Clinical Record Book of Medical-Surgical Nursing Himalayani Sharma
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Fundamentals of Medical-Surgical Nursing1

Medical-Surgical Nursing is the health promotion, health maintenance, health care, and illness care of adult patients with suspected or confirmed diagnosis of patho-physiological function. The care in this specialty is based on the knowledge derived from the amalgamation of arts and sciences, and shaped by the knowledge of nursing.
Today medical-surgical nursing is recognized as a specialty in a full-fledged manner and the focused practice areas are seen as sub-specialties like cardiovascular nursing, oncology nursing, orthopedic nursing and so on.
Irrespective of the type of health care service or setting medical-surgical nurse should be able to use the knowledge and skills with full competence and safety when providing the client care. Rapid development in technology, increase in knowledge, and transition in health care system demands medical-surgical nurse to practice the critical thinking skills to provide holistic and comprehensive patient care. To provide quality care, the nurse uses cognitive, technical, interpersonal, and ethical competencies essential to nursing profession.
Nature of Nursing
  1. Nursing is caring.
  2. Nursing is an art and a science.
  3. Nursing is holistic.
  4. Nursing is adaptive.
  5. Nursing is patient centered.
Aims of Nursing
Four aims of nursing practice are:
  1. To promote health
  2. To prevent illness
  3. To restore health
  4. To facilitate coping with death and/or disability.
Who are the Recipients of Nursing
Patient: Any sick person waiting or undergoing treatment and care at a health care agency.
Society: A group of people forming a community, and receiving a health care service.
Health is a state of being that people define in relation to their own value, personality and lifestyle. It is also the ability to maintain roles and responsibilities.
World Health Organization (1948) defines health as ‘a state of complete physical, mental, social and spiritual well-being and not merely an absence of disease or infirmity’. This is an all encompassing definition and perfectly places health on a higher pedestal in comparison to disease. This is also the most widely accepted definition among students.
Florence Nightingale states health as ‘being well and using to the fullest extent every power we have’.
An illness is the response of the person to a disease. It is an abnormal process in which individual's functioning capacity is generally lowered as compared to the previous level. Illness and illness behaviour are described according to individual perception.2
Disease is a medical term, meaning that there is a pathologic change in the structure or function of the body or mind. It process comprises of specific symptoms.
Always remember that an individual may have a disease but still achieve maximum functioning and quality of life.
Acute Illness
An acute illness has a rapid onset of symptoms and last for a shorter period and is self limiting in nature. Acute illness may prove fatal, some like common cold may not require any medical aid. It responds to self treatment or to medical-surgical intervention. A client with an acute illness has a full or rapid recovery. The patterns of acute illness behavior are: (i) temporary, (ii) reversible, (iii) pathology in one restricted body system, (iv) immediate short treatment plan, (v) achieving full recovery.
Chronic Illness
Chronic illness is a term that encompasses myriad lifelong pathologic or psychologic alteration in health. It includes: (i) Permanent, (ii) Nonreversible, (iii) Pathologic impairment in more than one body system, (iv) It requires long treatment plans, (v) Special rehabilitation training as well.
Disease Classification
Wellness is a state of well being. Wellness includes self-responsibility; a dynamics and growing process Well-being is a subjected perceptionof vitality and feeling well.
Wellness is defined as being equivalent to health. It is a dynamic state of optimal health in which an individual maximizes human potential, achieving an optimal balance between internal and external environment.
It integrates physical, intellectual, sociocultural, psychological and spiritual wellness.
During the entire tenure of service nurses work to promote wellness, and prevent illness. The top level of wellness should be the goal of every nurse and client.
Primary Prevention: Primary prevention is a true form of prevention; as it precedes disease or illness behavior. It is focused on health promotion activities such as exercise, dietary modification, immunization, health education programs as these are aimed at improving the general health of individuals, families and society at large.
Secondary Prevention: Secondary prevention focuses on individuals who have developed the disease and are at risk of developing complications or worsening conditions. It is directed at precise diagnosis and treatment and assisting the individual to resume normal level of health as early as possible.
