. One of these is HIV/AIDS, a problem that growing each year. The centers for disease control and prevention report that a total of 886,575American have been diagnosed with AIDS through 2002 and the estimated number of deaths is 501, 669.worldwide, it is estimated that 37 million adults and 2.5 million children are living with HIV/AIDS as of the end of 2003 According to the National Coalition for the homeless and poverty are inextricably linked. Limited resources result in difficult choices when trying to pay for housing, food, and child care, health care so on .limited access to health care services significantly impacts the health of the poor and the homeless. Helth Care Access: Several alternative health delivery systems have been implemented to control costs. These include Health Maintenance Organization (HMO), Preferred Provider Organization (PPOs) Physician/Hospital Organization (PHO) and so on. Additionally, the development of prospective payment systems significantly influenced the health care system. Concerns remain however about ways to further reduce health care cost and at the same time achieve the desired goal of improving the quality of health care delivery. Employers, legistivelaters, insurers, and health care providers continue to collaborate in efforts to resolve these concerns. Ethical issues such as rationing of health care, access to health care, the use of health care technology and extra ordinary interventions, and organ transplantation can be resolved only through collaboration. Technological Advances: Technology has had a major influence on health care cost and services with advances in medicine and technology, an individual‘s life span can in many case extended. However the same technology may result in fragmentation of care and acceleration of health care costs. New medical devices, technology advances, and new medicines frequently are introduced with, limited considerations to the associated cost or the efficacy of their use. Partnership and Collaboration Workshop March 2nd 2003: Stage 1: Problem Setting: Shared understanding of problems and goals. Shared definition of the problem. Shared commitment of the collaboration. Identification for recourses required to support the collaboration. Collective identification of key stake holders and the convector. Stage 2: Reaching Agreement: Establish the ground rules. Jointly agree on agenda for the collaboration venture. Reach agreement on how problems will be solved. Stage 3: Implementation: Build external support for the problem solutions agreed. Institutionalizing/Implementing agreements reached. Monitoring the agreement and enduring compliance.
696
Success Indicators: Success indicators from the strategy can be characterized in 3 groups. Leadership and organizational structure workforce development and resource and planning. These include: Senior managers participating on health promotion committees/working parties. Senior managers advocating and understanding the importance of consumer participation strategies. Senior manager and staff have a common understanding of the determinants of health and how this then affects the delivery of both clinical direct care services and health promotion programs. The development of policies and procedure that enable consistent, quality health promotion reporting and communication. Resources allocated for positive dedicated to health promotion co-ordination (Either through once position for each alliance or through each member agency taking a lead on different components of the strategy) Resourcing of alliance networking and backfill of staff (Where possible) to allow intersectional and interagency alliance to function. Linking integrated health promotion planning, overall PCP executive/governance decision making and individual member agency planning. This then must be supported by clear and active communication and dissemination strategies across and within each member agency. Flat management and governance structures with developed, shared and transparent decision making particularly in relation to resolve allocation. Flexible work practices (Flexible working hours, ability to work from home, flexible use of leave and flexible policies relating to family and children at work). Support for staff to access professional development opportunities such as relevant courses and conferences, mentoring opportunities, the internet libraries and subscription to primary care/health promotion journals. Trust both between agencies and trust with department. Support from the department centrally and regionally to being able to provide content specific health promotion support. I have to make a special mention of the capital regional health promotion officers. Thee positions are in each of the nine DHS Regions across the state. Their regional leadership participation and ability to provide on the ground support and expertise remains absolutely critical. A centrally driven reform process that did not have this regional leadership simply would not have worked. Disseminating health promotion practice guidelines and promotion, and information, planning and reporting preformed. Conducting regional and sate wide workshops on quality health promotion planning. Sponsoring the development and delivery of a five day core health promotion short cores. Disseminating a series of evidence-based health promotion reviews on specific health issues and risk factors. Disseminating of learning from individual PCPs across the state through the development of health promotion web page. 697
Ensuring participation by the population group (as defined) in the program planning. Having clear but realistic identification of defined goals and program objectives. Having a realistic definition of the target population groups. Mapping existing program delivery (for that defined population group or priority area) to determine opportunities to build on and co-ordinate activities. Defining the mix of interventions and using published literature to inform this selection of interventions. Leadership Senario: You are a member of the falls prevention working group of the Utopia Alliances A health promotion comity was established to develop a health promotion plan for the Utopia area in south west WA. Membership includes a range of individuals from organizations (service providers to managers) and two consumer representatives with varied experience knowledge and involvement of health promotion. In most cases individual have self selected, however, in some situations targeted recruiting of individuals from agencies considered crucial to the partnership occurred. Agencies are services such as community health, local government, Psychiatric disability support service, aged care assessment teams, geriatrics rehabilitation centers, division of general practice, women‘s health and a migrant recourse service are represented on the working group. The group has met on three occasions over last six months and in that time a got to know one another, developed agreed terms of reference and created a vision for what they would like to achieve in health promotion. The aged care branch of the health department is providing an opportunity for local health promotion groups to apply for funding to undertake a collaborative falls prevention program targeted to older people. The project management group of Utopia alliances decides to apply for funding and delegates the task of developing the project proposal to a falls prevention working group. That ha ten days to complete the task. All of the agencies represented on the working group agreed to support and work in partnership on the falls prevention proposal. However several problems arise. Firstly there is some discrepancy about who will take the ‗Lead‖ for the project has two different agencies with a key role in falls prevention are strongly advocating for their right to take these positions. Secondly the commitment of the individuals on the working group to the proposed project differs to that of their agencies. Thirdly, there is a problem obtaining consensus among agencies as to what constitutes success in terms of the tangible (activity oriented) and the in tangible (process oriented) outcomes of the proposed collaborative project. It is imperative that each of these three issues are addressed and resolved prior to submitting the funding proposal to the health department, which is now done in one week. A model of community: based interdisciplinary team training in the care of the frail elderly.
