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10 ASSESSING • Write nursing interventions

Nursing Process is a systematic, rational method

IMPLEMENTING Carrying out (or delegating) and
of planning and providing individualized nursing care.
documenting the planned nursing interventions
Hall originated the term nursing process in 1955,
• Reassess the client
and Johnson (1959), Orlando (1961), and Wiedenbach
• Determine the nurse’s need for assistance
(1963) were among the first to use it to refer to a series
• Implement the nursing interventions
of phases describing the practice of nursing.
• Supervise delegated care
The nursing process in clinical practice gained
• Document nursing activities
additional legitimacy in 1973 when the phases were
included in The American Nurses Association (ANA)
EVALUATING Measuring the degree to which goals or
Standards of Nursing Practice.
outcomes have been achieved and identifying factors
The Standards of Practice within the most
that positively or negatively influence goal achievement
current Scope and Standards of Nursing Practice
• Collect data related to outcomes
include six phases of the nursing process:
• Compare data with outcomes
Assessment
• Relate nursing actions to client goals/outcomes
Diagnosis
• Draw conclusions about problem status
Outcomes Identification
• Continue, modify, or terminate the client’s care plan
Planning
Implementation
Characteristics of the Nursing Process
Evaluation
These characteristics include its cyclic and dynamic
The National Licensure Examination for
nature, client-centeredness, focus on problem-solving
Registered Nurses (NCLEX) uses five phases:
and decision-making, interpersonal and collaborative
assessment
style, universal applicability, and use of critical thinking
Analysis
and clinical reasoning
Analysis
Planning
Types of Data
Implementation
Subjective Data
Evaluation
Also referred to as symptoms or covert data, they are
Overview of the Nursing Process
apparent only to the individual affected and can be
ASSESSING Collecting, organizing, validating, and
described or verified only by that individual.
documenting client data
Objective Data
• Collect data
Also referred to as signs or overt data, are detectable by
• Organize data
an observer or can be measured or tested against an
• Validate data
accepted standard.
• Document data
Sources of Data
DIAGNOSING Analyzing and synthesizing data
Primary
• Analyze data
The client is the primary source of data.
• Identify health problems, risks, and strengths
Secondary
• Formulate diagnostic statements
Family members or other support persons, other health
professionals, records and reports, laboratory and
PLANNING Determining how to prevent, reduce, or
diagnostic analyses, and relevant literature are
resolve the identified priority client problems; how to
secondary or indirect sources.
support client strengths; and how to implement nursing
interventions in an organized, individualized, and
Interviewing
goal-directed manner
A focused interview the nurse asks the client specific
• Prioritize problems/diagnoses
questions to collect information related to the client’s
• Formulate goals/desired outcomes
problem.
• Select nursing interventions
Two types of Interviews
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Directive interview is highly structured and elicits Diagnose

specific information. Nursing diagnoses
Nondirective interview, or rapport-building interview, A statement of clinical judgment that concerns a human
the nurse allows the client to control the purpose, response to a health condition that nurses, by virtue of
subject matter, and pacing. their education, experience, and expertise, are licensed
to treat.
TYPES OF INTERVIEW QUESTIONS
Closed questions, used in the directive interview, are Medical diagnoses
restrictive and generally require only “yes” or “no” or Made by a physician and refer to a condition that only a
short factual answers physician can treat. Medical diagnoses refer to disease
Open-ended questions, associated with the nondirective processes
interview, invite clients to discover and explore,
elaborate, clarify, or illustrate their thoughts or feelings. Formulating Diagnostic Statements
Most nursing diagnoses are written as two-part or three
part statements, but there are variations of these.

