Essentials of Medical Surgical Nursing BT Basavanthappa
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Introduction to Medical Surgical NursingCHAPTER 1

 
EVOLUTION OF MEDICINE AND NURSING IN INDIA
The history of medicine in India goes back through the centuries to about 3000 BC. The beginnings are shrouded in the mist of ancient myths. The experience and concern in health development date back to vedic period between 3000 BC and 1400 BC. The Indus Valley Civilization showed relics of planned cities and practice of environmental sanitation. According to Dr. Wheeler on the basis of his research studies from South, Arikamedu (Pondicherry) to North Mohenjodaro and Harappa, only one culture had been followed. An ideal healthful living of the people, such as every house of Mohenjodaro and Harappa had separate good water supply. In every backguard of the houses, there was a wide royal street and by the side of the street there was an arrangement of safe drinking water. Actually, this was followed by Dravidians who lived at that time. After the invasion of Aryans, the Dravidian got relegated to South. The specialist of pictograph reader, Father Heras says that it was a fact that ancient people of Mohenjodaro were proto-Dravidians, a fact also hinted by Sir John Marshall that there was a link between all that is the Dravidian culture, including Mohenjodaro and Karnataka. The Ayurveda and other system of medicine practised during this time suggests the development of comprehensive concept of health by the ancient sages of India.
 
Traditional Medicine and Surgery In India
Indian medicine is ancient. Its earliest concepts are set out in the sacred writings called the Vedas, especially in the metrical passages of the Atharvaved, which may possibly dates as far back as the second millennium BC. According to a later writer, the system of medicine called Ayurveda was received by a saint Dhanvantari from Brahma, and Dhanvantari was defined as the God of medicine. In later times, his status was gradually reduced, until he was credited with having been an earthly king who died of snakebite. Legends tell of Dhanvantari's relations with snakes and illustrates the skill with which early Indian practitioners treated snakebite.
The period of Vedic medicine lasted until about 800 BC. The Vedas are rich in magical practices for the treatment of diseases and in charms for the expulsion of the demons traditionally supposed to cause diseases. The chief conditions mentioned are fever, cough, constipation, diarrhea, dropsy, abscesses, seizures, tumors and skin diseases (including leprosy). The herbs recommended for treatment are numerous.
 
Golden Period of Indian Medicine
The golden age of Indian medicine, from 800 BC until about 1000 AD may be termed the Brahmanistic period. It is marked especially by production of the medical treatises knwon respectively as the Charaka-Samhita and Sushruta-Samhita, attributed respectively to the physician Charaka and Susruta, traditionally a surgeon. Both these works were formerly regarded as being of great antiquity, and hence claims arose for the priority of Indian scientific medicine over its Greek counterpart.
Another school asserted that these works were written many centuries after the beginning of the Christian Era. The most recent estimates place the Charaka-Samhita its present form as dating from the Ist century AD, and there were earlier versions. The Sushruta-Samhita probably originated in the last 2centuries of the pre-Christian Era and became fixed in its present form in the 7th century AD at the latest. Other medical treatises of lesser importance are those attributed to Vagbhata (8th century). All later treatises were based on these works.
Because the Hindus were prohibited by theirreligion from cutting the dead body, their knowledge of anatomy was limited. The Sushruta-Samhita recommends that a body be placed in a basket and sunk in a river for seven days. On its removal, the parts could be easily separated without cutting. As a result of these crude methods, the emphasis in Hindu anatomy was given to the bones, and then to the muscles, ligaments and joints. The nerves, blood vessels and internal organs were very imperfectly known.
The Hindus believed that the body contained three elementary substances, microcosmic representatives of the three divine universal forces, which they called spirit (air), phlegm, and bile. These were comparable with the humours of the Greeks. Health depends on the normal balance of these three elementary substances. The spirit has its seat below the navel the phlegm about the heart, and the bile between the heart and the navel. The seven primary constituents of the body-blood, flesh, fat, bone, marrow, chyle, and semen are produced by the action of the elementary substances. Semen was supposed to be produced from all parts of the body and not from any individual part or organ. Both Charaka and Sushruta state the existence of a large number of diseases (Susruta says 1,120). Rough classifications of diseases are given. In all texts “fever” of which numerous types are described, is regarded as important, phthisis (wasting disease, especially pulmonary tuberculosis) was apparently common, and the Hindu physicians knew the symptoms of cases likely to terminate fatally. Smallpox was common, and it is probable that smallpox inoculation was practised.
 
HINDU WRITINGS ON DIAGNOSIS AND PROGNOSIS
In diagnosis, the Hindu physicians used all five senses. Hearing was used to distinguish the nature of the breathing, alteration in voice, and the grinding sound produced by the rubbing together of broken ends of bones. They appear to have had a good clinical sense, and their sections on prognosis contain acute references to symptoms that are of grave import. Magical beliefs still persisted, however, until late in the classical period, the prognosis could be affected by such fortuitous factors as the cleanliness of the messenger sent to fetch the physician, the nature of his conveyance, or the types of persons whom the physician met on his journey to the patient.
Indian therapeutics was largely dietetic and medicinal. Dietetic treatment was important and preceded any medicinal treatment. Fats were mostly used internally and externally. The most important methods of active treatment were referred to as the “five procedures”; the administration emetics, purgatives, water enemas, oil enemas, and sneezing powders, inhalations were frequently employed, as were leeching, cupping and bleeding.
The Indian materia medica was extensive and consisted mainly of vegetable drugs, all of which were from indigenous plants. Charaka knew 500 medicinal plants, and Sushruta knew 700. But animal remedies (such as the milk of various animals, bones, gallstones) and minerals (sulfur, arsenic, lead, copper sulfate, gold) were also employed. The physicians collected and prepared their own vegetable drugs. Among those that eventually appeared in western pharmacopoeias are cardamom and cinnamon.
As a result of the strict religious beliefs of the Hindus, hygienic measures were important in treatment. Two meals a day were prescribed with indications of the nature of the diet, the amount of water to be drunk before and after the meal, and the use of condiments. Bathing and care of the skin were carefully prescribed, as were cleaning of the teeth with twigs from neem trees, anointing of the body with oil, and use of eyewashes.
 
HINDU SURGERY
In surgery, ancient Hindu medicine reached its zenith. Detailed instructions about the choice of instruments and the different operations are given in the classical texts. It has been said that the Hindus knew all ancient operations except the arrest of hemorrhage by the ligature. Their operations were grouped broadly as follows: excision of tumors; incision of abscesses, punctures of collections of fluid in the abdomen; 3extraction of foreign bodies; pressing out of the contents of abscesses; probing of fistulas; and stitching of wound.
The surgical instruments used by the Hindus have received special attention in modern times. According to Sushruta, the surgeon should be equipped with 20 sharp and 101 blunt instruments. The sharp instruments included knives of various patterns, scissors, trocars (instruments for piercing tissues and draining fluid from them), saws and needles. The blunt instruments included forceps, specula (instruments for inspecting body cavities or passages), tubes, levers, hooks and probes. The Sushruta-Samhita does not mention the catheter, but it is referred to in later writings. The instruments were largely of steel. Alcohol seems to have been used as a narcotic during operations.
Especially in two types of operations the ancient Hindus were outstanding. Stone in the bladder (vesical calculus) was common in ancient India, and the surgeons frequently carried out the operation of lateral lithotomy for removal of the stones. They also introduced plastic surgery. Amputation of the nose was one of the prescribed punishments for adultery, and repair was carried out by cutting from the patient's cheek a piece of tissue of the required size and shape and applying it to the stump of the nose. The results appear to have been tolerably satisfactory, and the modern operation is certainly derived indirectly from this ancient source. The Hindu surgeons, also performed an operation for the cure of anal fistula and in this they were definitely in advance of the Greeks.
In the past there had been much speculation as to whether the Greek derived any of their medical knowledge from the Hindus. Mid-20th century opinion held that there was certainly intercommu­nication between Greece and India before the time of Alexander the Great.
 
CHRONOLOGICAL EVENTS
A brief description of chronological events related to development of health and medicine in India is given below:
3000 BC: In the Indus Valley Civilisation, one finds evidence of well developed environmen­tal sanitation programs such as underground drains public baths, etc. ‘AROGYA’ or ‘Health’ was given high priority in daily life and this concept of health included physical, mental, social and spiritual well-being.
2000 BC: Rigveda marks the beginning of the Indian system of medicine. Medicine was considered part of VEDAS or Scriptures. ‘Ayurveda’, a ‘Science of life and art of living’ said to be founded by Sage ‘Atreya’. Good health implies an ideal balance between tridoshic factors, i.e. wind, bile, phlegm (Vata-Pitta and Kapha) according to Ayur-Veda. Health promotion and health education were also emphasized by following ‘Dinacharya’. 1000 BC: Atharvaveda mentions the twin aims of medical sciences as health and longevity and curative treatment. Hygiene and dietetics are considered important in treatment. Beneficial effects of milk are described in detail.
800 BC: A codification of medical knowledge scattered through vedas by Bhela called Bhela-Samhita. 700 BC: A codification of medical know­ledge by Agni-Vesa, said to be disciple of Atreya, called Agnivesa Samhita became the basis of later Charaka.
600 BC: A treatise by Kasyapa mainly dealing with paediatrics.
500 BC: ‘Chivaravastu’, a book written by unknown author is found. It mentions prince Jivika, the court physician of Bimbasara, King of Magadh, as a marvellous physician and surgeon. He is credited with such difficult operations as piercing the skull to operate on the brain, surgery of the eyes, etc. and medical treatment of dropsy, internal tumors and varicose veins.
272 BC-236 BC: King Asoka, a convert to Buddhism, built number of hospitals. More emphasis was laid on the preventive aspects. Doctors, nurses, and midwives were to be trustworthy and skillful. The nurses were usually men and old women. This period saw famous medical schools at Taxila and Nalanda.
237 BC-201 BC: St. Buddha instituted a state medical system, appointed doctors for every 10 villages on the main roads of India. Pharmaceutical gardens were also maintained.
200 BC-100 BC: Patanjali explored the yoga system of philosophy of men and physical discipline–the starting point of yoga therapy later continued.4
100 BC: Charaka-Samhita, the first classical exposi­tion of Indian system medicine deals with an almost all the branches of medicine, anatomy, physiology, etiology, prognosis, pathology, treatment procedure, and sequence of medication and an extension Materia Medica for more than 600 drugs. This treatise formed the basis of the Atreya School of Medicine in India, in (100) AD. The qualification of attending nurse, enshrined in the Charaka-Samhita, i.e. knowledge of preparation and compounding of drugs for adminis­tration, cleverness, devotedness to patient under care and purity of both mind and body.
200-300 AD: Sushruta-Samhita appears to have been revised by Nagarjuna, laid main emphasis on surgery. This great treatise described more than 300 operations, 43 different surgical processes and 121 different types of instruments. The Materia Medica is also extensive covering more than 650 drugs of animals, plant and mineral origin. This treatise forms the basis of Dhanwantari School (300 AD).
Sushruta defines ideal relations of doctor, patient, nurses and medicine as the four feet upon which a cure must rest.
500-600 AD: Vagbhata wrote Astanga Hridaya (8 limbs and heart). The eight limbs refer to the eight traditional branches of Ayurvedic knowledge, i.e. therapeutics, surgery, ENT, mental and superstitious diseases, infantile diseases and treatment, toxicology, arresting physical and mental decay, and rejuvenation or regaining lost virility potency and procreative ability.
This book is the most concise and scientific exposition of Ayurveda. It is in verse form, making it easy to memorise. It incorporates the teachings of the sages Atreya and Dhan-Wantari and the Rasayana school of medicine. It is distinguished but its knowledge of chemical reactions and laboratory processes. This book has been translated into foreign language.
600-800 AD: Sodhala (700 AD) two treatises, Gandani-ghraha, a medical treatise and Sodhala a medical Lexicon.
Vrudukunta (750 AD) writes Siddayoga, the earliest treatise on Rasa Chikitsa now existing intact. The Rasa Chikitsa system considers mercury as the king of all medicines. Siddayoga explain the various preparations of mercury and other metals, alloys, metallic compounds, salts and sulphur. This school of medicine is called SIDDHA school. All of them are made of metals, salts and sulphur. It is supposed to be a continuation of the pre-Aryan medical system in India. It is popular in Eastern and Southern India.
Siddha Nagarjuna two treatises on the Siddha systems, Rasarathanakara and Arogya Manjari. Madhavacharya (700-800 AD) wrote Madhava Nidana. This is a compilation from the earlier works of Agnivesa, Charaka, Sushruta, Vagbhata. It is specially useful as a chemical guide to preparations. It is famous allover India as the best Ayurvedic work on the diagnosis of diseases.
800-1300 AD: A number of treatises were written in India during this period. Arkaprakasha, a book on tincture extraction, Sarangadhara Samhita, Chikitsa, Sangraha and Yoga Ratnakara are the better known among them.
The period also witnessed a spirit of writing on the Rasa Chikitsa system. Rasha Hridaya by Govind Vagbhata, Rasaratnakara by Siddha Nityananda, Rasara-Tnasammukta by Vagbhata (another), Rasarnava by Sambhu, Rasendrachintamani by Ramachandra, and Rasendra Choodamani by Somadeva.
1300-1600 AD: Bhavamisra wrote Bhava Pra-Kasha. This is the most renowned Indian treatise during the period. It contains an exhaustive list of diseases and their symptoms and complete list of drugs including many not mentioned in the earlier works. It includes etiology and treatment of syphilis, a disease brought into India by Portuguese seamen.
Other works of this period are Chikitsaliye by Trisata, a manual on diagnosis; Chintamani by Ballbhendra on aetiology and diagnosis; and Vaidyamrutha by Moreswara on the treatment of diseases.
Another class of works produced during this period are Medical Lexicons by Madanapala, Nagahari, Bimapala, and Rajavallabha.
1600: East India Company established British Rule in India. Western medicine and surgery started to be practised and became popular in India.5
 