Tertiary Prevention: Tertiary prevention is followed as a result of a disability or an irreversible damage to health. Activities at this level helps patients to achieve a higher level of functioning irrespective of the degree of disability or impairment.
Rehabilitation helps restore a person to the fullest physical, mental, social, vocational, and economic potential possible. Patients need rehabilitation after any kind of physical or mental illness or injury or substance abuse. Initial rehabilitation focuses on prevention of complications related to illness. As the patient condition improves rehabilitation helps to maximize the patient's functioning and level of independence.
Infection is the multiplication and invasion of a disease causing microorganism (pathogen) in the body tissue.
Inflammation is the basic pathophysiological reaction of the vascular and supporting elements of the cells or tissues which result in the formation of a protein rich exudates, 3and is caused by injury, provided the injury has not been so severe as to destroy the area.
Cardinal signs of inflammation are – Redness, heat, pain, swelling and exudate formation.
Atrophy is the reduction in size of an organ or part of it or tissues or of a single cell. Atrophy of an organ may be due to decrease in number of its structural units or in size of the individual units or both.
It may occur due to many reasons but few of them are: starvation, prolonged chronic infections, or senile changes, organ disuse.
Not always atrophy is pathologic in nature. In normal event organ atrophy takes place. Common examples are ovaries and breast atrophy after menopause.
Necrosis is the local death of cells without showing any signs of degeneration, still it is a part of living tissue. There is a loss of enzymatic and metabolic function. It may occur due to loss of blood supply, bacterial toxins or other factors like physical, chemical, radiation exposure.
Disturbance in Fluid, Electrolyte and Acid-Base Balance
Any kind of imbalance occurs when homeostasis mechanism is no more effective. Almost every organ and body system helps to maintain a homeostasis.
1. Acid-Base Imbalance
A respiratory disturbance alters the carbonic acid portion in the body.
Respiratory acidosis is the excess of carbonic acid in extracellular component. Respiratory acidosis is caused due to alveolar hypoventilation. The PaCO2 increases causing an excess of carbonic acid in the blood which decreases pH. The kidneys compensate by increasing metabolic acids secretion in the urine, causing increased blood bicarbonate levels.
Respiratory alkalosis is the deficit of carbonic acid in the extracellular fluid. Respiratory alkalosis arises from alveolar hyperventilation. The lungs start excreting excess of carbonic acid (CO2 and H2O). The PaCO2 decreases, which results in carbonic acid deficit in blood, which increases pH. Since respiratory alkalosis is mostly short lived; kidneys do not have time to compensate. If pH rises high enough CNS depression can set in. An increase in respiratory rate and depth causes CO2 loss at a faster rate than normal.
Metabolic acidosis occurs when there is an increase in metabolic acid or a decrease of base (bicarbonate). The kidneys do not excrete enough metabolic acid which accumulates in the blood or bicarbonate is removed from the body directly as in diarrheal conditions and the HCO3 decreases. Fall in pH stimulates the chemoreceptors so the respiratory system compensates for acidosis by hyperventilation. Metabolic acidosis is a proportionate deficit of bicarbonate in ECF (or acid excess) due to a gain of fixed acid or a loss of bicarbonate.
Metabolic alkalosis occurs when there is an increase in base (HCO3). The respiratory compensation for metabolic alkalosis is hypoventilation. The decreased rate and depth of respiration causes carbonic acid levels to increase in blood and increased PaCO2. Metabolic alkalosis is a primary excess of bicarbonate in ECF due to excessive acid losses or internal base retention.
2. Electrolyte Imbalances
Electrolyte imbalance refers to a deficit or excess of an electrolyte such as sodium, potassium, calcium, magnesium or phosphate.