11 Diagnosing Basic Two-Part Statements

1. Problem (P): statement of the client’s response
Diagnosing is the second phase of the nursing process.
2. Etiology (E): factors contributing to or probable
In this phase, nurses use critical thinking skills to
causes of the responses.
interpret assessment data and identify client strengths
Basic Three-Part Statements
and problem.
The basic three-part nursing diagnosis statement is
Diagnosis is a statement or conclusion regarding the
called the PES format
nature of a phenomenon.
The three phases of the diagnostic process are data
The identification and development of nursing
analysis; identification of the client’s health problems,
diagnoses began formally in 1973
health risks, and strengths; and formulation of
The term diagnosing refers to the reasoning
diagnostic statements.
process, whereas the term diagnosis is a statement or
1. Problem (P): statement of the client’s response
conclusion regarding the nature of a phenomenon. The
(nursing diagnosis label)
nursing diagnosis contains a diagnostic phrase or
2. Etiology (E): factors contributing to or probable
diagnostic label followed by an etiology phrase.
causes of the response
3. Signs and symptoms (S): defining characteristics
Components of a Nursing Diagnosis
manifested by the client.
A nursing diagnosis has three components:
(1) the problem and its definition
Actual nursing diagnoses can be documented by using
The problem statement, or diagnostic label, describes
the three-part statement because the signs and
the client’s health problem or response for which
symptoms have been identified.
nursing therapy is given.
This format cannot be used for risk diagnoses because
(2) the etiology
the client does not have signs and symptoms of the
Etiology (Related Factors and Risk Factors) The
diagnosis. The PES format is especially recommended
etiology component of a nursing diagnosis identifies
for beginning diagnosticians because the signs and
one or more probable causes of the health
symptoms validate why the diagnosis was chosen and
problem(Cause of Disease), gives direction to the
make the problem statement more descriptive.
required nursing therapy, and enables the nurse to
individualize the client’s care.
(3) the defining characteristics.
The cluster of signs and symptoms that indicate the
presence of a particular diagnostic label.

Differentiating Nursing Diagnoses from Medical

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12 Planning Realistic
Time bound
Planning is an intentional, systematic phase of the
nursing process that involves decision-making and
Setting Priorities
problem-solving.
Priority setting is the process of establishing a
Planning is the process of designing nursing activities
preferential sequence for addressing nursing diagnoses
required to prevent, reduce, or eliminate a client’s
and interventions
health problems.
( Maslow’s hierarchy)
Planning is basically the nurse’s responsibility, input
Establishing Client Goals or Desired Outcomes
from the client and support persons is essential if a plan
After establishing priorities, the nurse and client set
is to be effective. Nurses do not plan for the client but
goals for each nursing diagnosis
encourage the client to participate actively to the extent
-High Priority
possible.
-Medium Priority
-Low Priority
Types of Planning
-Life-Threatening
Planning begins with the first client contact and
continues until the nurse–client relationship ends,
Short-Term and Long-Term Goals
usually when the client is discharged from the
Goals may be short term or long term. A short-term
healthcare agency. All planning is multidisciplinary
goal might be “Client will raise right arm to shoulder
(involves all healthcare providers interacting with the
height by Friday.”
client) and includes the client and family to the fullest
A long-term goal or outcome might be “Client will
extent possible in every step.
regain full use of right arm in 6 weeks.”
Short-term goals are useful for clients who
Initial Planning(Nangyayari)
(a) require healthcare for a short time
The nurse who performs the admission assessment
>7 DAYS
usually develops the initial comprehensive plan of care.
(b) are frustrated by long-term goals that seem difficult
Ongoing Planning
to attain and who need the satisfaction of achieving a
All nurses who work with the client do ongoing
short-term goal.
planning.
<10 DAYS
Discharge Planning(Patient Needs)
The process of anticipating and planning for needs after
Guidelines for Writing Goals or Desired
discharge, is a crucial part of a comprehensive
Outcomes
healthcare plan and should be addressed in each client’s
The following guidelines can help nurses write useful
care plan.
goals or desired outcomes
Standardized Approaches to Care Planning
(SMART)
Providing essential nursing care to specified groups of
clients who have certain needs. (Relevant para kay
patient yun ang gagawin).
ADOPIE
Protocols are predeveloped to indicate the actions 13 Implementing and Evaluating
commonly required for a particular group of The nursing process is action-oriented, client centered,
clients.(Pag hindi nasunod=Risk kay patient) and outcome directed. After developing a plan of care
Policies(Nurse) and procedures (Client) are developed based on the assessing and diagnosing phases, the nurse
to govern the handling of frequently occurring implements the interventions and evaluates the desired
situations. outcomes.
Implementing is putting planned nursing interventions
The Planning Process into action.
Specific
Measurable Implementing
Achievable The action phase in which the nurse performs the
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nursing interventions. have been the best ones to achieve the goal.
Implementing consists of doing and documenting the IMPLEMENTING
activities that are the specific nursing actions needed to Even if all sections of the care plan appear to be
carry out the interventions. The nurse performs or satisfactory, the manner in which the plan was
assigns the nursing activities for the interventions that implemented may have interfered with goal
were developed in the planning step and then concludes achievement.
the implementing step by recording nursing activities
and the resulting client responses. Evaluating the Quality of Nursing Care
Quality Assurance frequently refers to evaluation of the
Relationship of Implementing to Other Nursing level of care provided in a healthcare agency, but it may
Process Phase be limited to the evaluation of the performance of one
The first three nursing process phases—assessing, nurse.
diagnosing, and planning—provide the basis for the Quality assurance requires evaluation of three
nursing actions performed during the implementing components of care: structure, process, and outcome.
step. In turn, the implementing phase provides the Structure evaluation focuses on the setting in which
actual nursing activities and client responses that are care is given. It answers this question: What effect does
examined in the final phase, the evaluating phase. the setting have on the quality of care?
(DO NOT DOCUMENT IN ADVANCE!) Process evaluation focuses on how the care was given.
It answers questions such as these: Is the care relevant
Process of Implementing to the client’s needs?
The process of implementing Outcome evaluation focuses on demonstrable changes
• Reassessing the client in the client’s health status as a result of nursing care.
• Determining the nurse’s need for assistance Outcome criteria are written in terms of client responses
• Implementing the nursing interventions or health status, just as they are for evaluation within
• Supervising the assigned care the nursing process. For example, “How many clients
• Documenting nursing activities. undergoing hip repairs develop pneumonia?”