NURSING IN INDIA
 
Beginning of Modern Nursing
In the past, the progress of nursing in India has been hindered by many difficulties, such as: the low status of women, the system of purdah among Muslim women, the caste system among Hindus, illiteracy, poverty, political unrest, language differences, and the fact that nursing has been looked upon as servant's work.
Since Independence day 1947, many changes have taken place and the attitude towards nursing is changing. More women are being educated and many are taking up nursing as their profession.
We have very little information about medicine and nursing in India until the 15th century, when Vasoco da Gama came to India. He set up trading posts on the west coast. Franciscan, Dominican and Jesuit missionaries came to minister to the sick and needy. The Portuguese set up European type of dispensaries at Goa and Madras and physicians from Europe were invited to India. One of these, Garcia da Orta, in 1550 wrote “Simples Drugs of India”.
 
Military Nursing
Military nursing was the earliest type of nursing. In 1664, the East India Company helped to start a hospital for soldiers at Fort St. George, Madras. Later, acivilian hospital was built and the medical staff, appointed by the East India Company, served in both hospitals. In 1797, a Lying-in-Hospital was built and in 1854 the government sanctioned a training school for midwives. In 1861, through the efforts of Miss Nightingale, reforms in military hospitals led to reforms in civil hospitals. Efforts were made to provide health services for the people of India. This laid the foundation for public health nursing.
Nursing in the military hospitals was of poor quality carried on by male orderlies and menial staff. In 1871 the Government General Hospital, Madras undertook a plan to train nurses. Nurses were brought from England to be in-charge and the first six students were those who had previously received their diploma in midwifery. Later this plan was reversed. General training was taken first followed by a course in midwifery.
In Bombay, among the one of the earliest hospitals is the Jamsetjee Jeejeebhoy group, the first of which was opened in 1843. Another hospital which was to play an important part in the development of modern nursing in India was the Pestani Hormusji Cama Hospital for women and children, which was founded in 1883 but not opened until 1886.
Provision for the nursing care of patients in these early hospitals was very limited. In the JJ Group, nursing was done by medical students and menials until 1868 when the government invited the Sisters of the Community of All Saints to come from England and take over the work of nursing. Their work was appreciated and the need for training nurses was felt. At this time, it was difficult to get nurses. There were only a few Anglo-Indian and Indian Christian girls working in mission hospitals. The sisters of all saints took the first steps to establish a training school for nurses in this hospital. In 1891, Bai Kashibai Ganpat was the first Indian nurse to come for training. Training was at first two years but became three years when the Bombay Presidency Nursing Association was established in 1909.
An outstanding graduate of the JJ Group of hospitals was Miss. TK Adranvala. After her graduation, she worked as a ward sister, then became assistant Matron under the sisters and finally, superintendent of the hospitals. She held this position until she was asked to accept the position of Nursing Superintendent and Nurse adviser to the Government of India. She remained in this position until retiring in 1966. She continues active participation in nursing as a WHO representative in Nepal. Miss Adranvala has worked very hard to raise the status of the nursing profession in India. She has given much of her time to the interests of the TNAI having held the office of president for two terms and that of treasurer until she was released at her own request. The nursing profession in India is fortunate to have had such a capable person as Miss Adranvala as its representative in the World Health Organization. She is highly respected by all and many seek her wise counsel.
 
Mission Hospitals
Mission Hospitals were the first to begin the training of Indians as nurses, very gradually overcoming the 6prejudices of parents against sending their girls for a training which was felt to be beneath the dignity of decent educated girls. Religion prevented Hindu and Muslim girls from joining at all and so only Christian girls could be trained at first. But for many years, even they felt nursing was an inferior profession.
In the beginning there was no uniformity of courses or educational requirements. About 1907-1910 the North India United Board of Examiners for Mission Hospitals was organized and set up rules for admissions and standards of training and conducted a public examination. On 24th May 1909 the Indian Medical Mission Association granted the Nursing Diploma after examining student by Central Board for Nurses’ Training Schools in South India. A few years later the Mid-India and the South India Boards of Nurse examiners were similarly set up. These are Examining Boards of the Nurses’ League of the Christian Medical Association of India. The name of the South India Board was changed to ‘The Board of Nursing Education, Nurses’ League of Christian Medical Association of India branch in 1975.
 
The Dufferin Fund
Until the late 19th century there were no women doctors and therefore, no care for women except in mission hospitals. This fact was brought to the attention of Queen Victoria. At this time, Lady Dufferin was coming out to India with her husband who was on government service. Queen Victoria instructed Lady Dufferin about the need for medical care for women and children in India and asked her to take a special interest in this problem. Lady Dufferin wrote to her friends and influential people to get financial aid. Thus, in 1885, Lady Dufferin was responsible for starting the ‘National Association for supplying Medical Aid by Women to Women of India’. This is commonly called the Dufferin Fund and continues to provide medical education for women, to train nurses and midwives for hospitals and private work, and to improve medical facilities for women.
Between 1890 and 1900, many schools under either missions or government were started in various parts of India. The directors fo these schools were English or American. Each school sets up its own pattern of training familiar to the director. There was a need for systematic training of nurses like that given in the Nightingale School in England. Thus it was, that in 1886, money from the Dufferin Fund was made available for this purpose. Miss Atkinson, a Nightingale nurse, was brought out from England to Bombay to set up and be the superintendent of the First Modern Training School for Nurses in India. The school was established in the Cama Hospital for Women and Children in 1891. It began with a one year course but by 1995 it had been extended to three years.
The leaders of nursing in India realized that more and better qualified teachers and ward supervisors were needed if standards were to be maintained and nursing was to advance. Hence, courses were set up in several places to give Indian nurses an opportunity to prepare themselves for responsible positions in hospitals and schools of nursing. Post-certificate courses were first offered in nursing administration, supervision and teaching. These originated at the College of Nursing, New Delhi; the College of Nursing, CMC Hospital Vellore and the Government General Hospital, Madras.
The first four year basic bachelor degree programmes were established in 1946 at the Colleges of Nursing in Delhi and Vellore. This programme is now offered in a number of other colleges.
In 1963, the School of Nursing in Thiruvanantha­puram instituted the first two year post-certificate bachelor degree programme. Other schools have begun this programme since that time.
In recent years, as higher education for nurses has developed around the world, courses in India have developed so that the nurse can specialize in almost any subject and continue education through the level of the Master's degree. The first Master's degree course, a two-year postgraduate programme was begun in 1960 at the College of Nursing in Delhi. (Now Rajkumari Amrit Kaur College of Nursing, New Delhi-110 024). In 1970, many colleges of nursing were started and offering PCBSc Nursing and Basic BSc Nursing courses in various parts of India. In Karnataka, Bangalore University instituted Ph D programme for nurses in 1991. The author of this book is the first person to get Doctoral degree in Nursing in the State of Karnataka.7
 
AUXILIARY NURSING
The use of auxiliary nursing personnel to ease the shortage of professional nurses had been common in some countries when it was first put into practice in India. A two-year programme for the Auxiliary Nurse-Midwife was first established in 1951 at St. Mary's Hospital, Tarn Taran in Punjab state. By 1962, there were 263 courses being offered in India. The auxiliary nurse midwife is prepared to practise elementary nursing and full midwifery. She functions primarily in the community rather than the hospital. The practice of the auxiliary nurse-midwife has helped to improve the amount of care given to the patient as well as the health teaching given to the public. In 1977 the ANM course was completely revised by the Indian Nursing Council and expanded to include sociology health education and communication skills and subjects necessary to equip the multipurpose health worker/ANM to serve effectively as a primary health care worker in the community. Such workers are key persons for achievement of the goal of ‘Health for all by 2000 AD” to which we in India are committed.
 
Textbooks
One of the handicaps in the development of nursing schools was the lack of textbooks. In other countries books had been written by doctors and nurses. Some of these were translated into the vernacular for the early schools and colleges. Many English and American textbooks are being used in the schools today. There is a great need for textbooks which have been written by Indian nurses. A beginning had been made in this work and the first Textbook for Nurses in India was printed by the South India Examining Board of the Nurses’ League of the Christian Medical Association of India in 1941. The Nurses’ League has also directed the publishing of a Textbook For Auxiliary Nurse-Midwives, first printed in 1967. This book was completely revised and published in two volumes in 1985 as a Textbook For The Health Worker (ANM) to meet the needs of the health worker. Several manuals related to the basic sciences and nursing have been published by other professional nursing bodies. Although progress has been made in the publication of textbooks by the nurses of India, there remains a wide area of subjects which have not been touched upon and the general need for more and varied textbooks continues. Since a few nursing educator started writing texts on Nursing, to quote, Late Dr. (Mrs) Kasturi Sunder Rao wrote text on ‘Community Health Nursing, and a few Bombay-based Nurses made an effort to write guides and two books on Nursing. In later part of 1990s onwards the author of this book also has written on ‘Nursing Research’ (1998), Community Health Nursing (1998), Nursing Administration(2000), Nursing Education (2003), Fundamentals of Nursing (2002) Medical surgical Nursing (2003), Pediatric Child Health Nursing (2004), Midwifery and Reproductory Health Nursing (2006), Psychiatric Mental Health Nursing (2006), Nursing Theories (2007), on the basis of present needs in Indian context and started revision of earlier text and Essential series of all the books also availble are written by author.
Nursing education in India began with very brief periods of training as mentioned in the first part of this chapter. Orderlies and midwives were often chosen for this and were given a period of two to six months of closely supervised practical experience in general nursing, then called ‘sick nursing’. This was training in the hospital, and certificates were given after completion of a training.
The basic Program for combined general nursing and midwifery developed rapidly after 1871. The need for theory as well as practical experience was felt. The training for general nursing was extended to two years and then three years before the student went on for midwifery training. The present basic program for nursing education throughout India consists of a three and half year program in general nursing and six to seven months in midwifery. Uniformity of training is maintained by recognition of schools which meet the standards and requirements given by the Indian Nursing Council. The basic certificate program now includes all areas of nursing as integrated community health nursing.
Now, most of the states in India started basic B.Sc Nursing, Postcertificate B.Sc Nursing and M.Sc Nursing degree courses in their related universities. And also there is Doctoral degree course in nursing leading to Ph.D in nursing.8
 
REGISTRATION OF NURSES
As training for nurses, midwives, and health visitors progressed, the need for legislation to provide basic minimum standards in education and training was felt. It was also felt that registration would give greater professional status. For some years, nurses struggled to obtain proper examinations and examiners and registration for nurses. In 1926 Madras State formed the first Registration Council. While most states now have a recognized Registration Council, all do not. It is now possible for the students of all schools in India to be registered in one of the State Registration Councils.
 