Hypernatremia – Hypernatremia refers to an excess of sodium (Na) in ECF due to excessive water loss or an overall sodium excess. Hypernatremia, also called water deficit, is a hypertonic condition that makes body fluid too concentrated: loss of more water than salt or gain of more salt than water. It may occur in combination with extracellular volume deficit resulting in clinical dehydration. Due to increasing extracellular osmotic pressure fluid moves out of the cells.
Hyponatremia - Hyponatremia refers to a sodium deficit in ECF due to excessive water gain or an overall sodium loss. Hyponatremia is, also called water excess or water intoxication, is a hypotonic condition that makes body fluid too diluted: loss of more salt than water or gain of more water than salt. Due to increasing extracellular osmotic pressure, fluid moves out of the cells. Hyponatremia refers to a sodium deficit in ECF due to excessive water gain or an overall sodium loss. Due to increase in osmotic pressure, fluid moves in the cellular wall making it turgid.
Hyperkalemia – Hyperkalemia refers to excess potassium in ECF. Hyperkalemia is high potassium ion concentration in the blood. It is caused by shift of potassium from cells into the ECF, and increased potassium intake and absorption.
Hypokalemia - Hypokalemia is abnormally low potassium concentration in blood. This results from decreased potassium intake and absorption, and a shift of potassium from ECF into the cells. Hypokalemia can result in life- threatening weakened respiratory muscles and cardiac dysrythmias.
Skeletal muscles are the first to get affected by potassium deficit in the form of muscular weakness.
Hypercalcemia and hypocalcemia: Hypercalcemia refers to an excess of calcium in ECF. It quite often results in cardiac arrest, therefore it should be treated as an emergency. Hypocalcemia refers to a calcium deficit in ECF. 4Prolonged hypocalcemia results in Ca absorption from bones resulting in osteomalacia.
Hypermagnesemia and hypomagnesemia: Hypermagnesemia refers to excess of magnesium. It is specially seen in end stage renal disease when kidneys fail to excrete magnesium. Hypomagnesemia is the deficit in magnesium levels.
Hyperphosphatemia and hypophosphatemia: Hyperphosphatemia refers to an above normal serum concentration levels of inorganic phosphorus, it causes numbness, muscle spasm, tingling. Hypophosphatemia refers to a below normal serum concentration levels of inorganic phosphorus, it can result in seizure, acute respiratory failure.
3. Fluid Imbalances
Fluid volume deficit: Fluid volume deficit can be caused due to deficiency in the amount of both water and electrolytes in the ECF. This state is called as hypovolemia or dehydration. Due to changes in osmotic and hydrostatic pressure interstitial fluid is forced into the intravascular space causing the depletion of interstitial space. The fluid now becomes hypertonic and cellular fluid is now drawn into the interstitial space leaving the cells without adequate fluid to function effectively.
Fluid volume excess: Retention of water and sodium in ECF results in fluid volume excess. This state is called as hypervolemia. Retention of sodium increases extracellular osmotic pressure.
Shock is defined as a condition of acute peripheral circulatory failure due to derangement of circulatory function. It is evidenced in the form of hypotension, cold and clammy skin, tachycardia, anxiety, and disturbed mental equilibrium.
  1. Hypovolemic shock – Hypovolemia is encountered in sudden fluid loss through hemorrhage or the shift of fluid from vessels to the interstitial or intracellular spaces. There is reduction of effective circulatory blood volume, diminished venous return, low central venous pressure, tachycardia, reduced stroke volume, low cardiac output, drop in peripheral blood pressure and reduced oxygen delivery. If not managed it results in irreversible shock.
  2. Cardiogenic or central shock – Any disease producing acute cardiac failure is related to this kind of situation. The basic hemodynamic defect is great loss of myocardial strength, reduction in stroke volume, cardiac output, fall in blood pressure. Compensatory mechanism is activated resulting in sympathetic vasoconstriction, increased peripheral resistance, tissue underperfusion, low urine output, elevated lactate levels, fall in blood pH. Unless this crisis is controlled, the patient goes in ever deepening shock and dies.