ASSESSING
An incomplete or incorrect database influences all
subsequent steps of the nursing process and care plan. If 14 Documenting and Reporting
data are incomplete, the nurse needs to reassess the
Effective communication among health professionals is
client and record the new data.
vital to the quality of client care. Generally, health
DIAGNOSING
personnel communicate through discussion, reports,
If the database was incomplete, new diagnostic
and records.
statements may be required. If the database was
Client records are legal documents that provide
complete, the nurse needs to analyze whether the
evidence of a client’s care.
problems were identified correctly and whether the
nursing diagnoses were relevant to that database
A discussion is an informal oral consideration of a
PLANNING: DESIRED OUTCOMES
subject by two or more healthcare personnel to identify
If a nursing diagnosis was inaccurate, obviously the
a problem
goal or outcome statement will need revision. If the
A report is oral, written, or computer-based
nursing diagnosis was appropriate, the nurse then
communication intended to convey information to
checks if the goals were realistic and attainable.
others. For instance, nurses always report on clients at
Unrealistic goals require correction.
the end of a hospital work shift.
PLANNING: NURSING INTERVENTIONS
A record, also called a chart or client record, is a
The nurse investigates whether the nursing
formal, legal document that provides evidence of a
interventions were related to goal achievement and
client’s care and can be written or computer-based
whether the best nursing interventions were selected.
Even when diagnoses and goals or outcomes were
The process of making an entry on a client record is
appropriate, the nursing interventions selected may not
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called recording, charting, or documenting subsequent plans, including revisions, are entered into
the progress notes
Purposes of Client Records
Client records are kept for a number of purposes Over the years, the SOAP format has been modified.
including communication, planning client care, auditing The acronyms SOAPIE and SOAPIER refer to formats
health agencies, research, education, reimbursement, that add interventions, evaluation, and revision:
legal documentation, and healthcare analysis.
TAKENOTE I—Interventions refer to the specific interventions that
Take safety measures before faxing confidential have actually been performed by the caregiver.
information. A fax cover sheet should contain
instructions that the faxed material is to be given only E—Evaluation includes client responses to nursing
to the named recipient. Consent is needed from the interventions and medical treatments. This is primarily
client to fax information. Make sure that personally reassessment data.
identifiable information (e.g., client name, Social Newer versions of this format eliminate the subjective
Security number) has been removed. and objective data and start with assessment, which
combines the subjective and objective data. The
Progress Notes acronym then becomes AP, APIE, or APIER.
A progress note in the POMR is a chart entry made by
all health professionals involved in a client’s care; they Kardexes
all use the same type of sheet for notes. Progress notes The Kardex is a widely used, concise method of
are numbered to correspond to the problems on the organizing and recording data about a client, making
problem list and may be lettered for the type of data. information quickly accessible to all health
professionals. The system consists of a series of cards
The SOAP format is frequently used. SOAP is kept in a portable index file.
an acronym for subjective data, objective data,
assessment, and planning. Long-Term Care Documentation
Long-term facilities usually provide two types of care:
S—Subjective data consist of information obtained from skilled or intermediate. Clients needing skilled care
what the client says. It describes the client’s perceptions require more extensive nursing care and specialized
of and experience with the problem. When possible, the nursing skills. In contrast, an intermediate care focus is
nurse quotes the client’s words; otherwise, they are needed for clients who usually have chronic illnesses
summarized. Subjective data are included only when it and may only need assistance with activities of daily
is important and relevant to the problem. living (such as bathing and dressing).