698
Objective: It is widely recognized that interdisciplinary team care is essential for effective management of complex patients such as the frail elderly. Physicians need to understand the operational mechanisms that drive the team care model. While such concepts should be an integral part of medical education, teaching such a model of care that demonstrates effective provider communication, coordination of multiple services, and the provision of cost-effective health care can be difficult. The Program of Allinclusive Care of the Elderly (PACE) is a well-established, high-quality program that has been replicated nationally and can serve as an effective teaching model. Achieving the goals of the PACE program requires strong team leadership and communication, clear patient-oriented goal definition, an understanding and appreciation of roles among various disciplines, skillful negotiation, and shared responsibility for the patient. The PACE model offers medical and family practice residents a non-traditional clinical setting with educational opportunities not available in most hospital or ambulatory settings. DESCRIPTION: For several years the Fallon Healthcare System Elder Service Plan (ESP), one of 25 national PACE programs, has provided an educational setting for medical and family practice residents as a component of their clinical rotations in geriatrics. This training experience has been expanded to include additional residents in on-site interactive seminars that focus on effective communication using an interdisciplinary team approach to care. The ESP program provides comprehensive medical and social services to a frail, non-institutionalized nursing-home-eligible population. The aim of the program is to preserve the health and independence of its participants for as long as possible. The ESP team consists of physicians, nurse practitioners, nurses, nurse's aides, home health workers, social workers, therapists, nutritionists, and pharmacists. The seminar includes a slide and video presentation led by members of the ESP team using selected scenarios that portray both effective and poor team dynamics and communication. Definitions of a team, the process of establishing patient- and family-oriented goals, interdisciplinary role appreciation and responsibility, and the basics of financing a comprehensive health care delivery system for the frail elderly are discussed. Approximately half of each session is devoted to interactive discussion and critiquing of the scenarios by the residents and faculty, which is derived from the ESP team. DISCUSSION: For most of the medical and family practice residents, this experience represents their first exposures to this model of coordinated team care for the elderly. Preliminary evaluation results indicate that residents have generally been unaware of the services available to the elderly and of the opportunities for coordinated care using the expertise of multiple disciplines. There is a lack of knowledge of key non-physician professional roles. The expanded use of PACE models as training sites could be beneficial in preparing future health care professionals for interdisciplinary team care of the growing numbers of frail elderly. Evolution of a Collaborative Model between Nursing and Computer Science Faculty and a Community Service Organization to Develop an Information System
699
Following the 9/11 disaster two faculties from the Department of Nursing at Miami University in Oxford, Ohio, who are American Red Cross volunteers, identified an emergent need for a disaster information system to support Red Cross disaster services nurses. At that time faculty and students in the Computer Science Department were researching mobile co Early in 2002 the needs identified by the nursing faculty, and the research interest of the computer science faculty, combined in the form of an interdisciplinary research project to aid the Red Cross disaster services nurses. The project has improved delivery of care to Red Cross disaster victims and created a sustainable learning and research environment for both the nursing and computer science departments. This paper describes the background that led to the project vision, the evolutionary collaborative model between the Red Cross and Miami University faculty to implement the project, and the benefits of the collaborative model. Evolutionary Model: The faculty developed an evolutionary collaborative model to guide their work, progressing from an informal conceptual stage to a formal, operational partnership. This is similar to a collaborative model used by Schemer, Geisler and Vang1 in their nursing thesis database project involving a nursing faculty member, a computer laboratory administrator, and a programmer. This section discusses investigative, operational, and expansion phases of the model whereas Schermer1 et al organized their model into concept, planning and implementation phases. Benefits of the Collaborative Model: Schermer, Geisler, and Vang's1 cooperative venture with nursing faculty and computer science professionals resulted in similar benefits to the collaborative model presented in this paper. Schermer etc… All found that the combined efforts resulted in closer interdisciplinary relationships and sharing of nursing research information within the university.1 Collaboration with faculty from nursing, other disciplines, and community agencies in the CDIS project opened new and exciting learning and research opportunities, especially as they address current issues. Linkages developed by faculty engaged in community service can evolve into meaningful, real-life projects for students, faculty, and society. Nursing students were challenged to apply their community health knowledge as they learned the process of developing a disaster information system. Nursing students experienced an application of informatics in their discipline. Computer science students worked with innovative mobile computing, web-services and the Internet as they learned about disaster nursing response. The students and faculty learned about the disciplines of nursing and computer science. They discovered that their vocabularies and critical thinking patterns were very diverse and this proved to be a challenge in communicating their ideas. They learned how to understand each other and respect the expertise that each brought to the project. These skills will enhance the students‘ ability to work with interdisciplinary teams.
700
Motivated by the obvious need for the system, the students and faculty dedicated themselves to producing a significant and impressive informatics application. Through interdisciplinary collaboration nursing and computer science students learned to apply informatics to solve a community need. Both groups frequently commented about their personal satisfaction of working on a project that would actually be implemented in the community and increased their interest and dedication to the project. The students learned how to work together to accomplish a mutual goal from very different perspectives. Nursing and computer science faculty found a new energy that came from expanding their horizons beyond their comfort zone. This synergy has evolved into an empowered team that together has received departmental, divisional, university, local and national recognition. The Red Cross and ultimately their communities benefit from an information system that can be used for local and national disasters. With the expertise and funding sources available from academia, faculty and students capitalized on an educational and research opportunity to collaborate with a service organization to produce a much needed community resource. All parties benefit by producing products and services that neither would have produced individually. Collaboration and Independent Practice: Ongoing Issues for Nursing Inter-professional collaboration and independent practice: Why these issues are important During the twentieth century, the nursing profession has undergone immense change. Nursing has progressed from an occupation to a fully licensed profession, with members that provide a broad range of services independently, and in a variety of professional relationships with other providers. This evolution has changed how nurses are educated, clinically prepared, and how they perceive their role. Starting with turn-of-the-century debates concerning the appropriateness of professional nursing practice, registered nurses began assessing not only their licensure status, but their roles related to other professionals. (1, 2) In the early years of the nursing profession, it was generally believed that nurses served and cared for their patients by assisting physicians. However, the perception of nursing often varied dramatically from its practice. During wars and times of crises, nurses worked with and beside physicians conducting surgical procedures, diagnosing care, and prescribing treatments and drugs. These practices were documented as occurring in the U.S. as early as the Civil War. The role of the public health nurse, as it developed earlier in this century, was often independent, with nurses working with families of patients with tuberculosis or other highly contagious diseases and providing a broad range of interventions, both health- and socially-focused. Intrinsic to nursing is the collaborative process: nurses and physicians working together and independently assessing, diagnosing, and caring for consumers by preparing patient histories, conducting physical and psychosocial assessments, and reviewing and discussing their cases with other health professionals to determine the hanging health status of each client. Yet the products of these fruitful relationships and work structures were discounted due to state regulation of health care and the additional need to define relationships and responsibilities in statute. Nurses and physicians have understood the importance of this overlap in scopes, practices, and patient care, yet there is little literature and virtually no legislation that 701
clearly provides a balanced accounting of the benefits of this working relationship. This article describes the regulatory and professional history of collaboration and nursing practice and explains the distinctions in state law related to collaborative practice. This article also provides a historical basis for review of collaboration and incorporates a survey on case law and collaborative practice.
702
BIBLOGRAPHY: 1. Kathleen kiering Blois, Janice S. Hayes, Barbara Cozier, Glenore, Erg ―Professional Nursing Practice Concept and Perspectives‖. 5th edition, passion education. Page no: 216227. 2. Adapted from Victorian 5 day health short course module E: Actions for health promotion policies, funding and collaboration. State government of Victoria 2003. 3. Upshaw Irk, MD is a Healthcare Management fellow at Harvard University. Keough ME, Field TS, Gurwitz JH. 4. Department of Family Medicine and Community Health, Meyers Primary Care Institute, Fallon Healthcare System and University of Massachusetts Medicall School, 01605, USA.
