Liaquat University of Medical and Health Sciences

Jamshoro Sindh

Advance Concept of Nursing

Khairunisa
(BScN Year I)
College of Nursing, JPMC

Mrs. Ruth K. Alam

Liaquat University of Medical and Health Sciences
Jamshoro Sindh

Advance Concept of Nursing

Mussarat Begum
(BScN Year I)
College of Nursing, JPMC

Mrs. Ruth K. Alam

LIAQUAT UNIVERSITY OF
MEDICAL
AND HEALTH SCIENCE
JAMSHORO SINDH

Valvular Heart Disease

Ms. Capt. Dur-e-Yakhta
ACN II
Ms. Yasmin
 OBJECTIVES

By the end of this session the learners will be

able to:

1. Define Valvular Heart Disease.

2. Discuss etiology and pahtophysiology of
Valvular Heart Disease.
3. Identify signs and symptoms of Valvular
Heart Disease.
4. Describe the management of Valvular
Diseases.
5. Explain Nursing management in Valvular
Heart Disease.
6. Enlist Nursing intervention in Valvular
Heart Disease.
7. Know about preventing of Valvular Heart
Disease.
 1
VALVULAR HEART DISEASE
The heart valves when healthy keep blood flowing through the
heart an lungs in the proper unilateral direction.
Diseased valve may impede the flow of blood from one chamber
to the next (valvular stenosis) or they may allow blood to leak
(regurgitate) back into the chamber from which blood is being
pumped (valvular insufficiency or regurgitation).

Valvular Disease
1. Mitral valve stenosis/Regurgitation.
2. Aortic valve stenosis/Regurgitation.
3. Tricuspid valve/Regurgitation.
4. Mitral valve prolapse syndrome.

Mitral Valvular Disease

The mitral (bicuspid) valve lies between the left atrium and
ventricle. The mitral valve allows free blood flow forward, from
the left atrium to the left ventricle. Equally important, it prevents
backward flow from the ventricle to the atrium. Lesions of the
mitral valve either obstruct the flow of blood from atrium to
ventricle (stenosis) or allow blood to leak back from ventricle to
atrium (regurgitation). In either case, mitral valve lesions
overwork the left atrium.

Mitral Stenosis
Mitral stenosis is the commonest valvular lesion in people with
rheumatic heart disease.

Etiology

Mitral stenosis results in obstruction to left ventricular filling. It

must be differentiated from other (rare) conditions that impede
left heart filling such as LA tumors, thrombus and cor triatriatum,
and pulmonary vein stenosis.

Reheumatic fever – the most common cause of mitral stenosis,

which ultimately leads to retraction, scarring, thickening,
calcification, and immobility of the valve leaflets and subvalvular
apparatus. Two-thirds of cases of rheumatic mitral stenosis
occur in women.
 2

Other conditions – rare causes of mitral include:

• Mitral annulus calcification (elderly).
• Malignatn carcinoid syndrome.
• Systemic lupus erythematosus.
• Rheumatoid arthritis.

Congenital causes – in infants and children, mitral stenosis

occur as a result of congenital deformity of the mitral valve,
obstructing membranes, or abnormalities of the MV apparatus.

Pathophysiology
⇒ Valvulitis, from acute rheumatic infective endocarditis.
⇒ Leads to fibrosis and retraction of the valve leaflets.
⇒ The chordae tendinease contract and shorten and the
mitral commissures fuse.
⇒ As the valves become calcified and immobile, the valvular
orifice narrows, preventing normal passage of blood from
left atrium to left ventricle.
⇒ The left atrium hypertrophies to compensate for the
narrowed orifice.
⇒ Blood trapped in the atrium causes congestion and
pulmonary hypertension.
⇒ These conditions overwork the right ventricle, sometimes
leading to right ventricular failure. Inadequate filling of the
left ventricle (preload) sometimes results in reduced
cardiac output.

Diagnosis
Only 50% to 60% of patients may remember having had an
attack of acute rheumatic fever (ARF).
 3

Signs and Symptoms

1. Pulmonary Signs and Symptoms

a) Dyspnea

Dyspnea is the most common symptom.

⇒ With moderate mitral stenosis, dyspnea occurs in

settings that require increased cardiac output (CO)
(fever, anemia, pregnancy, exercise).

⇒ As mitral stenosis progresses, dyspnea occurs with

minimal exertion and eventually at rest.

b) Hemoptysis

Hemoptysis is caused by rupture of thin-walled bronchial

veins due to an acute rise in pulmonary venous pressure.
Hemoptysis may be massive and life-threatening. Other
causes of hemoptysis include pulmonary edema and
chronic bronchitis.

c) Hoarseness
Hoarseness due to compression of the left recurrent
laryngeal nerve by a dilated left atrium (LA) or pulmonary
artery (PA) (Ortner’s syndrome) is a rare symptom.