The Indian Nursing Council
The Indian Nursing Council Act was passed by an ordinance on December 31st 1947. The council was constituted in 1949. The purpose of the council is to co-ordinate activities of the various State Registration Councils, to set up standards for nursing education and to make sure these standards are carried out. Before this time, nurses registered in one state were not necessarily recognised for registration in another. The condition to mutual recognition by the State Nurses Registration Council called reciprocity was possible only if uniform standards of nursing education was maintained. Therefore, the INC was given authority to prescribe curricula for nursing education in all of the states. At the same time, it was given authority to recognize programmes of nursing education or refuse recognition. The Indian Nursing Council is not itself a registering body nor examining body but it can enforce its standards by recognizing or refusing to recognize schools. And now almost all the states of India has their State Nursing Council for example, Karnataka State Nursing Council, etc….
 
Community Health Nursing
In India community health nursing had its beginning when the terrible conditions under which children were born were recognized as a cause for the high civilian mortality rate. It was realized that the untrained dais who attended women during delivery must be given training. This was not an easy job as the dais were unwilling to be trained and the patients were very willing to accept the old customary methods and could see no need to change. The first attempts to train dais were carried out by missionaries as early as 1886. In 1900, Lady Curzon brought about the establishment of the Victoria Memorial Scholarship for the purpose of improving safe delivery practices. The need for training a better type of midwife was felt. In this, Madras State led the way when they passed the Madras Registration of Nurses and Midwives Act of 1926.
Slowly the need for trained personnel for maternal and childhealth, as part of community health nursing was felt. To supply this need a Health School for the training of health visitors was started in Delhi in 1918. This has now become the Lady Reading Health School.
A further step forward was taken in 1948, when community health nursing was integrated in the basic programme of the new degree courses which were started at the College of Nursing, Delhi and the School of Nursing, CMC Hospital, Vellore under the University of Delhi and Madras respectively.
Since 1953, a post-certificate course in community health nursing has been given at the All India Institute of Hygiene and Public Health in Calcutta. In 1960, a course was established by the Lady Reading Health School in Delhi. Several other schools now offer this programme.
To prepare more community Health nurses, in 1957 the Government of India selected ten schools of nursing and gave assistance so that they could integrate community health nursing into their basic course. Since that time, recognition of a programme of basic nursing education required that community health nursing be integrated into the basic course. Thus, all professional nurses today can function in the hospital and the community at the level of a staff nurse.
Various international organizations, such as WHO, UNICEF and Colombo Plan have assisted by supplying trained personnel and equipment to help in the training of students in the rural field, maternity work and paediatrics.
 
THE NURSE’S RESPONSIBILITY FOR THE FUTURE OF NURSING
Throughout this study of nursing we have seen nursing advance from the kindly ministrations of a mother or 9a neighbour to the highly organized service of today. In the beginning individuals were inspired to help one another in distress. This essential care or service still remains but time has brought about changes in our ideas regarding nursing. Today we are not only relieve and give comfort but help our patients to live upto their opti­mum health. The new emphasis is on health nursing-nursing the mind, the family as a whole and as part of the community with the nurse as the health teacher.
Growing specialisation in medicine is resulting in a trend towards increased specialisation in nursing. The development of new tests and diagnostic procedures, new medicines and new equipment make specialisation even more necessary as the amount of scientific knowledge needed for a certain speciality becomes greater. Developments in other professions also influence trends in the nursing profession. As other members of the health team become more available and more highly specialized, the work of the nurse is changing towards more specific nursing functions. It has also added to the number and kind of professional relationships which must be maintained by the nurse. The power of spiritual factors is becoming of increasing interest as reports of the healing power of spiritual activity such as meditation is receiving more attention. Just as advances in technology tend to take the nurse away from the bedside and a direct relationship with the patient, so these developments are showing the need for a deeper therapeutic relationship between the nurse and the patient. The future will demand a balance of these factors in order to meet the total health needs of the individual and the community. Future trends are likely to show an effort to make this balance.
Many trends leading to professionalism are taking place because of the untiring efforts of nurses dedi­cated to achieving the aim of becoming a profession. In 1970, WHO recognized Nursing as a profession. It has often been a difficult struggle requiring real courage and vision by nursing leaders in the face of serious obstacles. Today nurses enjoy many rights and privileges, though desired standards are still not achieved in all areas, because nursing leaders have struggled to achieve them. Nurses who are going to be the future leaders have to carry on this work of greater achievement through growing amounts of writing and research.
Nursing today provides an ever widening scope of opportunity for service. With present trends leading towards greater opportunities, varieties of services and growing social and professional recognition, it should be exciting and challenging for nurses to know that all nurses members of this profession since they fulfill the criteria of the profession. (for further details please read the authors text on “NURSING ADMINISTRATION”, 2nd Edition.)
Medical Surgical Nursing Medical-Surgical nursing is commonly defined as the nursing care of adults with suspected or diagnosed pathology of physiological function. It encompasses such a large scope that the trend is to subdivide medical-Surgical, Oncological (cancer) nursing, and only recently have the other specialties been developed.
Currently, all basic nursing programs prepare nurses to practice medical-surgical nursing. Advanced preparation at the master's and doctoral levels is necessary if the nurse wishes to devlop expertise and acquire in-depth knowledge in particular aspects or subdivisions of the specialty. These specialties would include intensive care units, the emergency room.
Medical-surgical nursing is the area of practice concerned with the care of adults with predicted or exisiting physiologic alterations, trauma, or disability. It is the backbone of modern nursing and the practice foundation of virtually all health care institutions.
Traditionally medical-surgical nursing was not considered a specialty area. Rather, practices with a focus on a specific type of health problem within the area of medical-surgical nursing were considered specialties. These included cardiovascular, perioperative, neurologic, gynecologic, infection control and emergency nursing, and practices limited to problems such as wound care, burns, hypertension and diabetes. Today this view has changed. Medical-surgical nursing is now formally recognized as a specialty in its own right, and the focused practice areas are seen as subspecialties.
Formal recognition as a specialty means that a practice area meets the criteria for specialty status, which were published in the document titled “Recognition of a Specialty Approval of Scope” Statements and Acknowledgement of Nursing practice Standards (ANA).10
The criteria are that the practice area must:
  • Be clearly defined and subscribe to the overall purposes and functions of nursing
  • Define itself as nursing
  • Adhere to the overall licensure requirements of the profession
  • Be national or international in scope
  • Be able to identify a need and demand for itself
  • Have a well-derived knowledge base particular to the practice of the specialty
  • Be organized and represented by a national specialty association
  • Be concerned with phenomena within the discipline of nursing
  • Have defined competencies for the area of specialty practice
  • Have existing mechanisms for supporting, reviewing and disseminating research to support its knowledge base
  • Have continuing education programs that prepare nurses in the specialty
  • Include a substantial number of nurses who devote most of their practice to the specialty
The nursing profession has adopted standards of practice that describe the responsibilities for which are accountable. All nurses, regardless of education, Standards of Clinical Nursing Practice to guide their practice. This broad set of standards has two components: standards of care and standards of professional performance. The nursing process and competent level of nursing care are the foundation of the standards of care. The standards of professional performance address expected quality of care, performance appraisal, education, collegiality, ethics, collaboration, research, and resource utilization. Each standard has measurement criteria to demonstrate competent practice.
The Academy of Medical Surgical Nurses, founded in 1991, is an international organization dedicated to fostering excellence in medical-surgical nursing practice. Its mission is to “enhance the clinical expertise, professionalism, and leadership of nurse's caring for adults in hospitals, the community, and long-term care.”
 
CONCEPTS OF HEALTH AND ILLNESS
Health is a state of well-being of individual and community. So it can be examined at individual or community level. For individual the term ‘health’ refers to the optimal functioning of the individual, absence of disease, illness, impairment or injury. In the context of the community it refers to various objective measures of health, health status or health indices like incidence of, and prevalence of disease applied to different segments of population. Defining good health is difficult, because each person has personal concept of health.
The definition of health range on a continuum from the absence of diseases to optimal functioning to utopian ideals of complete state of physical, mental, emotional, spiritual and social well-being.
About 500 BC, Pericles defined ‘health’ as “That state of moral, mental and physical well-being which enables a person to face any crisis in life with the utmost grace (of God) and facility.”
HS Hayman defines health as a state of feeling sound in body, mind and spirit, with a sense of reserve power. This perception, if health is based on normal functioning of the body's physiological process, understanding the principles of healthful living and attitude that regards health not only as a means of survival and self-fulfilment in itself, but as means to a creative social adjustment and a richer, fuller life as measured in constructive service to mankind.
H Blum defines ‘health’ as the person's capacity to function in a way to maximise potential, to maintain a balance appropriate to age and social needs, to be reasonably free of gross dissatisfaction, discomfort, disease or disability, and to behave in ways that promote survival as well as self-fulfilment or enjoyment.
  • Health is the condition of being sound in body, mind or spirit especially freedom from physical disease or pain (Webber).
  • Health refer to a “soundness of body or mind; that condition in which its functions are duly and efficiently discharged (Oxford English Dictionary).
  • Health is a condition or quality of the human organism expressing the adequate functioning of the organising the given conditions, genetic and environmental.
  • Health is a modes vivondi enabling imperfect men to achieve a rewarding and not too painful existence while they cope with an imperfect world.11
R Dubiois views ‘health’ as adaptation a function of adjustment. He believes an (WHO's) utopian state of health can never be reached because the person can never be so perfectly adapted to the environment that life will not involve struggle, failure and suffering. Humans can adapt to environmental conditions or change the environment but each new adaptation produces new problems that demand new solution.
“Health is the achievement of a state of harmony between man's internal and external milieu” (Liverpool School of Tropical Medicine).
F and E Rathbone formulates health as a whole­ness of function, movement towards self actualisation, relating to effective, creative use of potential, realistic interpretation of experiences and co-ordination of attitudinal, physiological and behavioural adaptations.
Imogene King defined ‘health’ as a dynamic state in the life cycle of an organism that implies continuous adaptation to stresses in the internal and external environment through optimum use of one's resources to achieve maximum potential for daily living.
According to S Perkin “health is a state of relative equilibrium of body form and functions which results from its successful, dynamic adjustment to forces tending to disturb it. It is not passive interplay between body substance and forces infringing upon it, but an active response of the body forces working towards adjustment.
Health is wellness of an individual. According to Dunn the term ‘high level wellness’ implies well-being in degree or level.
High level wellness for the individual is defined as an integrated method of functioning which is oriented towards maximising the potential of which the indivi­dual is capable. It requires that an individual maintains a continuous balance and purposeful direction within the environment whereby he is functioning.
WHO defines “Health as state of complete physical, mental, social and spiritual well-being and not merely absence of disease.”
This definition is positive and includes more than physical health, it infers that health is an absolute or ultimate state. But all individuals cannot achieve the same level of health because of innate differences, some of us are born with severe physical and mental limitations. So according to WHO, the complete well-being for all is unattainable goal. Hence, the U.S. President's Commission stated, “health means an optimum state of physical, mental and’ social well-being.”
Terris M, a famous epidemiologist believes the WHO definition should be re-worded as “Health is a state of physical, mental and social well-being and ability to function and not merely the absence of ‘illness’ or infirmity.” Thereby replacing ‘disease’ by illness and excluding ‘complete’ as health is not an absolute. The addition of “and ability to function” is necessary, as a definition of health requires both objective and subjective components. The objective component being the “ability to function,” the subjective being “feeling of well-being.”
A singular definition, and one which returns more to Pericles’ version is that of the Liverpool School of Tropical Medicine: “Health is the achievement of a state of harmony between man's internal and external milieu.”
However, WHO's definition has the following characteristics that promote a more positive concept of health.
  1. A concern for the individual as a total system.
  2. A view of health that identifies internal and external environment.
  3. An acknowledgement of the importance of an individual's role in life.
Health is a changing, evolving concept that is basic to nursing. For centuries, the concept of disease was the yardstick by which health was measured. Now there has been an increasing emphasis on health. Health is very difficult to define. There is no consensus about any definitions of health. There is no consensus about any definitions of health. There is knowledge of how to attain a certain level of health, but health itself cannot be measured.
Health is described in various sources as a value judgment, a subjective state, a relative concept, a spectrum, a cycle, a process, and as an abstraction that cannot be measured objectively. In many definitions physiological and psychological components of health are dichotomised. Other subconcepts that might be included in definitions of health include environ­men­tal and social influences (economical or financial), freedom of pain or disease, optimum capability, ability to adapt, purposeful direction and meaning in life, and harmony, balance, or sense of well-being.12
Historically, health and illness were viewed as extremes on a continuum, with the absence of clinically recognisable disease being equated with the presence of health. In 1974 World Health Organiza­tion defined health in terms of total well-being and discouraged the conceptualisation of health as simply the absence of diseases. At the time, some considered this definition impractical; some viewed it as a possible goal for all people, while others consider complete well-being unobtainable. However this definition of health includes three characteristics of basic to a positive concept of health:
  • It refers concern for the individual as a total person rather than a merely the sum of various parts
  • It places health in the context of environment
  • It equates health with productive and creative living.
  • The harmonious balance of the state of physical, mental, social and spiritual well-being of the human individual integrated into his health and constitutes health.
The state of positive health implies the notion of “perfect functioning” of the body and mind. It conceptualise health biologically as a state in which every cell and every organ is functioning at optimum capacity and in perfect harmony with the rest of the body; psychologically, as a state in which the individuals feels a sense of perfect well-being and of mastery over his environment; socially, as a state in which the individual capacity for participation in the social system are optional, and spiritually, as state in which the individual which reaches out and strives for meaning and purpose in life.
The concept of perfect positive health cannot become a reality because man will never be so perfectly adapted to his environment that his life will not involve struggle, failure, and suffering positive health will therefore, always remain a mirage because every thing in life is subject to change. So health is a dynamic state of physical, mental, social, and spiritual well-being of an individual, not merely an absence of disease or infirmity.
More contemporary definitions of health have emphasized the relationship between health and wellness. Although health may be viewed as a static state of being at any given point of time, wellness is the process of moving toward integration of human functioning; maximisation of human potential; self-responsibility for health; greater awareness of self-satisfaction; and wholeness in body, mind and spirit.
 