703
FAMILY NURSING Introduction: Nursing care directed to improving the potential health of a family or any of its members by assessing individual and family health needs and strengths, by identifying problems influencing the health care of the family as a whole and those influencing the individual members, by using family resources, by teaching and counseling, and by evaluating progress toward stated goals. Nurses and other health care providers regularly receive encouragement to evaluate care practices, develop continuous quality improvement initiatives, and find ways to demonstrate accountability. Nevertheless, health care providers sometimes shy away from evaluation, thinking they are too busy with patient care or administrative demands, that evaluation is too hard to do, or because of uncertainty about how to approach evaluation of family nursing in a way that is useful and practical. The family is so important that it is recognized in every society. The family as most significant unit of social behavior has been experiencing considerable changes. These changes have affected the family‘s development in relation to structure, functions and interactions. Definitions: Family: It refers to two or more individuals who depend on one another for emotional, physical, and/or financial support. ―A social group characterized by common residence, economic co-operation and reproduction. It includes adults of both sexes, at least two of whom maintain a socially approved sexual relationship and one or more children‖ -Murdock GP ― a group that that engages in socially sanctioned, enduring and exclusive relationships that are based on marriage, descent, adoption or mutual definition, as in common-law marriage. -Yorburg Health: Health is a state of complete physical, mental and social wellbeing and not merely an absence of disease or infirmity. Family Health: it is a dynamic changing relative state of well being which includes the biological, psychological, spiritual, sociological and cultural factors of the family system. Family Nursing: It is the provision of care involving the nursing process, to families and family members in health and illness situations. Types of Family: The family may take one of several following forms:1. Nuclear Family: It consists of the husband, wife and perhaps one or more children. For children, this family is often referred to as family of origin. For the parents it is the family of procreation. 2. Joint Extended Family: It includes members of the nuclear family and other relatives, aunts, uncles, grandparents and cousins are all parts of the extended joint family. 704
3. Blended Families: Are formed when parents bring unrelated children from prior marriages into a new, joint living situation because of remarriage or cohabilitation. 4. Single Parent Families: Are formed when one parent leaves the nuclear family because of divorce, desertations or death. The circumstances of the seperation influence its impact on the family. Characteristics of Family: The family is a primary reference group having following five universal characteristics:1. Every family is a small social system. 2. Every family has its own cultural values and roles. 3. Every family has its own structure. 4. Every family performs certain basic functions. 5. Every family moves through stages of the life cycle. Traits of the Family: According to Curran D the traits of family are as follows:1. The family communicates and listens. This trait or strength is based on the notion that the major function of a family is relational rather than physical. 2. The family members affirm and support one another. 3. The family teaches respect for individual members and others. 4. The family develops a sense of trust between and among its own members. 5. The family has a sense of humor and play. 6. The family exhibits sense of shared responsibility. 7. There is a strong sense of family in which rituals and traditions abound, and there is often an identifyable locus for family activity. 8. The family has a shared religious core and respects religious differences. 9. The family members respect the privacy of one another. 10. The family values services to others within and outside, the family unit. Roles of the Family: • Child socialization. • Child care. • Provider role. • House keeper role. • Sexual role. • Therapeutic role. • Recreational role. Functions of the Family: • Generating affection. • Providing personal security and acceptance. • Giving satisfaction and sense of purpose. • Ensuring continuity of companionship. • Providing social placement and socialization. • Imposing control and sense of what is right. Approaches to Family Nursing: The approaches that nurse use are determined by many factors, including the issues for which the individuals or families as 705
a whole are seeking help, the environment in which they coexist with other family members and the community. 1.) Family as the Context: The family has a traditional focus that places the individual first and the family second. The family as a context serves as either a strength or a stressor to individual health and illness issues. 2.) Family as the Client: The family is primary and individuals are secondary. The family is seen as the sum of individual family members. The focus is concentrated on each individual as they affect the family as a whole. Family as a system: The focus is on the family as client, and the family is viewed as an interactional system in which the whole is more than the some of its parts. This approach focuses on individual members and the family as a whole at the same time. The interaction among family members becomes the target for nursing intervention. The system approach to families always implies that when something happens to one family member, the other members of the family system are affected and vice versa. 3.) Family as a Component Of Society: The family is seen as one of many institutions in society, along with health, education, religious and financial institutions. The family is a basic or primary unit of society, as are all the other units and they are all a part of the larger system of society. The family as a whole interacts with other institutions to receive exchange or give services. 4.) Family as a Unit of Health Services: The emergence of family health has been hailed as a rediscovery of the human social and cultural aspects of health and disease and the recognition of family as a focal point of health care and the right place for integrating preventive, promotive and curative services. The family system is a basic unit within which, health behavior including health values, health habits and health risk perceptions are developed organized and performed. The interrelationship between health, health behavior and the family is a highly dynamic one in which each may have a dramatic effect on the others. Theoretical Frameworks: 1.) Family Nursing Theory: It is an evolving synthesis of the scholarship from three different traditions; family social science, family therapy and nursing. Of these three categories of theory, the family social science theories are the best developed and informative with respect to how families function, the environment-family interchange, interactions within the family, how the family changes over time, and the family‘s reaction to health and illness. 2.) Structure Function Theory: The structure function framework from a social science perspective defines families as social systems. This approach describes the family as open to outside influences, yet the same time the family maintains its boundaries. Assumptions of this theory includes: A family is a social system with functional requirements A family is a small group that has basic features common to all small groups. Social systems such as families, accomplish functions that serve the individuals in addition to those that serve society. 706
Individuals act within a set of internal norms and values that are learned primarily in the family socializing process. 3.) System Theory: The system approach to understanding families was influenced by theory derived from physics and biology. A system is composed of a set of interacting elements; each system can be identified and is different from the environment in which it exists. Assumptions includes: Family systems are greater than and different from the sum of their parts. There are many hierarchies within family systems and logical relationships between subsystems, Boundaries in the family system can be open, closed or random. Family system change constantly in response to stresses and strains from within and from outside environments. There are structural similarities in different family systems Change in one part of the family system affects the total system. The family system theory encourages nurses to view clients as participating members of the family. Nurses using this theory determine the effects of illness or injury on the entire family system. 4.) Interactionist Theory: It views families as units of interacting personalities and examines the symbolic communications by which family members relate to one another. Within the family, each member occupies positions to which a number of roles are assigned. Members decide their role expectations in each situation through their perceptions of the role demands. Assessment of families using the interactionist theory emphasizes interaction between and among family members and family communication patterns about health and illness behaviors appropriate for different roles. Principles of Family Health Nursing: • Establishing good professional relationship with the family. • Proper health education and guidance should be provided to family to take care of themselves according to their needs, intelligently. • Gather all relevant information about family to identify problems and set priorities. • Provide need based support and services to the family to improve their health status. • Health care services should be provided to the family irrespective of sex age,income, religion, etc, • Duplication of health services should be avoided, and there is need to co-ordinate services with other disciplines providing health service. • Proper health messages to be communicated to family in every contact. Nursing Process for Family: Family nursing process is the same, regardless of the setting or whether the focus is on the family as the context or as a client. It is also the same process as that used with individual clients. Three beliefs underlie the family approaches to the nursing process: All individuals must be viewed within their family context. Families have an impact on individuals. Individuals have an impact on families. Family nursing process is the same, whether the focus of the family is as patient or as environment. The nursing process is used in the same way as with individuals. The goal 707