  3. Irreversible shock – Whatever the type and cause of shock, unless the hemodyanamics and metabolic deterioration is controlled, there comes a stage when the patient condition is worst and is known as irreversible shock. It is evidenced by drastically reduced circulatory blood volume, resulting in tissue ischemia, acidosis, hypoxia, bacterial toxins (normally GIT contains bacterial flora) contribute to fall of arterial pressure. Damage to cellular membrane leads to leakage of lysosomal enzyme and intracellular ions and to cellular destruction.
  4. Toxic Shock Syndrome – Toxic Shock Syndrome (TSS) is an acute condition caused by exotoxins secreted by strains of Staphylococcus aureus. TSS is characterized by fever above 102° F (38.90), hypotension, erythematous rashes, multiple organ system injury. Prompt diagnosis and treatment and antibiotic therapy is crucial.
  5. Septic Shock – Septic shock is a state of widely disseminated infection in the bloodstream (i.e. septicemia). Initial septic shock begins with fever hypoxia, cloudy sensorium, hypotension, tachycardia, tachypnea. Treatment is with antibiotics, fluid volume replacement oxygen, diuretics, inotropic agents and heparin.
  6. Neurogenic Shock – Loss of vasomotor tone in peripheral blood vessels leads to sudden vasodilation and pooling of blood. Vasodilation causes hypotension. Causes may be brain hemorrhage, congestive heart failure, pulmonary edema, deep anesthesia, vagal reflex and emotional trauma.
Pain is a complex, multidimensional, elusive, subjective and personal experience. ‘Pain is whatever the experiencing person says it is existing whenever the person says he does’. Margo Mc Caffery, 1979).
Two basic categories of pain are generally noticed: acute pain and chronic pain.
  1. Acute pain – Acute pain lasts from few seconds to 6 months and has an immediate onset. It is described as ‘sharp’ ‘shooting’ and ‘stabbing’ kind. It is controllable with adequate treatment. It is accompanied by sympathetic over activity – (i) increased or decreased blood pressure, (ii) tachycardia (iii) diaphoresis (iv) tachypnea (v) focusing on the pain and (vi) glairing the painful part. Unrelieved acute pain leads to chronic state.
  2. Chronic pain – Chronic pain may be divided into three types:
    • Chronic nonmalignant pain, e.g. rheumatoid arthritis
    • Chronic intermittent pain, e.g. migraine headache
    • Chronic malignant pain, e.g. cancer pain
Chronic nonmalignant pain - Chronic nonmalignant pain lasts for more than 6 months. It is continuous and recurrent in nature. It is generally associated with concomitant disability like rheumatoid arthritis in which severe pain results in restricted mobility.5
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Fig. 1.1: Maslow's hierarchy of basis human needs
Chronic intermittent pain – Chronic intermittent pain refers to exacerbation or remission of the chronic illness. This pain occurs at particular periods and at other times the client is free from pain. For example, a variation in weather conditions may aggravate a particular kind of pain.
Chronic malignant pain – Malignant pain is also called cancer-related pain. It has the quality of both the acute and chronic pain. The diagnosis of cancer adds to an increased anxiety and the potential for impending death preceded by agonizing illness.
Basic Human Needs
Human being has both the physical and psychosocial needs. Abraham Maslow (1868-1954) developed a hierarchy of basic human needs. The basic human needs in the level of priority are (Fig. 1.1):
Role of Medical-Surgical Nurse
Caregiver: As a caregiver nurse combines the art and science of nursing in providing the comprehensive care to her patients.
Communicator: Effective use of communication skills helps maintaining relationship with different kinds of patients.
Teacher: Nurse uses teaching skills to meet the learning needs of patients and their families.
Counselor: Communication skills help share information about need based referrals and develop patient's problem-solving and decision making skills.
Leader: Nurse acts as a leader by being assertive and self confident when providing care and function in/with the group.
Researcher: Being a part of any research, project broadens its knowledge base and quality nursing care.
Advocate: The nurse protects human rights of all her patients based on the fact that patients have all the rights to make informed decisions about their own health and lives.