ILLNESS, SICKNESS, AND DISEASE
Illness is a highly personal state in which the person feels unhealthy or ill. Illness may or may not be related to disease. An individual could have a disease, for example, a growth in the stomach, and not feel ill. Parsons defines illness as “a state of disturbance in the normal functioning of the total human individual, including both the state of the organism as a biological system, and of his person and social adjustments.”
Sickness is a status or social entity that is usually associated with disease or illness but can occur independently of them. When a person is defined as sick, several dependent behaviours are accepted that otherwise might be considered unacceptable. Bauman found that people use three distinct criteria to determine whether they are ill:
  1. The presence of symptoms, such as elevated temperature or pain.
  2. Their perceptions of how they feel; for example, good, bad, sick.
  3. Their ability to carry out daily activities, such as job or schoolwork.
Disease can be described as an alteration in body functions resulting in a reduction of capacities or a shortening of the normal life span. Disease may further be described as acute or chronic, communicable, congenital, degenerative, functional, malignant, psychosomatic, or idiopathic. Intervention by physicians has the goal of eliminating or ameliorating disease processes. Primitive people thought disease was caused by “forces” or spirits. Later, this belief was replaced by the single causation theory. Increasingly, a number of factors are considered to interact in causing disease and determining the individual's response to treatment.
The causation of disease is called its etiology. A description of the etiology of a disease includes the identification of all causal factors that act together to bring about the particular disease. For example, the tubercle bacillus is designated as the biologic agent of tuberculosis. However, other etiologic factors, such as age, nutritional status, and even occupation, are 13involved in the development of tuberculosis and influence the course of infection.
Risk factors are situations, habits, or other phenomena that increase a person's vulnerability to illness or injury. Risk factors can be categorized into five interrelated areas: genetic makeup, age, physio­logic factors, life-style, and environment: Examples of each follow:
  • Genetic makeup: A person with a family history of diabetes mellitus or cancer is at risk of developing the disease later in life.
  • Age: The risk of birth defects and complications of pregnancy increases after age 35; the risk of communicable disease is higher in school age children; and the risk of cardiovascular disease increases with age for both sexes.
  • Physiologic factors: Pregnancy places the fetus and mother at increased risk of disease; obesity increases the risk of heart disease.
  • Lifestyle or health habits: Overeating increases the risk of heart disease; smoking increases the risk of lung cancer; poor nutrition leads to several deficiencies; promiscuity increases the risk of sexually transmitted disease; excessive use of alcohol increases the risk of accident, liver disease, and disability; unabated stress increases the risk of accidents and illness; and certain activities such as skiing or mountain climbing increase the risk of injury.
  • Environment: Exposure to specific hazards, such as asbestos, rubber, and plastic, increases the risk of certain kinds of cancer; unclean, overcrowded living conditions predispose people to infections and other communicable diseases; air, water, and noise pollution all increase susceptibility to illness.
All of these risks present challenges to health care workers, especially nurses, in terms of prevention. Measures to enhance health include maintaining ideal body weight; eating regular meals with few snacks; elimination of cigarette smoking; moderation of alcohol consumption; safety measures, such as using seat belts, to prevent accidents and injuries; and periodic screening for such health problems as cancer.
Health field concept view, all causes of death and disease have four contributing elements: (a) human biologic factors, such as genetic makeup and age; (b) behavioral factors or unhealthy life-styles; (c) environmental hazards; and (d) inadequacies in the health care system. Using these four elements as a framework, a group of experts devised a method to assess the relative contributions of each of these elements to the ten leading causes of death. The results indicated that approximately 50% of deaths were due to unhealthy behavior or life-style; 20% to human biologic factors; 20% to environmental factors; and 10% to inadequacies in health care. These results have implications for nursing; the most important is that a substantial number of deaths could be avoided by efforts directed at health promotion and illness prevention.
Traditionally, medical practitioners have dealt with disease at a subsystem level. Subsystems are those aspects of the body subsystemed in the larger system of the whole body. A subsystem may be a cell, an organ, or an organ system. Only recently medical practitioners started looking at the person as an entity, or whole. Nurses, by contrast, have traditionally viewed the person as an entity, taking a holistic view of people. Nursing practice today is based on the multiple causation theory of health problems. Unemployment, pollution, lifestyle, and stressful events, while not disease, may all contribute to illness. These can be considered suprasystem problems, i.e., problems stemming from systems in which the individual is a subsystem. Thus, the concept of illness must include all aspects of the total person as well as the biologic and genetic factors that contribute to disease. Illness, then, is influenced by a person's family, social network, environment, and culture.
 
ILLNESS BEHAVIOUR STAGES
Illness behaviour is “any activity, undertaken by a person who feels ill, to define the state of his health and to discover a suitable remedy.” Illness behaviour depends on the way in which the person perceives illness, and it is selectively affected by multiple modifiers of patterning. For example, age, gender, occupation, socioeconomic status, religion, ethnicity, psychological stability, personality, education, meaning attached to symptoms, methods of coping with anxiety, attitude toward self, prior health-illness experiences, availability of resources, and degree, type, and duration of current stress situations are all factors that may be related to illness behaviour.14
Various scientists have described the stages of illness. By knowing these stages and the illness behaviors that accompany them, nurses can better understand their clients’ behaviour and determine ways to assist them. Illness behaviour is “any activity undertaken by a person who feels ill, to define the state of his health and to discover a suitable remedy.” How people behave when they are ill is affected by many variables, such as age, sex, occupation, socio-economic status, religion, ethnic origin, psychologic stability, personality, education and modes of coping. Such man describes five stages of illness as given below:
 
Symptom Experience Stage
The symptom experience stage is the transition stage during which people come to believe something is wrong. Either a significant person mentions that they look unwell, or people experience some symptoms, which can appear insidiously. The symptom experience stage has three aspects:
  • The physical experience of symptoms (e.g., pain or elevated temperature)
  • The cognitive aspect (the interpretation of the symptoms in terms that have some meaning to the person)
  • The emotional response (e.g., fear or anxiety).
During this stage, unwell persons usually consult others close to them about their symptoms or feelings. People validate with their spouses or support persons that the symptoms are real. At this stage, sick persons sometimes try home remedies, such as laxatives or cough medicines.
 
Assumption of the Sick Role
The second stage signals acceptance of tile illness. At this time, individuals decide that their symptoms or concerns are sufficiently severe to suggest that they are sick. Some people seek professional help quickly; others continue self-treatment, often following the suggestions of family and friends.
In this stage, sick people are usually afraid, but they now accept that they are ill even though they may not be able to accept the possible reasons. In conferring with people close to them, sick people seek not only advice but also support for the decision to give up some activities and, for example, stay home from work.
At the end of this stage, sick people experience one of two outcomes. They may find that the symptoms have changed and that they feel better. If family members support the perceptions of such persons, they are no longer considered or consider themselves sick. Then the recovered persons resume normal obligations, such as returning to work or attending a school concert.
If, however, the symptoms persist or increase and if lack of improvement is validated by the family or significant others, then sick people know they should seek some treatment. The choice of a treatment plan is often affected by the known available alternatives and previous experience.
 
Medical Care Contact Stage
Sick people seek the advice of a health professional either on their own initiative or at the urging of significant others. When people go for professional advice they are really asking for three types of information:
  • Validation of real illness
  • Explanation of the symptoms in understandable terms
  • Reassurance that they will be all right or prediction of what the outcome will be.
If the health professional does not validate illness, people have two recourses: to return to normal activities or to seek other advice. If the symptoms disappear, people often perceive that they really are not ill. If symptoms continue, people usually return to the health professional or go to a second person for care. People who are repeatedly told that they are not ill, may seek out quasi practitioners as a last resort to alleviate the perceived symptoms. Some people will go from health professional to health professional until they find someone who provides a diagnosis that fits their own perceptions.
Most people also want an understandable explana­tion of their symptoms. When symptoms are not explained, people may assume the health professional does not believe them or perhaps that they are imagi­ning the symptoms. Overly technical explanations, however, often confuse and frighten people.15
People often experience anxiety about seeking help with health problems. Even minor symptoms can be construed as serious. Therefore, clients need reassurance that they will be cured. Even when this reassurance cannot be given, most people want to know the likely outcome.
 
Dependent Patient Role Stage
When a health professional has validated that the person is ill, the individual becomes a client, dependent on the professional for help. During this stage, sick people may or may not be reluctant to accept a professional's recommendations. They may vacillate about what is best for them and alternately accept and reject the professional's suggestions. People vary greatly in the degree of ease with which they can give up their independence, particularly in relation to life and death. Role obligations—such as those of wage earner, father, mother, student, baseball team member, or choir member—complicate the decision to give up independence.
It is also common for the client and the health professional to hold different notions of the nature of the illness, unless complete and open communication exists. During this stage, a nurse can often provide information that may allay some fears and/or provide data that support the person. Misconceptions can result from limited information, which clients interpret in the light of their experiences. For example, a woman may be told by a physician that there is a small encapsulated growth in the right groin and that surgical removal is advised. If the woman's mother died after being told she had a growth in her breast, that person may assume that she also will die.
Most people accept their dependence on the physician, although they retain varying degrees of control over their own lives. For example, some people request precise information about their diseases, their treatment, and the cost of treatment, and they delay the decision to accept treatment until they have all this information. Others prefer that the physician proceed with treatment and do not request additional information.
During this period, sick people often become more passive and accepting. They require a predictable environment in which people are genuinely concerned about them. In addition to being concerned about themselves, some sick people regress to an earlier behavioral stage in their development. As a result, they may have fewer coping mechanisms (physical and emotional adaptive or defensive abilities). Frequently reactions are related to previous experiences and to misconceptions about what will happen.
People have varying dependence needs. For some, illness may meet dependence needs that have never been met and thus provide satisfaction. Other people have minimal dependence needs and do everything possible to return to independent functioning. A few may even try to maintain independence to the detriment of their recovery.
 