of the community health nurse is to help the family reach and maintain its maximum health in any given situation. Assessing the Needs of the Family: Family assessment is essential for providing adequate family care and support. The nurse begins assessment by determining the client‘s definition of and attitude towards family and the extent to which the family can be incorporated into nursing care. Family assessment is an essential component of the nursing process. Here the nurse collects the data by using the methods of interviewing, observation subjective appraisal, communication, reviewing records and reports. Family health assessment will be done by collecting relevant information of basic information i.e. housing condition, and surroundings, family composition, socio economic status, educational status, means of communication, dietary pattern, health status of each individual in the family- including mother and child, vital statistics, immunization status, family planning status and any information related to health of the family and community. Nursing Diagnosis: Nursing assessment results in clustering pertinent data that support the nursing diagnosis and identifies inadequate or deficient functioning and interventions needed. The diagnostic label may include family‘s health needs, current, and potential health problems, level of wellness, or combination of the above. Planning: Planning of family health care includes setting goals, identifying potential internal and external resources, choosing effective approaches and setting priorities. The plan of care should be clearly understood by the family and they must agree to it. Goal setting must be a mutual endeavor. The goals must be concrete and realistic, compatible with the developmental stage and acceptable to family members. The nurses care plan should include following goals:I. The patient will use appropriate resources within the family. II. The family will accomplish appropriate development tasks. III. Family members will understand the patient‘s health problems. IV. The patient will return to a functional state within the family environment. Implementation: After goals and actions have been defined, implementation begins. Interventions are strategies that help families adjust goals or are the process by which the family attains them. Family interventions include nursing actions that increase members‘ abilities in a certain area, remove barriers to health a care and do things that family can not do for itself. Evaluation: When the patient‘s family functions as an environment, evaluation is patient-centered, although nursing measures may have involved assisting the patient to adapt to the environment. The response of the patient is compared with predetermined outcomes. Family Focused Care: Nursing practice is enhanced by a family focused approach. When the nurse has established a relationship with the family, it is important to identify potential and external so that effective nursing care approaches can be implemented. Any plan for nursing care 708
must be clearly understood by the family and mutually agreed to by all members. The nurse collaborates with all appropriate family members when determining what they hope to achieve with regard to the family health. Collaboration with family members is essential, whether the family is the client or the context of care. A positive collaborative relationship is based on mutual respect and trust. The family must feel ―in control‖ as much as possible. By offering alternative actions and asking family members for their own ideas and suggestions, the nurse can help to reduce the family‘s feelings of powerlessness. Implementing Family Centered Care: Whether caring for a client with family as a context or client, nursing interventions aim to increase family members‘ abilities in certain areas to remove barriers to health care, and to do things that the family cannot do for itself. The nurse guides the family in problem solving, provides practical services, and conveys a sense of acceptance and caring by listening carefully to family members‘ concerns and suggestions. One of the roles of the nurse will need to adopt is that of educator. Providing accurate health information about diagnosis, necessary self care activities and the projected course of the condition may be helpful. Health education is a process by which information is shared by nurse and client in a two way fashion. Family/clients needs for information may be recognized through direct questioning. Health Promotion: Implementation of family nursing care always includes health promotion. This encourages clients and families to reach their optimal levels of wellness. Identifying attributes that contribute to healthy, resilient families has been a focus of ongoing research for at least three decades. Strong families that adapt to expected transitions and unexpected crisis and change tend to be characterized by clear communication among members, good problem solving skills, a commitment to one another, and to the family unit, and a sense of cohesiveness and spirituality. One approach for meeting goals and promoting health is the use of family strengths. Family strengths include clear communication, adaptability, healthy child rearing practices, support and nurturing among family members, and the use of crisis for growth. The nurse can help the family focus on these strengths instead of its problems and weakness. Increased attention has been given to improving the health of everyone in the country. as a result of major public health and scientific advances, the leading causes of morbidity and mortality shifted from infectious diseases to chronic diseases, accidents and violence, all of which have strong life style components. A population- focused study in Alamedy County, California and breslow, demonstrated relationships between seven life style habits and decreased morbidity and mortality. These habits were as follows: Sleeping 7-8 hours daily. Eating breakfast almost everyday with out fail. Never or rarely eating between meals. Being at recommended height-adjusted weight. Never smoking cigarettes. Using no or only moderate amount of alcohol. Engaging in physical activity regularly. 709
Barriers to Practicing Family Nursing: Many barriers exist that affect the practice of family nursing in a community setting. Most practicing nurses had little exposure to family concepts during their under graduate education and have continued to practice using the individual focus. There has been a lack of good comprehensive family assessment models, instruments, and strategies in nursing. Nursing has strong historical ties with the medical model, which views families as structure not central to individual health care. The traditional charting system in health care has been oriented to the individual. The medical and nursing diagnosis system used in health care are disease centered, and diseases are focused on individuals. Insurance carriers have traditionally based reimbursement and coverage on the individual, not on a family unit. The hours during which health care systems provide service to families are at times of day when family members cannot accompany one another. CONCLUSION: Family Nursing examines a systemic approach to care which can be applied both in hospital and community settings. Working collaboratively with the family, the nurse is able to strengthen the level of care available to the patient and promote the health and well-being of the whole family.
710
HOME NURSING Introduction: Visiting the sick people at their home and giving them nursing care has been a tradition since early times. At present, in the field of community health nursing, the importance of home nursing is increasing day by day, especially due to unavailability of health services, their uneven distribution, and the lack of resources. These has made home nursing an essential feature for achieving the objectives of home nursing practice. Home health care nursing is defined as ―the delivery of specialized nursing care services in the home health care setting‖ Objectives: Protection against diseases. Providing essential treatment. Providing comfort and relief from pain to the patient. Giving a support and empathy to the patient and his family. Using domestic equipment for the nursing. Providing health education. Giving as much respect as possible to the faiths and beliefs of the family during the procedure. Role of Community Health Nurse in Home Nursing: Recording the history of family to ascertain the cause and duration of illness. Providing treatment and related care. Demonstrating the nursing procedure to educate the family members. Giving medicines as per the standing orders and providing essential nursing care in the grave situations. Supervising the nursing procedures provided by family members. Including the patient himself in taking care of chronic illness (heart, arthritis, cancer, diabetic patients, etc) and giving them mental support. Preparing plans to carry the patient to the hospital or clinic and then bringing him back to his home. General Instructions for Home Nursing: While nursing the patient at home, one should remember what Florence nightingale said; first objective of home nursing is to provide nursing, second is to keep the patient and his room in the nursing order and the third is to remove all those shortcomings of cleanliness, which can cause the illness or death. Try to include the aspects of general nursing in the home nursing. It is essential to make family independent in taking care of their health, so their activities should be carefully monitored. As far as possible, home nursing should not affect the daily life and normal activities of the family and their mental strength should be enhanced. In home nursing it is necessary to take care of the patient‘s age, his hierarchy to the family, financial condition, educational background etc. In case of chronic and fatal diseases diversional or recreational and occupational therapy should be used. 711
In home nursing there should be maximum utilization of family resources and items available in home. To increase the participation of family in home nursing, the class sessions should be preplanned. These sessions should be separately organized for the women, men and children. For home nursing the nurse should have a thorough knowledge of the diagnosis, etiology, sources of infection, course of disease, treatment, complications arising from the disease, surgery and aseptic techniques. In the home nursing, it is necessary to pay attention to social psychological and emotional aspects, because they influence the isolation treatment and the process of nursing. In home nursing the nurse should follow her professional standard and code of conduct (ethics). It should be remembered that 5-6 times actual nursing care given is more effective and benefiting than 10-15 times normal meetings. All principles of home visit should be followed in home nursing. Principles of Home Visit: Home visit is the process of providing nursing care to patients at their doorsteps. The goal of home visit is to provide appropriate nursing care leading to wellness of the patients. When carrying out home visits, the community health nurse should follow certain basic principles given below. 1. Home visits should be planned with purpose and should be beneficial to patients. 2. The purpose of home visits should be clear and must meet the needs of the patients. It should include surveys and statistics, MCH services, home nursing in cases of illness, including health teaching. 3. Home visits should be regular and flexible according to the needs of the patients. 4. Home visit should be educative, i.e., it gives excellent opportunities for health and education. 5. Home visits should give excellent opportunities for nurses to demonstrate hygienic principles. 6. Home visit should be convenient, acceptable and educative to the patients. 7. The nurse should make an attempt to include each family member while using nursing process. 8. The nurse and the family must develop positive interpersonal relationship in their work to achieve the goal. 9. The nurse must be flexible and must respect the patient‘s rights to accept or reject care and to participate in goal-setting and goal-achievement. 10. Home visits should be recorded in the diary and family folder. Advantage of the Home Visits: 1. Home visit provides an excellent opportunity to implement to implement the nursing process. 2. Home visits provide an opportunity to study the home and family situation. 3. Home visits provide an opportunity to render services to the family members at their own surroundings. 712