O—Objective data consists of information that is long-term care settings are based on professional
measured or observed by use of the senses (e.g., vital standards, federal and state regulations, and the policies
signs, laboratory and x-ray results). of the healthcare agency.

A—Assessment is the interpretation or conclusions

drawn about the subjective and objective data. During
the initial assessment, the problem list is created from 25 Promoting Health in Young and
the database, so the “A” entry should be a statement of
the problem. In all subsequent SOAP notes for that Middle-Aged Adults
problem, the “A” should describe the client’s condition The adult phase of development encompasses the years
and level of progress rather than merely restating the from the end of adolescence to death. Because the
diagnosis or problem. developmental tasks of young adults differ from those
of older adults, adulthood is often divided into three
P—The plan is the plan of care designed to resolve the phases: young adulthood, middle adulthood, and late
stated problem. The initial plan is written by the staff adulthood.
member who enters the problem into the record. All The baby boomers (born in years 1945–1964)
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Generation X (birth years 1965–1980) • Manifest visual and hearing abilities within normal
range.
Generation Y or the Millennials (birth years • Exhibit appropriate knowledge and attitudes about
1981–1994). sexuality (e.g., about menopause).
• Verbalize any changes in eating, elimination, or
The newest cohort is known as the iGeneration or exercise.
iGens.
This cohort has been identified by Twenge (2017) as PSYCHOSOCIAL DEVELOPMENT
those born between 1995 and 2012. Each cohort has • Accept aging body.
shared specific life events and has its own worldview, • Feel comfortable and respect self. • Enjoy new
making them quite diverse in some ways. freedom to be independent.
• Accept changes in family roles (e.g., having teenage
Young Adults (20 to 40 Years) The age at which an children and aging parents).
individual is considered an adult depends on how • Interact effectively and share companionable activities
adulthood is described in the social context of the with life partner.
individual, and this defining age is changing. Legally, • Expand and renew previous interests.
an individual in the United States can vote at 18 years. • Pursue charitable and altruistic activities.
Adulthood may also be indicated by moving away from • Have a meaningful philosophy of life.
home and establishing one’s own living arrangements.
Yet this independence also varies greatly. Some DEVELOPMENT IN ACTIVITIES OF DAILY
adolescents leave home because of family problems. In LIVING
recent years, however, boomerang kids have evolved as • Follow preventive health practice
young adults have moved back into their parents’
homes after an initial period of independent living. A variety of health threats, including cancer and heart
disease, begin to affect individuals in their middle age.
Psychosocial Development
The psychosocial development of the young adult is
great. This psychosocial development according to the
theories of Freud, Erikson, Havighurst, and Newman 32 Safety
and Newman. The basic developmental task is
A fundamental concern of nurses, which extends from
establishing intimacy or very close friendships.
the bedside to the home to the community, is preventing
injuries and assisting the injured. Motor vehicle
Middle-Aged Adults (40 to 65 Years)
crashes, falls, drowning, fire and burns, poisoning,
The middle years, from 40 to 65, have been called the
inhalation and ingestion of foreign objects, and firearm
years of stability and consolidation. For most
use are major causes of injury and death.
individuals, it is a time when children have grown and
moved away or are moving away from home.
Factors Affecting Safety
Age and Development
Physical Development
Individuals learn to protect themselves from many
A number of changes that start when young adults are
injuries. Children walking to school learn to stop before
in their mid-20s become noticeable as the fifth decade
crossing the street and wait for oncoming traffic. They
approaches. At 40, most adults can function as
also learn not to touch a hot stove. For the very young,
effectively as they did in their 20s. However, during
learning about the environment is essential. Only
ages 40 to 65, many physical changes take place.
through knowledge and experience do children learn
what is potentially harmful.