Recovery or Rehabilitation Stage
During this fifth stage, the client learns to give up the sick role and return to former roles and functions. For people with acute illnesses, the time as an ill person is generally short, and recovery is usually rapid. Thus, most find it relatively easy to return to their former life-styles. People who have long-term illnesses and who must make adjustments in life-style may find recovery more difficult. Recovery is particularly difficult for people who have to relearn skills such as walking or talking.
During this stage, readiness for social functioning may not coincide with physical readiness. People may be physically able to go out to dinner but find that functioning socially is still too stressful or they may find that they have the desire to perform activities but not the strength. Nurses can help clients function with increasing independence by planning with them those functions they can accomplish by themselves and those with which they need assistance, It is also important for nurses to convey an attitude of hope and to support the client's return to health.
 
SICK ROLE BEHAVIOUR
Sick role behaviour is “the activity undertaken by those who consider themselves ill, for the purpose of getting well.” Parsons describes four aspects of the sick role:
  1. Clients are not held responsible for their condition.
  2. Clients are excused from certain social roles and tasks.
  3. Clients are obliged to try to get well as quickly as possible.16
  4. Clients or their families are obliged to seek competent help.
Many Indians believe that illness, though undesirable, is beyond a person's control and that individuals are not responsible for incurring an illness, Some subcultures view illness as punishment from God, and therefore consider the infirm responsible for their illnesses, because of their sins, This folk belief persists to some degree in Indian society. A client may say something like, “What have I done to deserve this?” This remark reflects a sense that illness is a punishment. Today, because of the recognition that life-style contributes to illness and disease, some people–for example, the cardiac client who smokes or the overweight person who develops diabetes–are being held increasingly responsible for developing some illnesses.
Nurses can help clients by providing factual information and by not judging the client. It is important to encourage behaviors that promote health and not to reinforce behaviours that may have helped bring about an illness.
The sick person is usually excused from some normal duties. Social pressures on the sick and people's expectations of the sick usually depend on the prognosis and the severity of the illness. People who are severely ill and whose prognosis is poor or uncertain are permitted more dependence than people who are less seriously ill. People who are not seriously ill and whose prognosis is good are more likely to be encouraged to fulfill personal and social responsi­bilities. The person with a cold may still be expected to give a scheduled speech or to take an examination. People who are chronically ill may be permanently exempted from some duties or activities by society.
Some people may express feelings of guilt because they are unable to fulfill their normal responsibilities. Nurses can express support to clients who cannot fulfill their perceived roles and help them substitute other appropriate activities, when desirable. For example, a young father who cannot play ball with his son may be able to help his son build a model airplane, thereby fulfilling the father's role in another way.
Another aspect of the sick role is the obligation of the person to get well as quickly as possible. The sick role is a dependent one, at least in some respects. The person who fears dependence may be threatened by assuming a sick role and having to seek help. This individual might ignore advice despite the most serious consequences. Some people, however, find dependence gratifying, Some clients find dependence so satisfying that they perpetuate the sick role and do not try to get well or continue to complain of symptoms even after they are physically well. Some people in the dependent stage also find it satisfying to control others through excessive demands. With exceptions, people usually try to get well as quickly as possible.
Nurses can help clients assume a dependence appropriate to their developmental status and health. Part of the nurse's function is to reinforce both dependence and increasing independence at the appropriate times. For example, a man who is acutely ill may have to be shaved by the nurse; however, once he is stronger the nurse can assist him by providing shaving supplies and later complimenting him on his appearance.
An essential aspect of the sick role is seeking competent help. This presupposes that competent help is available to the client. It should also be recognized that the client's notion of competent help may be different from the general population's. For example, a man with a whiplash injury may become dissatisfied with his physician's treatment because of his slow recovery and may go to a healer who uses hypnotism. Or a domineering, talkative woman may reject advice to see a therapist and decide instead to join a cult of young people, considering the members of the cult competent help.
Nurses need to encourage some people to obtain competent heir from health professionals. Nurses who are aware of the health facilities available in a community can assist people to obtain care. People may require considerable support before seeking assistance because, for example, they fear the health problem might be serious or they believe competent help might not be available. A nurse's function in these instances is to provide accurate information about available health facilities while recognizing clients’ beliefs and their right to hold them.
 
EFFECTS OF HOSPITALIZATION
Normal patterns of behavior generally change with illness; with hospitalization, the change can be even 17greater. Hospitilization usually disrupts a person's privacy, autonomy, lifestyle, rules, and finances.
 
Loss of Privacy
When a client enters a hospital or nursing facility, the loss or privacy is instantly obvious. Privacy has been described as a comfortable feeling reflecting a deserved degree of social retreat. Its dimensions and duration are controlled by the individual seeking the privacy. It is a personal internal state that cannot be imposed from without.
People need varying degrees of privacy and establish boundaries for privacy; when these boundaries are crossed, they feel invaded. Hospital personnel sometimes show little concern for clients’ privacy. Clients are asked to provide information that often they consider private; they may share a roam with strangers; and their health is frequently discussed with many health professionals.
The boundaries of privacy are highly individual. The adult who lives alone may he used to privacy while eating, sleeping, and reading. A child from a large family may be accustomed to sharing these activities with others. It is important for nurses to ascertain what privacy means to the individual and try to support accustomed practices whenever possible.
 
Altered Autonomy
Autonomy is the state of being independent and self-directed without outside control. People vary in their sense of autonomy; some are accustomed to functioning independently in most of their life activities, while others are more accustomed to direction from others. An example of the Basanth is a writer who lives alone and works independently. By contrast, a wife in a patriarchal home may be accustomed to having decisions made by her husband and receiving direction from him.
Hospitalized people frequently give up much of their autonomy. Decisions about meals, hygienic practices, and sleeping are frequently made for them. This loss of individuality is often difficult to accept, and the client may feel dehumanized into “just a piece of machinery.” Nurses have a major responsibility to humanize care by learning about the client as a person and by individualizing nursing care plans.
 
Altered Lifestyle
Hospitalization marks a change in life style. Many hospitals determine when people wake up and when they sleep. The woman who normally rises at 8:00 a.m. and the man who usually works until 11:00 p.m. must change their habits. Food in a hospital is usually mass produced, and individual differences in taste are not always accommodated. Occasionally hospitals have relatively large populations from a particular culture and make special food arrangements. However, individual preferences are not always met.
Nurses can help clients adapt to life in a hospital in several ways:
  • Providing explanations about hospital routines.
  • Making arrangements wherever possible to accommodate the client's life-style, such as providing a bath in the evening rather than in the morning.
  • Encouraging other health professionals to become aware of the person's life-style and to support healthy aspects of that life-style.
  • Reinforcing desirable changes in practices with a view to making them a permanent part of the client's life-style.
 
Economic Burden
Hospitalization often places a genuine financial burden on clients and their families. Even though many people have health insurance, it may not reimburse all costs; in addition, many lose wages while they are hospitalized. Nurses can be aware of these costs and provide care that is as economical as is safely possible; for instance, they can use only the minimum supplies necessary for safe care. In some agencies, nurses may initiate referrals to the social service department to assist clients in making arrangements to address the financial burdens imposed by hospitalization. When this is not an independent nursing function, the nurse should consult with the client's physician to obtain such a referral.
 
EFFECTS OF ILLNESS ON FAMILY MEMBERS
A person's illness affects not only the person who is ill but also the family or significant others. The kind of effect and its extent depend chiefly on three factors: (a) 18which member of the family is ill, (b) how serious and long the illness is, and (c) what cultural and social customs that family follows.
The changes that can occur in the family include the following:
  • Role changes
  • Task reassignments
  • Increased stress due to anxiety about the outcome of the illness for the client and conflict about unaccustomed responsibilities
  • Financial problems
  • Loneliness as a result of separation and pending loss
  • Change in social customs.
Each member of the family is affected differently depending upon which member of the family is ill, because each plays a different role in the family and supports the family in different ways. Parents of young children, for example, have greater family responsibi­lities than parents of grown children.
The degree of change that family members experience is often related to their dependence on the sick person. For example, when a child is ill, there are few changes other than added responsibilities directly related to the child's illness. When the mother is ill, however, many changes are often necessary because other family members must assume her functions.
 
Sick Elderly Persons
When an elderly person is ill, a son or daughter often assumes the role of parent to the elderly person, providing housing, meals, and assistance with daily needs over a prolonged time. In other words, the parent-child roles are frequently reversed. This role reversal may be only temporary and may end when the illness ends, or it may become permanent.
The whole family, particularly the spouse of the sick person, experiences stress and concern about the outcome of the illness. Usually, the sick person's spouse feels a pending loss or separation most keenly. After a marriage of 50 at 60 years, elderly people may find it difficult to envisage what life will be like without a husband or wife. Younger persons in the family may deal with serious illness in an elderly person by stating, “He has led a good life” or “She had so much pain the past years.” In this way, the young prepare themselves for that person's death. This same reasoning is rarely applied to a child or younger adult who is ill.
When an elderly person is ill, adult sons and daughters may face conflicting responsibilities. A daughter who lives some distance away needs to maintain her job and look after her own family, but at the same time her parents need her in another city. How often should she visit? How should she fulfill her responsibilities? These questions pose problems for many families today who live far apart.
The financial problems of the sick elderly can be a major problem for a family as well as a community. Because illness in this age group tends to be chronic, the costs of illness are often considerable. The greatest change in life-style is that the family must now allot time for hospital visits to the elderly relative.
 
Sick Parents
When the sick person is a parent, the degree to which the family experiences change is related to the responsibilities the individual has and the number and age of dependents in the person's care. For example, when a father is ill for a long time, his roles are usually taken over by other members of the family, frequently the mother. Such tasks as doing chores in the house or attending a child's basketball games, for example, are either reassigned or not performed at all. Anxiety of family members about the outcome of a parent's illness is usually high, especially if the parent is a wage earner. The implications to the family of prolonged illness or death are great in almost all areas of living because of the needs of the dependents.
Prolonged illness of the mother can have equally serious consequences. Often the children do not understand why their mother is in the hospital, and they may feel lonely and unwanted. Sometimes the mother's functions are taken over by grandparents or by aunts and uncles as well as by the father. When a young mother has a serious illness of unknown outcome, the father and family face worrisome problems of how to manage over a long period of lime. Most arrangements have financial implications and involve role changes for the father and children. In this situation, the father must become both father and mother and give up many of his normal social activities. The children may also need to assume more housekeeping functions.19
 
Sick Children
Because a child is dependent on parents for so many daily needs, both sick children and their families may need to make fewer role adjustments than sick adults and their families. Task reassignments are also generally minimal. Sometimes a younger sibling takes over a paper route for a sick brother or sister, and other members of the family share the sick child's chores.
 
INFECTION AND INFLAMMATION
 
 
Infection
“Infection is a dynamic process involving invasion of the body by pathogenic micro-organisms and reaction of the tissues to organisms and their toxins.” Contamination is mere presence of organism at any site without invasion and without features of inflammation.
Process of Nosocomial (hospital) infection results from the transmission of pathogens to a previously uninfected patient from a source in the hospital environment which is also a cross infection. The pathogens may also come form the patient himself (autoinfection). He may be a carrier of the pathogen or may become contaminated with virulent hospital strains during stay in the hospital. Nosocomial infections are iatrogenic when the source is the attending physician or surgeon and the team or measures adopted viz. frequent or prolonged use of supportive procedures such as indwelling venous or urinary catheters, tracheostomy tubes, and equipments for respiratory care. Nosocomial infection increases morbidity, mortality, stay and expense of the patient and worriers of the relatives.
A surgical infection is an infection which requires surgical treatment of surgical treatment and essentially is a wound infection.
 