4. Prompt and proper home visits create a good understanding between nurse and family and builds good image of nurse. 5. Home visits clarify the doubts raised by the family members. 6. Home visits help to observe family practices and progress of care given by nurse and others. 7. Home visits help to prevent and handling the problems. 8. Home visits help the nurse and family members to modify the ways of their care. 9. Home visits are convenient for the patients. 10. Home visit facilitate patient control of the setting. 11. Home visits are the best option for patients unwilling or unable to travel. Home visits provide natural environment for the discussion of concerns and needs. Components of Home Visit: As it has already been stated that home visit provides an opportunity to implement nursing process in the community. The home visit itself can be viewed in a process in which the nursing activity may be initiation phase, pre-visit phase, activities during home visit phase, post-visit phase of visit or transfer phase of visit. The activities of a nurse in each phase are discussed here briefly:1. Initiation Phase: In this phase the community health nurse clarifies the source of referral for visit and purpose of visit an also share information on reason and purposes for home visits with family. 2. Pre-Visit Activities: When the nurses are assigned to home visit, they must know certain prior information regarding the home and the family which includes location of the house and its distance, and address and some information on need for visit. Pre-visit is the part of assessment phase in which the nurses gather information about the patient, investigates community resources assembles supplies and plans for the first patient contact. The information may be obtained from family-folders care agencies regarding age, sex, family culture and values, problems, care given and appropriate steps during the visit to meet the needs of the patient and also help to make initial planning. In brief, in this phase the CHN initiates contact-with the family; establishes shared perceptions of purpose with family; determines family willingness for home visit and review referred and/or/family record. 3. Activities during Home Visit: The community health nurse have to use their talents, to make family to be receptive to their visit, for which they have to begin to develop trust and rapport, which are the basis for positive inter-personal relationship. The nurse-patient relation is the basis for providing possible health services to the community. Here, the nurse introduces herself to family, shows professional identity, and establishes nurse-patient relationship. Here it is better to have little bits of hints about nurse-patient relationship. Nurse-patient relationship is defined as ―a professional relationship that occurs when the nurse and another person have entered into an agreement to interact to achieve some mutually determined health-oriented goals that are consistent with nursing professional obligation‖. 713
The society has assigned the nurse the responsibility for assisting the patient as unified whole, to adjust his activities of daily living so that his steady state is maintained or regained while he is moving to higher level of wellness. The health oriented goals are delineated by the nurses‘ professional obligations that are determined by the society. In order to fulfill this assignment, the nurse-patient relationship should have the following characteristics:I. One person must have knowledge and skills from which another can benefit. II. The needs or requirements of the person to be assisted must take priority over those of helping person, III. The relationship is self-limiting by virtue of the goals to be achieved, IV. The person to be helped must need and utilizes the assistance, V. The assistance must be given competently. The conditions imposed on the nurse-patient relationship evolve from the rights and obligations attached to each of the complementary counter positions of nurse and of patient the behaviors of the nurse which helps to establish positives interpersonal relationship includes creativity, flexibility, follow-through, respect and good communication. The inter-personal relationship starts when nurse enter into the house. The nurse has to introduce her or himself with the family members prior to entry into home or knocking the door of the house. The initial introduction tells the patient who you are and why you are there. The nurse makes an attempt to the acceptance of the patient by showing certain behaviors such the greeting the family members, shaking hands (in doing so) smiles, and takes a seat in a relaxed manner. And the nurse has to accept the culture of the family-forexample-traditionally, Indian families offer tea, coffee and fruits to any guest. Although it is not fair on the part of the nurse, but rejection of this type of formalities should be managed tactfully, but it should not hurt the family. Then the nurse should explain the purpose of visit and acknowledge each family member and seek co-operation from them for their care. Then the nurse should use their effective communication skills to implement the nursing process. During visit, nurse assesses the family needs and plans the nursing care. During home visits, nurse practice a variety of roles when intervening in patient care. The community health nurse has to take a role as collaborator, consultant, co-coordinators, preventer of disease, promoter of health, health educator and an epidemiologist and takes steps to implement nursing process. 4. Termination Phase of visit: Termination of visits occurs when:i. Nurse-patient goals are reached, health is restored and the patient can function without nursing actions; ii. A patient changes his residence or leaves the home to go to another home; iii. The nurse transfers the patients care to another nurse or other members to provide health care. In addition, the nurse has to review visit with family and plan for future visits.
714
5 Post-Visit Activities: Post-visit activities include recording and reporting. The nurse records the important events in the family and reports the necessary materials to the higher authorities and discusses the problems of the family with the colleagues and other members of health teams and make plans accurately to meet the needs of the family. The records are kept them. The nurse conducts the activities such as analyzing community resources and preparing for the next visit. In brief in this stage, nurse records the visit and plans for next. Adaptation of Nursing Procedures At Home: Community health nurse should have the knowledge of those conditions and diseases in which home nursing can be made available to patient. Similarly nurse should be aware of the limitations of the home nursing. Moreover, she should also be skilled in the use of domestic items in nursing. Situation appropriate for home nursing can be divided mainly into two categories:1. Non-Communicable Diseases Or Conditions: general fever, post operative conditions, nutritional disorders, deficiency disorders due to lack of vitamins, iron and iodine deficiency disorders, protein-calorie malnutrition, diabetes heart disease(other than acute and serious conditions) cancer patients, simple trauma and cut, skin diseases, followup to family planning operation and other related conditions. 2. Communicable Conditions: All those diseases and conditions (TB, cholera etc,) are included in this, which spread quickly. Utmost care and alert is needed in their treatment and the nursing at home. Simple Home Nursing Procedures: Hand Washing: Items available in the nursing bag or home visit bag can be used for washing hands at the home. Family should be advised to store sufficient water and the family members (especially in rural community) can be taught the advantages and the technique of washing hands with soap or ash instead of soil, through demonstrations. Thermometer Disinfection: To disinfect the thermometer used by patient, dip the cotton swab or clean cloth in antiseptic lotion and keep thermometer wrapped in it for 3 minutes. After this the thermometer can be reused once it is washed in clean water with proper technique and then dried. Thermometer can also be disinfected at home, by making antiseptic solution in an empty bottle. Dressing: Dressing equipment can be disinfected at home by using the boiling water. Paper bag or waste news paper can be used in place of kidney tray, for discarding the soiled dressing. For providing privacy, curtain or saree can be used. Soiled dressing can be disposed of by burial or burn. Readymade dressing packs may be used for dressing. Disposal of Sputum And Faeces: Patient can be given an earthern pot or disposable plastic cup with lid to collect sputum. Some water is kept in the pot so that sputum does not stick to the pot. Daily sputum is removed from the pot and buried in the soil. The cleaned pot can be reused; heating in fire can disinfect it. Disposable plastic cups are destroyed. 715
Similarly if there is no sanitary toilet in the house the faeces can be collected in a mud pot. It should be buried after 4 hours of mixing lime water in it. Home Nursing Techniques in Communicable Diseases: Isolation: generally isolation is a problem in home. As far as possible, the patient should be kept in a separate room or in a corner covered with curtain. Family members especially children should not come in contact with the patient. Order of visits: nurse should visit homes of patients suffering from communicable diseases around noon, while others should be visited in the morning. In every meeting, the family members should be demonstrated the procedures so as the spread of infections can be checked. These include:- Alteration in the technique: keeping the nursing bag outside the room of patient, not to carry those equipments in the bag, which can get infected, wearing apron or specific saree at the time of visit, all the necessary things should be carried together in the room of the patient, being extra careful in washing the hands, paying special attention to the cleaning of floors and furniture etc. - Destroying of organisms: sputum collected in the paper bag, earthern pot with a lid or in a plate made of leaf should be buried or burned in a safe place. Antiseptic lotion can also be poured in the pot. - Utensils for serving the food : serving the food on banana or any other leaf or using plastic disposable material is the best option, as these can be burned after the use, or the utensils used by the patients should be left in the patients room itself. It is necessary to clean them regularly. Similarly care should be taken in disinfecting the clothes, mattress, pillow, bed sheet and furniture used by the patient. Use of Domestic Articles In Home Nursing: - Use of earthen pot instead of bed pan. - Using a box, wooden plank, back of chair or pillow etc, in place of back rest. - Using a piece of clean cloth or sari etc, in place of bandage. - For isolation or protecting the bed or to serve the food using banana leaf. - Using saree for curtain and covers of mattress and pillow. - Sand bag can be made at home by stitching a bag of cloth. - Using disposable items in home nursing. - Using a glass bottle instead of hot water bag. CONCLUSION: Home nursing is a growing emphasis on providing nursing and care to chronically ill peoples in their homes to enable them to live as long as possible in their own homes. Implementing sound, rational infection control practices in home care has been challenging since guidelines, standards, and most references have been developed for the acute care setting. Such practices include handwashing, home infusion therapy, respiratory care, wound care, urinary tract care, and isolation precautions. Assessment of the home care environment, cleaning and reprocessing of equipment, surveillance, implications for occupational health.