PHYSICAL DEVELOPMENT Lifestyle
Risk-taking behaviors are contributing factors in some
• Exhibit weight within normal range for age and sex.
unintentional injuries
• Manifest vital signs (e.g., blood pressure) within
Mobility and Health Status
normal range for age and sex.
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Alterations in mobility related to paralysis, muscle The nurse follows the mnemonic PASS when using a
weakness, diminished balance, and lack of coordination fire extinguisher:
place clients at risk for injury. Pull out the extinguisher’s safety pin.
Sensory–Perceptual Alterations Aim the hose at the base of the fire.
People with impaired touch perception, hearing, taste, Squeeze or press the handle to discharge the material
smell, and vision are highly susceptible to injury. onto the fire.
Cognitive Awareness Sweep the hose from side to side across the base of the
Awareness is the ability to perceive environmental fire until the fire appears to be out
stimuli and body reactions and to respond appropriately
through thought and action.
Emotional State
Stressful situations can reduce a client’s level of
concentration, cause errors of judgment, and decrease
awareness of external stimuli. 39 Self-Concept
Ability to Communicate Self-concept is one’s mental image of oneself. A
ndividuals with diminished ability to receive and positive self-concept promotes an individual’s mental
convey information are at risk for injury. and physical health.
Safety Awareness Self-concept involves all of the self-perceptions—
Information is crucial to safety. Clients in unfamiliar appearance, values, and beliefs—that influence
environments frequently need specific safety behavior and are referred to when using the words I or
information me.
Environmental Factors There are four dimensions of self-concept:
Client safety is affected by the healthcare setting. • Self-knowledge- insight into one’s own abilities,
nature, and limitations.
Agency Fires • Self-expectation- what one expects of oneself; may be
fire is particularly hazardous when individuals are realistic or unrealistic expectations
incapacitated and unable to leave the building without • Social self- how one is perceived by others and
assistance. This incapacity makes it extremely society
important for nurses to be aware of the fire safety • Social evaluation- the appraisal of oneself in
regulations and fire prevention practices of the agencies relationship to others, events, or situations.
in which they work. Two mnemonics can help the nurse
remember the steps to follow. Self-awareness
First is the RACE protocol: refers to the relationship between an individual’s own
1. Rescue: If the area is safe to enter, protect and and others’ perception of self. Thus, a nurse who is very
evacuate clients who are in immediate danger. self-aware has perceptions that are very congruent.
2. Alarm: Pull the fire alarm and report the fire details Becoming more self-aware is a process that requires
and location to the hospital’s fire emergency extension. time and energy and is never complete.
3. Confine: Contain the fire by closing the doors to all Formation of Self-Concept
rooms and the fire doors at each entrance to the unit. An individual is not born with a self-concept; rather, it
4. Extinguish: Extinguish the fire. Use the appropriate develops as a result of social interactions with others.
type of fire extinguisher (see the PASS mnemonic)
According to Erikson (1963), throughout life
Extinguishing the fire requires knowledge of three individuals face developmental tasks associated with
categories of fire, classified according to the type of eight psychosocial stages that provide a theoretical
material that is burning: framework. The success with which an individual copes
Class A: paper, wood, upholstery, rags, ordinary with these developmental tasks largely determines the
rubbish development of self-concept. Difficulty coping can
Class B: flammable liquids and gases result in self-concept problems at the time and, often,
Class C: electrical. The right type of extinguisher must later in life
be used to fight the fire.
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Global self The spiritual needs of clients and support people often
refers to the collective beliefs and images one holds come into focus at a time of illness. Spiritual beliefs can
about oneself. It is also an individual’s frame of help individuals make sense of illness and cope with
reference for experiencing and viewing the world. what lies ahead.