Causative Agent
A variety of organisms may be responsible for wound infections. Pathogenic bacteria infecting wounds are:
  1. Aerobic bacteria:
    1. Gram-positive cocci—Streptococci, and Staphylococci.
    2. Gram-positive bacilli—C. diphtheriae.
    3. Gram-negative bacilli – B. pyoscyaneus, E. coli, B. proteus.
  2. Anaerobic bacteria:
    1. Gram-positive cocci – Streptococci.
    2. Gram-positive bacilli – Clostridia tetani, Clostridia welchii, Clostridia botulinum, etc.
  3. Microaerophilic bacteria: Streptococci.
The micro-organisms commonly encountered in surgical infections are staphylococci, streptococci, clostridia, bacteroides, and the enteric bacteria.
 
Sources of Infection
The sources of bacteria which may come in contact with the wounds are:
  1. The air and dust.
  2. The nose, throat, mouth, skin of surgeon and the team.
  3. The skin and other focal septic sources of the patient.
  4. Materials used for toileting or dealing with the wound or in the operation field viz., instruments, swabs, threads, dressings etc. In traumatic wounds the source of infecting bacteria are patient's skin or clothing or foreign body. In surgical wound the infection begins in the operation room, the sources being poor aseptic technique (including steriliza­tion), excessive tissue trauma, incomplete hemostasis etc.
Mode of entry: Sexual or close contact, skin to skin contact, parenneral fluid, through oral and respiratory passage etc.
 
Effects of Infection
Mode of Entry: The injurious effect of infection is due to the released toxins by bacteria. They may be either exo or endotoxins. Exotoxins are specific soluble diffusible proteins produced by gram-positive bacteria during the growth of organism e.g., clostridia group, Streptococci, Staphylococci, C. diptheriae, Sh. Dysenterae, Endotoxins are produced by the organisms and are kept inside the body. These are liberated after their death e.g., Salmonella typhi, E.coli, bacteroides. Most of the common pathogenic organisms produce endotoxin.
All these toxins have both toxicogenic action and property of inducing production of antibody in the 20host. When these toxins are isolated and toxic property is destroyed they can be used to produce antibodies in the host after destroying their toxic property only. These are called toxoids. The effects of toxins may be local or general.
Effects: Local effects are due to (i) Increased vascularity, (ii) vascular thrombosis, (iii) Tissue oedema, (iv) Fibrinolysis, (v) Suppuration and (vi) Necrosis.
The general effects are due to bacteremia, toxaemia, septicaemia or pyaemia.
 
Inflammation
“It is the reaction which occurs in immediate response to irritation or injury usually manifested locally.” The aim is to neutralize or remove the irritant.
The classical features of inflammation are redness, swelling, heat, pain, and impairment or loss of function of that part.
Fever and chills indicate septicaemia, while elevated pulse rate is a sign of a toxic state.
Leukocytosis accompanies an acute bacterial infection more often than a viral infection. The more severe the infection the greater is the leukocytosis. In most infections the total leukocyte count is only slightly or moderately elevated.
 
Some common surgical infections and conditions:
Cellulitis is a nonsuppurative inflammation of the subcutaneous tissue.
Lymphangitis is an inflammation of lymphatic pathway. This is usually visible as erythematous streaking of the skin in fair complexion subject and is commonly seen in infection by haemolytic streptococci.
Erysipelas is an acute spreading cellulites and lymphangitis, usually caused by haemolytic strepto­cocci which gain entrance through a break in the skin.
An abscess is a localized collection of pus surrounded by an area of inflamed tissue. A furuncle or boil is an abscess in a sweat gland or hair follicle.
Impetigo is an acute contagious skin disease characterized by the formation of intraepithelial abscesses.
A curbuncle is a multilocular suppurative condition in the subcutaneous tissues. The nape of the neck, dorsum of trunk, hands and digits are common sites. It is also called infective gangrene. This is commonly seen in diabetic persons.
Most abscesses are caused by pyogenic cocci. Commonest is Staphylococcus aureus.
Bacteremia is defined as presence of bacteria in the circulating blood.
Septicaemia is the condition in which bacteria multiply in the blood stream e.g., Salmonella, E. coli, Ps. Pycocyneus, Streptococci, Staphylococci, Proteus etc.
Pyaemia is when pyogenic micro-organisms are carried in the blood stream in the form of bacterial emboli or as infected clots to different parts of body where these initiate multiple focal abscesses.
In toxaemia toxins are circulating in the blood e.g. in Diptheria, Tetanus and Dysentery.
 
ASEPSIS
Asepsis can be defined as exclusion of organisms from coming in contact with the wound or operation field. It is basis of modern surgery. Louis Pasteur is called the father of aseptic surgery as he was the first to discover presence of microbes in the air and contamination by them.
  1. Medical asepsis: Those practices by which spread of infection from a diseased person is prevented. All articles coming in contact with the patient are rendered free form pathogenic organisms but are not necessarily sterile.
  2. Surgical asepsis: Indicates that all objects coming in contact with the patient are absolutely free from all organisms pathogenic and non-pathogenic, including sporebearers.
Sepsis: It denotes presence of infection.
Antisepsis is killing of all organisms already present in the wound. J. Lister first started antiseptic measures by disinfection of sewage etc. with carbolic acid and is called the father of antiseptic surgery.
For carrying out proper asepsis and antiseptis several rituals have to be observed.
 
 
Methods of Asepsis
  1. Designing of operation theatre: It should be air-conditioned, dustless, well ventilated with planned circulation of air. Regular cleaning and disinfection 21of wall. Separate septic and aseptic operation theatres and standardized operation theatre complex.
  2. Movements in operation theatre: should be restricted.
  3. Over crowding in operation theatre has to be avoided.
  4. Nasal carriers should be detected and are not allowed to enter operation theatre.
  5. Surgical team should no handle infected wound, burns or colostomy wound before going for an operation.
  6. Proper cleaning (including paring of nails) or surgical team and putting on sterilized gowns, masks, caps, gloves etc.
  7. Proper preparation of the patient (vide pre-operative prep).
  8. Sterilisation of instruments.
  9. Sterilisation of drugs as and when necessary.
 
Methods of Antisepsis
  1. Local treatment of wound – by cleaning, debridement, excision, application of medicines in the form of powder, drugs, lotion, ointments, packs, drainage etc.
  2. General – Administration of drugs viz., antibiotics, chemotherapy (bactriostatic or bactericidal) etc.
 
Sterilisation
Sterilisation is killing of al sorts of micro-organisms including bacteria, viruses, spirochaete, fungi, parasites and spores.
Disinfection – is killing of all organisms except spores.
Disinfectant – is a chemical substance of germicidal nature used to kill pathogenic micro-organisms of inanimate objects.
Antiseptic – is also a chemical agent but differs from disinfectant in a sense that these inhibit growth of micro-organisms so long they are in contact with them.
 
Methods of destruction of bacteria
All pathogenic organisms can be destroyed by any of the following methods as given below:
 
Natural method
Sunlight: The heat of sunlight have a drying or dehydrating effect on the organisms which enables it to destroy the germs. This method is not effective unless the contaminated articles are exposed for 2-3 days continuously and hence is not usually applicable.
 
Physical method
  1. Dry heat:
    1. Electric (hot air oven) – By special electric ovens in the form of hot air at 121°C for 6 hours (commercial).
      Materials – Glasswares, vaselin, fats, talc, oils, carbon steel materials.
      Linen, rubber or plastic articles are not sterilized in this method.
    2. Flaming – Contaminated noninflammable articles are sometimes disinfected by smearing with methyllated spirit and then flaming. This method destroys only surface bacteria and can be used in case of grave emergency or when no other way of disinfection is possible, e.g., tray, blunt instruments.
    3. Burning or incineration – Contaminated articles of highly infectious diseased patients are burnt to kill the micro-organisms and prevent spread of infection, e.g., mattress, pillow, bed linens used by tetanus or gas gangrene patient.
  2. Moist heat:
    1. Boiling – This is one of the commonest method of destruction of micro-organisms. In this, bacteria are killed within 5 to 30 minutes e.g., syringe. Almost all instruments except sharp, rubber goods, silk, nylon, etc.
    2. Chemical method – Chemical substances, called disinfectants are also used to kill pathogenic organisms. The stronger the chemical the lesser is the time required for disinfection. Common disinfectants are Lysol, carbolic acid, formalin.
The choice and action of disinfectants depend on:
  1. The type of article to be disinfected e.g. metal, rubber, or linen.
  2. The nature and strength of agent used and its effect on the qualities e.g., effet of Lysol 1:20 and carbolic 1:40 and its stability in the presence of organic matter.22
  3. Time required for disinfection by the chemical to act effectively.
  4. Nature of solvent used and its temperature.
  5. Nature of contamination, the number and virulence of organisms.
  6. The cost of the chemical to be used.
For practical purposes – Two common methods are there for sterilization – chemical and heating. A combination of pressure and heat is undertaken for a special advantage that pressure increases heat and power of penetration is more. The different methods are briefly tabulized.
Autoclaving – For materials that will stand up to heat and moisture. In this method with increased pressure, temperature of water can be raised. This the most reliable method because of the power of penetration, microbiologic efficiency, easy control, and economy. 15lb pressure per sq. inch for 15-45 minutes at 121°C destroys al forms of organisms.
Materials sterilized – Almost all materials except glass wares, vselin, fats, talc, oils, etc.
There are two types:
  1. Those with gravity displacement of air.
  2. Those with high vacuum sterilizer.
Steam with – Formaldehyde at subatmospheric pressure sterilization is done at a temperature below 90°C at 10 lbs pressure for 10 mts. All spores are killed when formaldehyde vapour is used. It is a modified autoclave system.
Pasteurisation – Is the method where materials are sterilized in thermostatically controlled water bath at 75-80°C for 10 minutes, e.g. – Endoscope.
Irradiation – Gamma ray is used for sterilization in industry – Irradiation is from a cobalt 60 source or electron bormbardment from a linear accelerator.
Mateials sterilized – viz. disposable hospital supplies, plastic, syringes, sutures-catgut, etc.
Ethylene oxide gas – for heat labile article – This is also commercial.
Materials – delicate surgical instruments with optical lenses, plastic parts of heart lung machine etc.
Chemicals – common solutions used are iodine, Lysol, carbolic acid, hibitane, cetrimide 1%, 2% glutaraldehyde.
 
Materials
  1. For sterilization of living tissues catguts etc.
  2. Sharp instruments in pure Lysol for half an hour, etc.
 
ROLE OF NURSES IN SURGICAL SETTINGS
 
 
General Pre-Operative Nursing Care
This is preparing a patient for a surgical procedure. The pre-operative period is the time during which a person is prepared for surgery. This period varies in length and depends on the patient's condition. Surgery is a traumatic event for most patients. The better the patient is prepared and instructed for surgical procedure the easier is his post-operative course and the shorter is the convalescence.
Psychological consideration: Surgery is viewed as a crisis in life. Emotional responses to surgery may be manifested in various ways. Some patients may be talkative, some withdraw and some other may show non-adoptive responses. After assessing the patient carefully, appropriate nursing intervention can be planned.
A complete assessment of health status is a part of a preparation for surgery.
  1. The patient's age: The young and old are less able to cope with stresses.
  2. Nutritional, water and electrolyte status: Surgical risk is increased when the patient is malnourished and dehydrated.
  3. The presence of previous pathological condition: The nurse should observe the signs of disease.
  4. Special conditions affecting the surgical risk:
    1. Obesity – The surgical risk is higher than the patient with normal weight.
    2. Acute infection – An acute infection anywhere in the body requires a delay in surgery in most instan­ces to help prevent post-operative complications.
    3. Drug therapy – The drugs which have profound effect are hypoglycaemic, hypotensive, psychic, anticoagulants, steroids, etc. Continued use of anticoagulants may cause serious haemorrhage. Steroids also have serious effects on surgical patients.23
    4. Addiction – Alcoholism – Withdrawal symptoms may develop when a patient suddenly is deprived of alcohol during the surgical experience. In smoking post-operative pulmonary complica­tions are more.
    5. Wasting diseases – In diabetes mellitus the stress accompany the surgery may increase the need for insulin.
  5. Skin disease at the operative site should be treated prior to operation.
 