716
BIBLIOGRAPHY: Potter & Perry's fundamentals of nursing By Jackie Crisp, Patricia Ann Potter, 2 nd edition, Anne Griffin Perry page no. 143-155 Gweneth Hartrick Doane, developing health-promoting practice, Gweneth Hartrick Doane, page no. 213-243 Promoting health in families: applying family research and theory to nursing, By Perri J. Bomar, page no. 203-123 Community and public health nursing, Marcia Stanhope and Jeanette Lancaster, sixth edition, Mosby, page no. 578-580. Community health nursing, B.T. Basavanthappa, JAYPEE publications, first edition, page no.66-96. References: Scribd.com Google.com Nursescribe.com Nursing journals.com
717
TRANS-CULTURE NURSING Introduction: The English word ―culture‖ has been used in various concepts. In common literature culture means social charm and intellectual excellence. Some sociologists have also accepted cultured people as leaders of society. According to Sorokin and Mclver, culture stands for the moral, spiritual and intellectual attainments of man. In the words of Bogardus, ―culture is composed of integrated customs, behavior patterns of human groups‖. The word culture has had a number of meanings. Originally it referenced to the art and humanities. The cultured man was one who was well-versed in drama, philosophy and the arts. Nurses have always been contender with the whole person including the physical, emotional, psychological, spiritual and developmental dimensions. The culture incorporates not only customs, but beliefs, values and attitudes shared by a group of people and passed down through generations. Culture: Broadly defines set of values, beliefs and traditions, that are held by a specific group of people and handed down from generation to generation. Culture is also beliefs, habits, likes, dislikes, customs and rituals learn from one‘s family. (Specter 1991) Religion: Is a set of belief in a divine or super human power (or powers) to be obeyed and worshipped as the creator and ruler of the universe? Ethical values and religion system of beliefs and practices, difference within the culture and across culture are found. Cultural identify: the sense of being part of an ethnic group or culture. Material culture: refers to objects (dress, art, religious arti1acts) Non-material culture: refers to beliefs customs, languages, social institutions. Subculture: composed of people who have a distinct identity but are related to a larger cultural group. Bicultural: a person who crosses two cultures, lifestyles, and sets of values. Diversity: refer to the fact or state of being different. Diversity can occur between culture and within a cultural group. Ethnic group: share a common social and cultural heritage that is passed on to successive generation. Example:- Indian culture, American culture. (Christians will go to church in Sunday) Race: the classification of people according to shared biologic characteristics, genetic markers, or features. Not all people of the same race have the same culture. For example:Indian race, African race etc… Definations: According to the American Nurses’ s Association (1976) ―Consideration of individual value systems and lifestyles should be included in the planning and health care for each client Nursing curriculum recognize the contribution nursing to the health care needs of a diverse and multi cultural society life-style may reflect cultural heritage‖. According to Leininger, the transcultural nursing is described as that which incorporates all aspects of a person‘s culture in planning and providing and providing care, transcultural nursing encourages an appreciation of all cultures and discourages imposing your/our cultural practices and others.
718
Historical Perspectives: 1. The transcultural nursing has its roots in the early 1900‘s when public health nurse cares for immigrants from Europe who came from a wide range of cultural background and had diverse health care practices. 2. During the 19th century, the words come to be used almost interchangeably with civilization. This civilization or culture was something achieved as society is evolved people who were cultured or primitive peoples of the world. 3. In the late 1940‘s Dr. Madeleine Leininger held the belief that ―care is essence of nursing and the central dominate and unifying focus of nursing‖. She then began to see the importance of nursing care that was beginning to understand the importance of nursing care that was based on the client‘s cultures that has unique values. 4. Belief‘s practices and life ways passed down from one generation to next. The idea the culture and care are inextricably linked, led her to study other cultures and she becomes the first nurse to obtain a doctorate in anthropology. 5. Transcultural nursing is a body of knowledge and practice for caring the people from other cultures. Many nurse leader and educators have embraced the need for culture specific care, and various approaches to gaining this knowledge have been developed. Goals Of Transcultureal Nursing: 1. According to Leininger, the goal of transcultural nursing careis to preserve, accommodate or repattern the cultures of the patient. 2. When cultural beliefs and values do not have negative effect on care, nursing must make every effort to help the patient preserve his or her culture. 3. In some situations, it may be necessary to make accommodations to preserve the culture of the patient and the family. 4. Repeating the culture of the patient requires the patient to essentially change his or her life. Concept of Culture: Culture is learned by each generation through both formal and informal life experiences. Language is primary through means of transmitting culture The practices of particular culture often arise because of the group's social and physical environment Culture practice and beliefs are adapted over time but they mainly remain constant as long as they satisfy needs. Transcultural Nursing Model or Sunrise Model:
719
Source: Leininger‟s sunrise model depicts dimensions of the theory of culture care diversity and universality. Reprinted with permission of author and national league for nursing, New York. Sunrise Model: a conceptual guide to knowledge discovery. A sunrise model was developed to give a holistic and comprehensive conceptual picture of the major factors held as important to the theory of culture care diversity and universality. The model is a conceptual visual guide depicting multiple factors predicted to influence culturally congruent care with people of different culture. The model essentially serves as a cognitive guide for the researcher to visualize and reflect on different factors predicted to influence culturally based care in the discovery process. The sunrise model has also been used as a valuable guide for doing culturalogical health care assessment of client‘s health needs. As the researcher used the model, the different factors depicted in the model are kept in mind in relation to discovering culture care phenonena. Gender and sexual orientation, race, class factors, biomedical condition and the extent of acculturation are all an integral part of the model and theory. The factors tend to be embedded in social structure; worldview and other dimensions identified in the sunrise model and are usually not quickly identifiable. Hence, they are not isolated variables but are lodged in their nature and meaningful culture context, yet are important discovery areas within the theory. According to the researcher‘s interests and skills one can being the discovery at any place in the model except with the three modes of action and decisions, which are studied last or after drawing upon data collected in the upper part of the model. All factors in the model need to be studied to obtain comprehensive or holistic data in order