Components of Self-Concept Spiritual disruption refers to a disturbance in or a

The four components of self-concept are personal challenge to an individual’s beliefs that provide
identity, body image, role performance, and strength, hope, and meaning to life. Possible factors in
self-esteem. spiritual disruption include physiologic problems,
Personal Identity treatment-related concerns, and situational concerns.
Personal identity also includes beliefs and values, Spiritual disruption may be reflected in a number of
personality, and character. For instance, is the behaviors, including depression, anxiety, verbalizations
individual outgoing, friendly, reserved, generous, or of unworthiness, and fear of death.
selfish? Personal identity thus encompasses both the
tangible and factual, such as name and citizenship, and Nurses must follow ethical guidelines for providing
the intangible, such as values and beliefs. Identity is spiritual care, and not impose personal beliefs or
what distinguishes self from others. practices on clients.

Body Image Nursing interventions that promote spiritual health

The image of physical self, or body image, is how an include offering one’s presence, conversing about
individual perceives the size, appearance, and spirituality, supporting the client’s religious practices,
functioning of the body and its parts. empathic communication, assisting clients with prayer,
Role Performance and referring the client to a spiritual care expert.
A role is a set of expectations about how the individual
occupying a particular position behaves. Nurses need to be aware of their own spiritual beliefs to
Role performance is how an individual in a particular be comfortable assisting others.
role behaves in comparison to the behaviors expected of
that role. Role mastery means that the individual’s Nurses can support clients’ religious practices if they
behaviors meet role expectations. understand needs related to holy days, sacred texts,
sacred symbols, prayer and meditation, dietary
Factors That Affect Self-Concept practices, dress requirements or prohibitions, healing,
Many factors affect an individual’s self-concept. Major birth rituals, and death rituals.
factors are:
Stage of development It is important for nurses to increase their own spiritual
Family and culture awareness to understand and respond to a client’s
Stressors spiritual needs.
Resources
History of success and failure
Illnes 42 Stress and Coping
Stress is a universal phenomenon. All individuals
experience it.
41 Spirituality
To provide holistic care, nurses need to care for the Concept of Stress
physical body and mind, and also need to care in ways Stress is a condition in which an individual experiences
that are sensitive to the client’s spirit. changes in the normal balanced state.
Clients have a right to receive care that respects their A stressor is any event or stimulus that causes an
individual spiritual and religious values. individual to experience stress. (Ayaw ko na, nai-istress
na ako gumawa ng reviewers!)
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When an individual faces stressors, responses are 43 Loss, Grieving, and Death
referred to as coping strategies, coping responses, or
Everyone experiences loss, grieving, and death during
coping mechanisms.
his or her life. Individuals may suffer the loss of valued
Internal stressors originate within an individual, for
relationships through life changes, such as moving from
example, infection or feelings of depression.
one city to another; separation or divorce; or the death
External stressors originate outside the individual
of a parent, spouse, or friend. Individuals may grieve
changing life roles as they watch grown children leave
Developmental stressors occur at predictable times
home or they retire from their lifelong work.
throughout an individual’s life.
Situational stressors are unpredictable and may occur at
Nurses help clients deal with many losses,
any time during life. Situational stress may be positive
including loss of body image, a loved one, a sense of
or negative.
well-being, or a job.
Examples of situational stress include:
• Death of a family member
Loss, especially loss of a loved one or a valued body
• Marriage or divorce
part, can be viewed as either a situational or a
• Birth of a child
developmental loss and as either an actual or a
• New job
perceived loss (both of which can be anticipatory).
• Illness

Grieving is a normal, subjective emotional

Effects of Stress
Stress can have physical, emotional, intellectual, social,
Knowledge of different stages or phases of grieving and
and spiritual consequences. Usually, the effects are
factors that influence the loss reaction can help the
mixed because stress affects the whole individual.
nurse understand the responses and needs of clients.
Physically, stress can threaten an individual’s
physiologic.
Caring for the dying and the bereaved is one of the
nurse’s most complex and challenging responsibilities.
Response-Based Models
Stress may also be considered as a response. This
Death-related legal issues include advance healthcare
definition was developed and described by Selye (1956,
directives, do-not-resuscitate orders, organ donation,
1976) as “the nonspecific response of the body to any
and euthanasia, aid in dying.
kind of demand made upon it”. Selye’s stress response
is characterized by a chain or pattern of physiologic
Nurses’ attitudes about death and dying directly affect
events called the general adaptation syndrome (GAS) or
their ability to provide care.
stress syndrome. To differentiate the cause of stress
from the response to stress, Selye (1976) used the term
Nurses must consider the entire family as requiring care
stressor to denote any factor that produces stress and
in situations involving loss, especially death.
disturbs the body’s equilibrium.
They need to maintain a sense of control in managing
-General adaptation syndrome (GAS) is a multisystem
the events preceding death.
response to stress and involves three steps: alarm
reaction, stage of resistance, and stage of exhaustion.