Nursing Intervention
The most important part in pre-operative management is health teaching. Teaching should include sharing information about purposes of various types of care the patient receives pre-operatively and post-operatively.
  1. Diaphragmatic breathing. This causes deep breathing and helps the patient ventilate thoroughly. It is carried out as follows:
    1. The patient lies on low Fowler's position, flexing knees and placing his hands over his lower rib cage and on sides of the abdomen.
    2. The patient exhales thoroughly, his ribs move downward with exhalation.
    3. Then he takes deepest breath.
    4. The patient holds the breath for 3-5 seconds after inhaling deeply.
    5. Then he exhales through pursed lips holding in a manner as though he will whistle taking double the time to inhale action. The patient is helped to practice this breathing twice a day for at least 15 times in each sitting.
  2. Coughing:
    1. The patient lies in Fowler's position or a side-lying position.
    2. The patient's hands are placed on the incision area to splint the surgical wound.
    3. The patient takes a deep diaphragmatic breath.
    4. After inhalation the patient is asked to make two strong coughs while keeping the mouth open, tongue extended and hands in position.
    5. The patient then takes another deep breath and gives two more strong coughs.
    6. The patient pratices coughing at least two or three times a day.
  3. Moving in bed:
    1. The patient is placed on back and is asked to flex on knee to about 45° to 90° and holding this position for a few seconds to extend the leg. This is done alternately. These exercise are repeated four to five times every 3-4 hours.
 
2. Legal considerations:
  1. The patient is placed must be told about the operative procedures, risk, possible complications and what disfigurement can occur.
  2. He should be informed what expect during post-operative period.
  3. Operative consent is to be taken from the patient, in the presence of witness. Parents or a guardian must sign for minor.
 
3. Psychological preparation of the patient and family:
Most of the patients fear for surgery. Common fears include fear of death, unfavourable diagnosis, disablement which may bring disruption in family lift etc. There is worry about anaesthesia, loss of self control and financial and employment limitations.
  1. The nurse should have knowledge of the type of surgery the patient is to undergo to guide for preparing the patient both psychologically and physically.
  2. The patient is to be given opportunity to discuss his fear and concern. It also includes listening to what is being said as well as nonverbal communication. Touch when used appropriately conveys the message of showing an interest in what the patient is experiencing.
  3. It is important to consider each patient as an individual person. Each will respond emo­tionally to a surgical experience in his own way.
  4. The nurse should also prepare family members for the special equipment needed in the care of the patient. She should offer emotional support to family members.
    1. Regular bath with soap or cleaning after admission.
    2. Maintenance of oral and general hygiene.
    3. Any infective fever should be treated.
    4. Bowel should move regularly.
    5. Fluid intake should be plenty. When necessary glucose drinks in large amount e.g., in jaundice.24
    6. Adequate diet followed by light diet in evening before operation and nothing by mouth on the day of operation is the standard method unless ordered specially
    7. Tranquiliser on the night before operation.
    8. Infants, children are old–age require special care. Infant and children are susceptible to infection; they tolerate fluid and electrolyte imbalance badly and they may have congenital disorders. The elderly are prone to have pulmonary, cardiovascular, urinary and liver disorders which should be taken care of.
    9. Pre-operative antibiotic administration to prevent risk of post-operative infection.
 
4. Preparation of the patient immediately pre-operatively:
  1. Skin preparation at the site of surgery – The area of the skin prepared is larger than the immediate area around the incision to reduce the chance of infection. Where applicable the hair in the operative area is shaved. Sterile dressing may be applied to the cleaned and shaved area.
  2. Administration of a cleansing enema as ordered because a full colon can cause contamination during surgery. The patient may have an involuntary bowel movement if the lower intestinal tract is not emptied while he is being anaesthetized.
  3. Checking of the vital signs. Any abnormality of vital sign should be reported promptly. Surgery may need to be cancelled if abnormalities are present.
  4. Removing of patient's valuables such as rings and wrist watch. Removing of dentures, contact lenses, artificial limbs and eyes, wigs, hair pin, clips and coloured nail polish. Braiding the long hair and putting on the hospital's cloth.
  5. The patient should void urine before going to operation theatre.
  6. Administration of the pre-operative medication at the time ordered.
  7. Completing the patient's record.
  8. Helping to move the patient in stretcher after checking the patient's identity.
  9. Accompanying the patient to the operative room and handing over the patient and records to be operation room nurses.
  10. Special preparations are given as ordered for some surgical conditions viz. cardiothoracic surgery, urosurgery, etc.
 
Preparation of Bad Risk Patients
This includes those patients who have
  1. Malnutrition.
  2. Vitamin deficiency.
  3. Anaemia.
  4. Hypoproteinaemia.
  5. Fluid and electrolyte intake.
  6. Obesity.
  7. Cardiac and respiratory diseases.
  8. Wasting diseases e.g., Diabetes, tuberculosis, cirrhosis of liver, rheumatic arthritis.
These should be treated as far as practicable.
 
General Postoperative Nursing Care
  1. Preparation of patient's room: Recovery room should be in the same floor. The furniture should be so arranged that stretcher on which patient is transported can be moved near the patient's bed.
    Preparation of the operation bed is done with clean linens. All equipments that may be necessary should be available viz. oxygen, suction machine, sphygmomanometer, infusion fluids and shock blocks, airway, emergency medicines etc.
  2. Maintenance of pulmonary ventilation: The patient should be in a position so that he can breath normally with full use of all portions of his lungs and that vomitus, blood and mucus can drain and will not be aspirated. They lying position on the side is preferred after the airway has been removed to facilitate drainage from mouth and nose.
  3. Maintenance of circulation and prevention of shock: As soon as the nurse is certain that the patient's airway is clear, she should check the blood pressure and pulse. The blood pressure, pulse and respiration are usually taken every 15 minutes for first 2 hours, then every half hour for another 2 hours and eventually every 4 hours until further orders. The rate, volume and rhythm of the pulse should be carefully observed and character and rate of respiration noted. A rapid 25thready pulse with sudden drop of blood pressure may indicate haemorr-hage or circulatory failure. The surgeon should be notified immediately. Oxygen may be given to increase its concentration in the available circulating blood
  4. Protection from injury: Following anaesthesia, side rails are usually placed on the bed and are left until the patient is fully awake. Hot water bottles, heating pads or heat lamps must be used with care while the patient is unconscious. When infusions are given, the patient's arm should be secured on an arm board so that needle is not dislodged. The patient should be turned frequently and placed in good body alignment to prevent –
    1. Nerve damage from pressure and
    2. Muscle and joint strain due to lying in the same position for a long period of time.
  5. Facilitate breathing and prevent hypostatic pneumonia: Frequent changing of position. Raise the head end of the bed as soon as the systolic B.P. rises to 100 mm. of Hg. Steam inhalation every 6 hourly.
  6. The nurse must check for soakage or bleeding. She should also look for tubes of any kind and connect them in drainage system as ordered.
  7. Maintenance of fluid and electrolyte balance: An adult requires about 2.5 litres and as much salt as contained in 1 pint of normal saline and 70 gm. of protein in 24 hours. This salt should be maintained when I.V. infusion is given.
    There should be complete and accurate intake/output charting in the post-operative period. All fluids, medications and treatments that the patient received during this time must be recorded so that there will be no duplication.
  8. The nurse can ascertain the return of reflexes and consciousness of the patient by asking him his name and others. The patient may be returned to his room as soon as his blood pressure is stable, he is breathing freely, not vomiting and fully awake.
  9. Retention of urine is a usual complain after perineal, rectal or hernia operation. An indwelling catheter pre-operatively introduced is safe, otherwise if conservative measures fail a self retaining cathether should be indwelled.
  10. Vomiting: This may occur after general anaesthesia. In abdominal operation if Ryle's tube is there suction prevents vomiting. Otherwise if needed may be introduced later. In other operations usually vomiting tendency passes off. Anitiemetics may be necessary.
  11. Oral hygiene: This is important to prevent parotitis, gingivitis, bad odour etc.
  12. Diet: It is advised depending on abdominal or extra-abdominal operations. In abdominal operations only water is first allowed till flatus is passed. In other water is first allowed till flatus is passed. In other conditions fluid is allowed after some definite period.
  13. Bowel: No purgative is advised in abdominal operations. Suppositories in some cases viz. appendicectomy and enema in selected cases viz., after cholecystectomy are advised after 4th or 5th day usually. In extra-abdominal operations it is usually not a problem.
  14. Ambulation: Nowadays, early ambulation is advised. This helps psychological, physical and physiological improvement.
  15. Wound care: Usually dressing is changed when a drain has been left or there is wound infection. Otherwise it is changed during stitch removal.
 
INTENSIVE CARE UNIT
 
ICCU and Role a Nurse in that Special Unit
ICCU is the acronym for Intensive Coronary Care Unit. The meaning of “Intensive” is close and maximum care to selected needy patients to over-come the crisis by watching the vital signs on the monitors and managing accordingly to save a life and to prevent further complication.
 
Physical Setup of ICCU
The bed strength of ICCU depends on the hospital's policy. The ideal setup should be oval shaped so that all the patients can be watched from the central monitoring system. All the beds should have glass partition covered with curtains.26
Bright lights should be avoided except in emer­gency. Attractive light, blue curtains can be used. In any case and quiet atmosphere should prevail in ICCU.
The nurse patient ratio should be 1 : 1, means one nurse for one patient. One doctor should be on duty round the clock in ICCU.
The nurses or doctors who are working in ICCU should not use outside shoes. Slippers should be provided. Masks should be used.
Each patient should have one bedside monitor which should be connected to the central monitoring system in the centre of the ICCU.
The central monitoring system should have –
  1. Monitoring scope or TV screen where all patients can be monitored together.
  2. Arrhythmia monitor – any type of arrhythmia can be monitored and recorded.
  3. Telemetry system of monitoring is the use of battery powered ECG transmitters that do not require direct connection of the patient to the oscilloscope.
Telemetry monitoring equipment is used in the ICCU as well as in the general medical surgical units for the ambulatory patients, hence the need for nurses to acquire some basic skills in rhythm interpretation.
A friendly behaviour towards the patient and their relatives is required.
 
Types of Patients Admitted in ICCU
  1. Cardiac:
    1. Acute myocardial infarction.
    2. Congestive cardiac failure, left ventricular failure.
    3. Pulmonary oedema.
    4. Heart block.
    5. After cardiovascular surgery.
  2. Others:
    1. Some post-operative patients with respiratory failure or shock of grave concern:
    2. Poisoning patients with respiratory failure.
    3. Some patients after neuro-surgical operations.
    4. Patients with cardiac arrest due to any cause.
 
Role of Nurse in ICCU
The nurse who is posted in ICCU, must have some knowledge of normal cardiac rhythm and cardiac arrhythmia for proper treatment and management.
  1. Functions of nurses in ICCU:
    1. Monitoring of cardiac activity.
    2. Meeting need for oxygen – By giving oxygen inhalation, keeping the airway clean, taking care of respirators, taking care of the tracheostomy tubes.
    3. Vital signs – Like regular checking of pulse, temperature and kidney function.
    4. Intake and output chart – To make sure of heart and kidney function.
    5. Proper medication – In time and correct dose recording on the nurses chart.
    6. Rest for the patient – mental and physical by ensuring calmness of the unit, comfortable bed etc.
      Mental rest – by medicines or injections.
    7. Special diet – Diet is very important – light and easily digestable diet to prevent extra burden on the heart.
    8. Lab. Investigations – Both general and special tests of blood, urine, stool, skiagram.
    9. Elimination – To keep bowel regular to avoid discomfort by giving mile laxatives etc.
    10. General physical care – Like backcare, mouth care, sponging etc.
    11. Ambulation – Doctors will instruct about the ambulation and gradual ambulation of the patient must be done.
    12. Daily reporting and recording of the patients condition, medication, rhythm strip etc. must be done so that the progress or deterioration can be determined.
    13. Proper identification of complication and treatment.
  2. Care of the operative wound if there be any.
 