to arrive at an accurate picture of culturally based care. Some researchers may want to start with generic and professional care, whereas others may being with the worldview and social structure dimensions. There is flexibility in the discovery process to fit the information‘s interested and level of comfort as well as the researcher‘s goals, domains of inquiry, and research skills. Because three modes of action and decision (in the lower part of the model) are studied and formulated with informants after the researcher has obtained data in the upper part of the model, the nursing actions or decision become evident. The researcher involves informants in the discussion to arrive at appropriate actions, decisions or plans. Throughout this discovery process the researcher holds his or her own etic views, presuppositions and biases in abeyance, so that the informants cultural ideas will come forth, because they rather than the researcher‘s views are important and are the reason for the study. Transcultural nurses are taught, guided, and mentored in ways to withhold and deal with their biases and prejudices through formal courses and clinical experience in transcultural nursing. As the researcher carefully documents the different factors influencing care, he or she focuses on a specific and explicit domain of inquiry. For example, the researcher may focus on a domain of inquiry (DOI) such as ―culture care of Mexican-American mother caring for their children in their home.‖ Every word in the domain statement is important to study, using the sunrise model and theory tenets. The researcher may have hunches about the domain, but holds them back until all data have been studied with the theory tents. Full documentation of the informant‘s viewpoints, experiences, and actions is 720
pursued. Generally, informants select what they first want to talk about with the researcher and then the researcher move with informants to cover all aspects of the model and theory tenets. During the indepth study of the domain of inquiry, all areas of the model are covered and discussed and confirmed with the informants. The informants remain active participants throughout the discovery process and in a manner that they feel is their unique and rich contribution. The sunrise model was developed with the idea of ―letting the sun enter the researcher‘s mind and discovering generally unknown care factors in nurses related to the cultural values and care needs cultures. The model depicts letting the sun ―rise and shine‖ to get fresh and new insights. A wealth of new and unexpected nursing knowledge can be the covered with the model that has never been known and used in traditional nursing for present-day nursing and medical services. Purposes of Knowing the Patients Culture and Religion For Health Care Personnel: Cultural background affect a person's health in all dimensions, so the nurse should consider the client's cultural background when planning care Although basic human needs are the same for all people, the way a person seeks to meet those needs is influenced by culture. To heighten awareness of ways in which their own faith system. Provides resources for encounters with illness, suffering and death. To foster understanding, respect and appreciation for the individuality and diversity of patients beliefs, values, spirituality and culture regarding illness, its meaning, cause, treatment, and outcome. To strengthen in their commitment to relationship-centered medicine that emphasizes care of the suffering person rather than attention simply more to the pathophysiology of disease, and recognizes the physician as a dynamic component of that relationship. To facilitate in recognizing the role of the hospital chaplain and the patient's clergy as partners in the health care team in providing care for the patient. To encourage in developing and maintaining a program of physical, emotional and spiritual self-care introduce therapies from the East, such as ayurveda and pancha karma Leininger (1991, 2002a) has defined transcultural nursing as a comparative study of cultures to understand similarities (culture universal) and difference (culture-specific) across human groups. Cultural competent care is the ability of the practitioner to bridge cultural gaps in caring, work without cultural differences and enable clients and families to achive meaningful and supportive care. Culturally competent care requires specific knowledge, skills and attitude in the delivery of culturally congruent care and awareness. Nursing Decisions: Leininger (1991) identified three nursing decision and action modes to achieve culturally congruent care. All three modes of professional decisions and actions are aimed to assist, support, facilitate, or enable people of particular cultures.
721
The three modes for congruent care, decisions, and actions proposed in the theory are predicted to lead to health and well being, or to face illness and death. 1. Cultural Preservation or Maintenance: Retain and or preserve relevant care values so that clients can maintain their well-being, recover from illness, or face handicaps and/or death. Example: - nutritional practice like malt to protect from PEM etc… 2. Cultural Care Accommodation or Negotiation: Adapt or negotiate with the others for a beneficial or satisfying health outcome. Example: - kasaya. 3. Cultural care repatterning or restructuring: Records, change, or greatly modify client‘s life ways for a new, different and beneficial health care pattern Example: - while sleeping head shouldn‘t be put in north side. Purpose and Goal of the Theory: The purpose and goal of the theory is to use research findings to provide culturally congruent, safe, and meaningful care to clients of diverse or similar cultures. Status of Traditional Practices: Many traditional practices are used to prevent and a redemptive practice used to prevent illness and harm treat illness, including objects and substances and religious practices. (Morgenstern, 1966) Example: - circumcision help to protect men from AIDS. Use of Protective Objectives: Protective objectives can be worn or carried or hung in the home. Amulents are objective with magical powers, for all walks of life and cultural and ethnic backgrounds is example, charms worn on a string or chine around the neck, wrist, or waits to protect the wearer from the evil eye or evil spirits. Amulets exist in societies all over the world and are associated with protection from trouble (Budge, 1978). Example: - Thayatha. Use of Substances: Substances are ingested in certain ways or amounts regimen, an effort must be made to determine if they are worn or hung in the home. This practice uses diet and consists of many different observances. It is believed that the body is kept in balance or harmony by the type of food eaten so many food taboos and combinations exist in traditional belief systems. For example, it is believed that some food substances can be ingested to prevent illness. People from many ethnic backgrounds eat raw garlic or onion in an effort to prevent illness or wear them on' the body or hang them in the home. Jews also believe that milk and meat must never be mixed or eaten at the same meal. Religious Practices: Another traditional approach to illness prevention female centers around religion and includes practices such as from a divine source the burning of candles, offering gold and silver to god, rituals of redemption, and in many instances a orthodox religious persons would always prefer to pray. Religion strongly affects the way people attempt to prevent illness, and it plays a strong role in rituals associated with health protection. Religion dictates social, moral, and dietary practices designed to keep a traditional healer (Kaptchuk and Croucherl987).