The body can also react locally; that is, one organ or a
part of the body reacts alone. This is referred to as the 44 Activity and Exercise
local adaptation syndrome (LAS). One example of the Our ability to move is an essential aspect of well-being
LAS is inflammation. Selye (1976) proposed that both and our overall health is affected by our activities. The
the GAS and the LAS have three stages: alarm reaction, nursing diagnosis of an inactive lifestyle emphasizes
resistance, and exhaustion. the role of exercise and activity as an essential
-Local adaptation syndrome (LAS) is a localized component of health. In fact, too much sitting is
physiologic response that also expresses the three emerging as a recognized health risk for a variety of
stages of GAS. chronic illnesses
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Purposeful coordinated movement of the body relies on Smoking

the integrated functioning of the musculoskeletal Alcohol consumption
system, the nervous system, and the vestibular Obesity
apparatus of the inner ear. lack of exercise
Insufficient amounts of sleep contribute to an increased
Body movement involves four basic elements: risk of hypertension, diabetes, obesity, depression, heart
Body alignment attack, and stroke
Joint mobility Neurotransmitters, located within neurons in the
Balance brain, affect the sleep-wake cycle. For example,
Coordinated movement serotonin is thought to lessen the response to sensory
stimulation and gamma-aminobutyric acid (GABA) to
Exercise is physical activity performed to improve shut off the activity in the neurons of the reticular
health and maintain fitness. Activity tolerance is the activating system.
type and amount of exercise or daily living activities an
individual is able to perform without experiencing The sleep cycle is controlled by specialized
adverse effects. areas in the brainstem and is affected by the individual’s
circadian rhythm.
Functional strength is the ability to do work.
NREM (non-REM) sleep sleep during which the
Exercise is classified as either isotonic, isometric, or individual experiences non–rapid eye movement
isokinetic and as either aerobic or anaerobic.
NREM sleep consists of three stages, progressing from
Many factors influence body alignment and activity. stage 1, very light sleep, to stage 3, deep sleep.
These include growth and development, nutrition, NREM sleep dominates during naps and nocturnal
personal values and attitudes, certain external factors, sleep periods. NREM sleep is essential for physiologic
and prescribed limitations to movement. well-being.

Positioning a client in good body alignment and REM sleep recurs about every 90 minutes and is often
changing the position regularly and systematically are associated with dreaming.
essential aspects of nursing practice.
REM sleep is essential for psychosocial and mental
The nurse can assist clients to prepare for ambulation equilibrium
by helping them become as independent as possible
while in bed. Ambulating techniques that facilitate During a normal night’s sleep, an adult has four to six
normal walking gait yet provide needed supports are sleep cycles, each with NREM (quiet sleep) and REM
most effective. (rapid-eye-movement) sleep.

45 Sleep The ratio of NREM to REM sleep varies with age.

Common sleep disorders
Sleep Insomnia, hypersomnia, narcolepsy, parasomnias (such
Is a basic human need; it is a universal biological as somnambulism, sleeptalking, and bruxism), and
process common to all individuals. Humans spend sleep apnea.
about one-third of their lives asleep. We require sleep
for many reasons: to cope with daily stresses, to prevent Assessment of a client’s sleep includes a sleep history, a
fatigue, to conserve energy, to restore the mind and health history, and a physical examination to detect
body, and to enjoy life more fully. signs that may indicate the presence of sleep apnea.

Five health-related behaviors that lead to the Nursing responsibilities to help clients sleep
development of chronic disease. (a) teaching clients ways to enhance sleep
 AYAW KO NA MAG NURSING DAPAT AKO
-KarecrisAva,RN 2027

(b) supporting bedtime rituals,

(c) creating a restful environment
(d) promoting comfort and relaxation
(e) enhancing sleep with medications