Wound and Its Healing
Wound may be defined as distruption or break in the continuity of epithelial tissue. It may be revealed on the surface i.e., external or may be concealed (e.g., wound of a peptic ulcer). In common practice wound means external or visible wounds caused by injury.
 
Causative Factors
Commonly wound may be caused by trauma, inflammation, pressure (decubitus ulcer), diseases 27(ulcerative colitis), chemicals (corrosive), extensive heat etc.
 
Effects
Temporary loss of functions of all or part of the organ, haemorrhage, setting up of local and general inflammatory response, death of cells (necrosis), infection.
 
Types
  1. Depending on cause wounds are broadly classified as follows:
    1. Incised – Interruption of tissue is made with sharp cutting instrument e.g., knife, blade, edges of paper. The edges of this type of wounds are straight. So they can be brought in close approximation and healing is better. All operative wounds are incised wounds. If proper care is taken before making the wound and afterwards it heals well.
    2. Lacerated – Usually disruption of tissue occurs by trauma with jagged irregular edged machinery, vehicle accident, teeth or claws of animal. Skin margin is irregular. Visible bleeding is less but chances of getting contami­na­tion is very high. It is difficult to suture and takes more time to heal.
    3. Punctured – A deep narrow wound resulting from injury by a pointed instrument. Though the external opening of the wound is very small but internal tissues at variable depth can be injured.
    4. Contusion – Interruption in the continuity of a tissue is caused by trauma with a blunt object or blow or fall on a blunt object. Skin is not split and bruising of the surrounding tissue occurs. Underlying structures are likely to be damaged e.g., in crush injury.
    5. Abrasion – In this type superficial layer of skin gets scraped off as a result of sliding, fall or friction. A raw tender area results which can get infected very easily.
    6. Penetrating – Wound results from bullet or a stab. As the bullet penetrates and enters deep cavities it injuries internal organs followed by bleeding and infection. There may be point of entrance and point of exit. When both of them are there they are called perforating.
  2. Depending on state of contamination:
    1. Aseptic wound,
    2. Potentially infected wound,
    3. Infected wounds.
 
Complications
  1. Shock – This varies in degree according to the size and number of wounds, amount of blood loss general condition and age of the patient.
  2. Haemorrhage.
  3. Infection – Septic fever is caused by the absorption of the bacterial toxins from an infected wound and is characterized by a persistent high temperature and other local and general symptoms of acute inflammation.
  4. Aseptic traumatic fever – is due to absorption of ferment liberated from extravasated blood. The temperature may rise to 100° to 101°F on the second day after injury or operation but usually subsides within 48 hours.
  5. Traumatic delirium – Delirium may occur in alcoholic subjects after injury or operation.
 
Healing of Wound
Healing means replacement of lost tissue by viable tissue. Replacement may be by repair or regeneration. Usually two types are considered:
  1. Healing by first intention or primary union: This occurs in clean wound where there is no loss of tissue and minimum space is there between margins, e.g., incised wound.
    Healing takes place with minimum granulation tissue and minimum scar. This is achieved by proper asepsis, no soiling, no tension, thorough haemostasis and proper apposition of different layers.
    Acute inflammation set within first 24 hours. Plasma or serum exudation occurs into the wound which gets solidified and glues the edges together. The fibrin of the solidified plasma becomes infiltrated with fibroblasts which is due course gives rise to immature fibrous tissues. Appearance of collagen fibrils occur within 4-5 days after injury. Adjacent capillaries supply fresh blood. The immature fibrous tissue becomes organized and epithelia grow from the 28edges of the skin or mucus membrane migrate and cover the surface.
  2. Healing by second intention or secondary healing: When, there is loss of tissue to great extent or a gap is there between edges granulation tissue develops from the side and bottom of the wound and gradually the cavity or gap is filled up. Copious discharge or pus formation may be there. This needs to be drained and healing starts after all discharges have been drained. The wound is filled scab forms and epithelium grows from margin underneath the scab. There is organization of the clot. This is followed by wound contraction by progressive fibrosis and cicatrisation of the fibrosed scar.
    Healing by secondary suture – Occasionally called healing by third intention. When wounds are grossly infected and primary sutures are without any effect or sutures have been applied late a secondary suture is necessary.
 
Factors Affecting Healing (Table 1.1)
 
Favourable Factors
  1. Accurate apposition under aseptic conditions and rest to the pat.
  2. Aseptic wound produced by sterilized instruments, e.g. at operation.
  3. Proper sterilization all materials used.
  4. Aseptic and antiseptic measures for the wound and surrounding tissue specially skin.
  5. Proper haemostasis.
  6. Provision for exit of collection (if any) by drainage tube or sheet.
  7. Dressing of the wound to prevent contact with air or clothing.
  8. Application of heat to the part to improve circulation.
  9. Elevation of the part to promote venous return.
  10. Nutritious diet.
  11. Prophylactic antibiotics.
  12. Correction of any persistent general or local cause.
 
Retarding Factors
  1. General – Old age, anaemia, hypoprotenaemia, cachexia, poor general health, wasting diseases viz. diabetis mellitus, use of steroids and anti-coagulants, immuno compromised patient and patient with hepatic and renal dysfunction.
  2. Local –
    1. Defective operative technique.
    2. Contamination of the wound, defective closure and drainage of the wound.
    3. Ischaemia of the part, local malignancy, tissue tension, presence of foreign body, lack of rest.
 
Common Sources of Wound Infection
 
In Operation Theatre
  1. Lack of knowledge regarding asepsis.
  2. Infected surgeon, nurse and technician.
  3. Dust and foreign materials on O.T. furniture (inadequate) carbolization.
  4. Inadequate masking of nose and mouth, use of soiled clothing and shoes by operating team (improper cleaning of clothes), inappropriate scrub up.
  5. Improper cleaning of skin and improper draping.
  6. Long exposure and subsequent drying of skin edges and wound surface during an operation.
  7. Trauma to tissue by excessive clamping and manipulation, excessive handling and testing of suture materials.
  8. Prolonged hypotension during and soon after surgery due to poor tissue perfusion.
 
In the Ward
  1. Breaking principles of surgical asepsis while caring a wound.
  2. Lack of personal hygiene.
  3. Cross infection from other patients, relatives, doctors, nurse etc.
  4. Injudicious use of antibiotics.
  5. Use of contaminated articles, use of same article for many patient.
  6. Inappropriate care for drainage bottle etc.
 
Common Organisms of Wound Infections
A surgical wound may get infected by any of the following organisms–Staphylococus, Streptococus-haemolytic or non-haemolytic, Clostridia, Pseudomonus, E. Coli etc.29
Table 1-1   Factors Affecting Wound Healing
Factors
Rationale
Nursing Interventions
Age of patient
The older the patient, the less resilient the tissues.
Handle all tissues gently.
Handling of tissues
Rough handling causes injury and delayed healing.
Handle tissues carefully and evenly.
Hemorrhage
Accumulation of blood creates dead spaces as well as dead cells that must be removed. The area becomes a growth medium for organisms.
Monitor vital signs. Observe incision site for evidence of bleeding and infection.
Hypovolemia
Insufficient blood volume leads to vaso-constriction and reduced oxygen and nutrients available for wound healing.
Monitor for volume deficit (circulatory impairment). Correct fluid replacement as prescribed.
Local factors Edema
Reduces blood supply by exerting increased interstitial pressure on vessels
Elevate pate; apply cool compresses.
Inadequate dressing technique
Too small
Permits bacterial invasion and contamination
Follow guidelines for proper dressing technique.
Too tight
Reduces blood supply carrying nutrients and oxygen
Nutritional deficits
Protein-calorie depletion may occur. Insulin secretion may be inhibited, causing blood glucose to rise.
Correct deficits; this may require parenteral nutritional therapy.
Monitor blood glucose levels.
Administer vitamin supplements as prescribed.
Foreign bodies
Foreign bodies retard healing.
Keep wounds free of dressing threads and talcum powder from gloves.
Oxygen deficit (tissue oxygenation insufficient)
Insufficient oxygen may be due to inadequate lung and cardiovascular function as well as localized vasoconstriction.
Encourage deep breathing, turning, controlled coughing.
Drainage accumulation
Accumulated secretions hamper healing process.
Monitor closed drainage systems for proper functioning
Institute measures to remove accumulated secretions.
Medications
Corticosteroids
May mask presence of infection by impairing normal inflammatory response
Be aware of action and effect of medications patient is receiving.
Anticoagulants
May cause hemorrhage
Broad-spectrum and specific antibiotics
Effective if administered immediately before surgery for specific pathology or bacterial contamination.
If administered after wound is closed, ineffective because of intravascular coagulation.
Patient overactivity
Prevents approximation of wound edges. Resting favors healing
Use measures to keep wound edges approximate: taping, bandaging, splints. Encourage rest
Systemic disorders
Hemorrhagic shock
Acidosis
Hypoxia
Renal failure
Hepatic disease
Sepsis
These depress cell functions that directly affect wound healing.
Be familiar with the nature of the specific disorder. Administer prescribed treatment. Cultures may be indicated to determine appropriate antibiotic.
Immunosuppressed state
Patient is more vulnerable to bacterial and viral invasion; defense mechanisms are impaired.
Provide maximum protection to prevent infection. Restrict visitors with colds; institute mandatory hand hygiene by all staff.
Wound stressors
Vomiting
Valsalva maneuver
Heavy coughing
Straining
Produce tension on wounds, particularly of the torso.
Encourage frequent turning and ambulation and administer antiemetic medications as prescribed. Assist patient in splinting incision.
30
Most common is staphylo. Aureus – which are found on the skin and live and grow in sweat and sebaceous glands. Staphylo albus – are responsible for stitch abscess. Streptococci do not cause wound infection normally. But accidental wound might get infected by haemoloytic streptococci. The most dangerous organisms which might cause wound infection are clostridia which cause gas gangrene or tetanus.
 
Symptoms and Signs of Wound Infection
  1. Local: pain and tenderness. Warmth, erythema, edema and often purulent discharge.
  2. General: Fever tachycardia, leucocytosis. Patient may be in a toxic state.
 
Methods to Reduce Wound Infection
Certain measures if adopted in time brings down rate of wound infection to a great extent. The nurse has an important role in reducing rate of infection.
  1. The medical measures:
    1. To improve general health by nutritious diet, vitamins.
    2. To treat preoperative infection.
    3. To use antibiotics.
  2. Nursing measures are to be adopted at three levels– preoperative, operative and post-operative.
    • Preoperative measures
      • - To encourage patient and relatives for short hospitalization.
      • - To ensure that co-existant infection is treated before operation.
      • - Limited shaving.
      • - Shaving is to be done on the previous night usually.
      • - Repeated antiseptic cleaning.
      • - Prophylaxis antibiotic according to doctor's order.
    • Operative measure
      • - Meticulous cleaning and asepsis.
      • - Proper carbolization of O.T. including furniture, machine, floor.
      • - Adequate scrub up and use of properly clean, ironed clothings and shoes.
      • - To ensure that no powder remains on gloves.
      • - Proper draping and less handling of suture material.
      • - Prompt assistance so that operation time is minimized
      • - Proper haemostasis.
    • Postoperative measure
      • - Proper care of wound maintaining strict asepsis.
      • - Daily observation of the wound with or without dressing.
      • - Maintain personal hygiene, early ambula­tion, adequate fluid intake and nutritious diet.
      • - Hyperbaric oxygen.
      • - Wound drainage and debriderment.