722
Traditional Remedies: The admitted use of folk or traditional medicine increasing, and the practice is seen among people from all walks of life and cultural ethnic back ground Use of folk medicine is not a new practice among heritage consistent people, so many of the remedies have been used and passed on for generations. The pharmaceutical, must be made to determine properties of vegetation-plants, roots, tested stems, flowers, seeds, and herbs-have been studied tested, cataloged, and used for countless centuries. Many of these plants are used by specific communities. Others cross ethnic and community lines and are used in certain Geographic areas in the person's country of origin. When patients do not adhere to a pharmacological regimen an effort must be made to determine the remedy if they are taking traditional remedies. Frequently, the active ingredients of traditional remedies are unknown. If a client is believed to be, taking them an effort must be made to determine the remedy as well as its active in gradients often, these ingredients can be antagonistic or synergistic to prescribed medications. Over dose may occur. Healers: In the traditional context, healing is the restoration of the person to a state of harmony between the bodies, within a given community; specific people are known to have the power to heal. The healer may be male or and is thought to have received the gift of healing In many instances a heritage consistent person may consult a traditional healer before, instead of, or in conjunction with a modern health care provider. Many differences exist between the Western physician and the Eastern A broad range of health and illness beliefs exist many of these beliefs have roots in the culture, ethnic, religious, or social back ground .of a person family, or community. 'When people anticipate fear or experience an illness or crisis, they may use a modern or traditional approach toward prevention and healing. Immigration: Every immigrant group has its own cultural attitudes ranging beliefs and practices regarding these areas Health and illness can be interpreted in terms of personal experience and expectations. There are countless ways to explain health and illness, and people base their responses on cultural, religious, and ethnic back ground. The responses are culture specific, based on a client's experience and perception. Example;- The people came from the Pakistan follow the same cultural, beliefs, tradition in the India the distance is thousands of kilometer then also they follow the same things. Traditional Beliefs about Mental Health: In the traditional belief system, mental illnesses are caused by a lack of harmony of emotions or, sometimes, by evil spirits. Mental wellness occurs when psychological and physiologic functions are integrated. Some elderly Asian Americans share the Buddhist belief that problems in this life are most likely related to transgressions committed in a past life. In addition our previous life and our future life are as much a part of the life cycle. Economic Barriers: Several economic barriers, such as unemployment, underemployment, homelessness, lack of health insurance poverty prevent people from entering the health care system. Poverty is by far the most critical factor. Poverty a relative term and changes from time and place. In the United States, poverty is pervasive and found extensively among people in certain norms geographical areas, such as rural populations, the elderly migrant workers, and 723
illegal aliens. Poor health, crippling diseases, drug and alcohol abuse, poor education; and inferior are contributing social causes of poverty. Several programs, both governmental and private, aid people with short- and long-tem problems. It is important for the nurse to be aware client‘s needs and financial resources available in the local community. Role of Nurse in Transculture Nursing: The nurse should begin the assessment by attempting to determine the client's cultural heritage and language skills. The client should be asked if any of his health beliefs relate to the cause of the illness or to the problem. The nurse should then determine what, if any, home remedies the person is taking to treat the symptoms. Nurses should evaluate their attitudes toward ethnic nursing care. Some nurses may believe they should treat all clients the same and simply act naturally, but this attitude fails to acknowledge that cultural differences do exist and that there is no one "natural" human behavior The nurse cannot act the same with all clients and still hope to deliver effective, individualized ,holistic care. Sometimes, inexperienced nurses are so self-conscious about cultural differences and so afraid of making a mistake that they impede the nursing process by not asking questions about areas of difference or by asking so many questions that they seem to try into the client' personal life. The process of self-evaluation can help the nurse become more comfortable when providing care to clients from diverse backgrounds. Culture is the sum total of mores traditions & beliefs about how people function encompasses others products of human works & thoughts. Specific to member of an intergenerational group, community or population. Nurses have a responsibility to understand the influence of culture, race ðnicity on the development of social emotional relationship child rearing practices &attitude toward health. Socioeconomic influences play major role in ability to seek opportunity for health promotion for wellness. Religious practices greatly influence health promotion belief in families. Many ethnic and cultural groups in country retain the cultural heritage of their original culture. How culture influences behaviors, attitudes, and values depends on many factors and thus is not the same for different members of a cultural group. The nurse should have an understanding of the general characteristics of the major ethnic groups, but should always individualize care rather than generalize about all clients in these groups. Before assessing the cultural background of a client, nurses should assess how they are influenced by their own culture. The nursing diagnosis for clients should include potential problems in their interaction with the health care system and problems involving the effects of culture. The planning and implementation of nursing interventions should be adapted as much as possible to the client's cultural background.
724
Evaluation should include the nurse's self-evaluation of attitudes and emotions toward providing nursing care to clients from diverse sociocultural backgrounds. When nurses provide care to clients from a background other than their own, they must be aware of and sensitive to the clients' sociocultural background, assess and listen carefully to health and illness beliefs and practices, and respect and not challenge cultural, ethnic, or religious values and health care beliefs. The nursing process enables the nurse to provide individualized care. The nurse should begin the assessment by attempting to determine the client's cultural heritage and language skills. The client should be asked if any of his health beliefs relate to the cause of the illness or to the problem. The nurse should then determine what, if any, home remedies the person is taking to treat the symptoms. The client‘s the nursing process; educational level and language skills should be considered when planning teaching activities. Explanations of and practices into nursing therapies; aspects of care usually not questioned by acculturated clients may be required for non-English speaking or nonacculturated clients to avoid confusion, misunderstanding, or cultural conflict. The nurse may have to alter her usual ways of interacting with clients to avoid offend ignore alienating a client with different attitudes toward social interaction and etiquette. A client who is modest and self-conscious about the body may need psychological preparation before some procedures and tests. The nurse can find out what care the client considers appropriate by involving him and his family in planning care and asking about their expectations. This should be done in every case, even if the nursing care cannot be modified. Because both the nurse and the client are likely to take many aspects of their cultures for granted, questions should be clear and explanations should be explicit. Discussing cultural questions related to care with the client and family during the planning stage helps the nurse understand how cultural variables are related to the client's health beliefs and practices, so that interventions can be individualized for the client. The nurse evaluates the results of nursing care for ethnic clients as for all clients, determining the extent to which the goals of care have been met. Br J Nurs. 2003 Feb 13-26; 12(3):185-94. Transcultural nursing: how do nurses respond to cultural needs? Narayanasamy A. University of Nottingham, Faculty of Medicine and Health Sciences, School of Nursing, Queen's Medical Centre, Nottingham. The aim of the study was to explore how nurses responded to the cultural needs of their clients. From the transcultural point of view, healthcare providers must deliver a service that is culturally sensitive and appropriate. However, for a variety of reasons, there is growing concern that the cultural healthcare needs of minority ethnic groups are not met adequately. This study was done to outline nurses' activity in transcultural care. Empirical data were obtained from a sample of registered nurses (n = 126) who were invited to complete questionnaires pertaining to cultural care. As a result of data analysis, the quantitative findings are presented as tables and the qualitative data as categories and themes. The findings suggest that most respondents felt that patients' cultural needs should be given consideration. Cultural aspects of care seem to be a feature of the overall 725
nursing picture within a multicultural context of health care. Many participants claimed that they responded to the cultural needs of patients. Some felt that patients' cultural needs are adequately met; such needs are perceived as religious practices, diets, communication, dying, prayer and culture. Furthermore, a significant number of respondents suggested that they would like further education in meeting the cultural needs of their patients. This study offers some insights into transcultural healthcare practice, and, in accordance with the findings, identifies strategies for improving these practices for nursing and nurse education. CONCLUSION: Nurses need to be aware of and sensitive to the cultural needs of clients. The body of knowledge relevant to this sensitive area is growing, and it is imperative that nurses from all cultural backgrounds be aware of nursing implications in this area. The practice of nursing today demands that the nurse identify and meet the cultural needs of diverse groups, understand the social and cultural reality of the client, family, and community, develop expertise to implement culturally acceptable strategies to provide nursing care, and identify and use resources acceptable to the client (Boyle, 1987).
726
BIBLIOGRAPHY (REFERENCES): 1. Boyle, JS: The practice of Tran‘s cultural nursing, Transcultural Nursing Morgenstern, J: Rites of birth, marriage, death, and kindred occasions. 2. George Julia B. Nursing theories: The base of professional nursing practice 3rd edition. Norwalk, CN: Appleton and Lange; 1990. 3. Kozier B, Erb G, Barman A, Synder AJ. Fundamentals of nursing; concepts, process and practice, Edn 7th, 2001. 4. Leninger M, McFarland M. Transcultural Nursing: Concepts, Theory, Research, and Practice; Edn 3rd, McGraw-Hill Professional; New York, 2002. 5. Potter a, Perry G .Basic Nursing-Theory and Practice, Edn 3rd Mosby Company. 6. Kathleen Koerning Blais etal, professional nursing practice concept and perspectives, low price edition, 5th edition, 2007, pp no 373-96. 7. Marilyn parker, Nursing Theories & Nursing practice, published by F.A Davis company, Philadelphia, 2001, pp no 365-72.
727