2. Cardiac Symptoms
⇒ Fatigue – is secondary to diminished CO.
⇒ Palpitation – is commonly the result of atrial arrhythmias.
⇒ Chest pain – occur in 10% to 15% of patients.
⇒ Systemic embolism – phenomena occur as a result of LA
body or appendage thrombus formation due to AF,
stagnant LA blood now, decreased CO, and LA dilatation.
Patients with suffering a systemic embolic event than do
patients with a normal MV in sinus rhythm.
 4

3. Physical Examination
⇒ Patients with a low CO have pink patches on the cheeks
(mitral facies).
⇒ Signs of systemic venous hypertension occur when RV
failure is present. These signs include:
• Jugular venous distention (a prominent V wave
suggests associated TR).
• Peripheral edema.
• Hepatomegaly.
• Ascites
⇒ An RV lift is palpable along the left sternal border when
significant pulmonary hypertension is present.
⇒ Sinus tachycardia or AF (more common) is present in
advanced cases.

Diagnostic Findings

Diagnostic Procedure Findings

Chest X-ray Left atrial enlargement; Pulmonary

venous congestion; Right ventricular
enlargement.

Electrocardiogram Left atrial hypertrophy; P-mitrale

(prolonged, notched P wave); Right
ventricular hypertrophy; Atrial
fibrillation.

Echocardiogram Thickened mitral valve with diminished

movement of leaflets; Left atrial
enlargement; Right ventricular
enlargement.

Cardiac Catheterization Increased pressure gradient across

mitral valve; Increased left atrial
pressure; Increased pulmonary
vascular resistance; Increased left
ventricular end-diastolic pressure
(LVEDP) preload); Increased
pulmonary artery wedge pressure
(PAWP); Decreased cardiac output.
 5

Management
1. Medical Therapy
a) Antibiotics

i) Rheumatic fever
Rheumatic fever antibiotic prophylaxis should follow
recommended guidelines.
ii) Infective endocarditis
Antibiotic prophylaxis for infective endocarditis is
necessary for all patients.
b) Diuretics and Sodium Restriction
Diuretic therapy and dietary sodium restriction are indicated
when pulmonary vascular congestion is present.
c) Treatment of Atrial Fibrillation
i) Digitalis
Digitalis is used to decrease the ventricular response to
AF.
ii) Beta Blockers and Calcium Channel Blockers
Beta blockers and Calcium channel blockers (verapamil,
diltiazem) are alternative agents that can be administered
in oral or intravenous form to slow the ventricular response
to AF.
iii) Warfarin
Long-term therapy sufficient to prolong the INR to 2.0 to
3.0 is recommended for patients with mitral stenosis and
chronic or paroxysmal AF to decrease the risk of
thromboembolic events.
2. Surgical Therapy
a) Valvular Surgery
Valvular surgery is another common operation. Indications
for this surgery include:
⇒ Progressive impairment of cardiac function due to scarring
and thickening of the valve with either (a) impaired
narrowing of the valvular opening (stenosis) or (b)
incomplete closure (insufficiency, regurgitation).
 6

⇒ Gradual enlargement of the heart with symptoms of

decreased activity, shortness of breath, and congestive
heart failure.
Today, surgeons can implant several different types of
valves. Valve prostheses are divided into two broad
groups:
i) mechanical prostheses and (ii) porcine bioprosthetic
valves. Commonly implanted mechanical prostheses
include:
• Caged-ball valve (Starr-Edwards): the most
extensively used valve.
• Eccentric monocusp or tilting disc valve.
• Caged-disc valve (Cooley-Cutter).
3. Intervention Therapy
Intervention therapy is indicated for the patient with moderate to
severe symptomatic mitral stenosis despite medical therapy
(NYHA class III and IV with mitral valve area <1.0cm2/m2).
a) Open Mitral Commissurotomy
Open mitral commissurotomy, performed with direct vision
on cardiopulmonary bypass, is indicated in the
symptomatic patient with moderate to severe mitral
stenosis whose valve is flexible and free of significant
calcification or regurgitation.
⇒ At surgery, the fused commissures are separated,
atrial thrombus is removed, and separation of fused
chordae or papillary muscles is performed.
⇒ This procedure is preferable to prosthetic mitral
valve replacement (MVR) because of lower
periopreative mortality, lower long-term morbidity,
and lack of requirement for long-term anticoagulation
if sinus rhythm is maintained.
Approximately 50% of patients require repeat surgery
(commissurotomy or MVR) within 10 years. After 10 years,
 the incidence of restenosis dramatically, requiring repeat
operation.
b) Percutaneous Balloon Mitral Valvuloplasty (PBMV)
Percutaneous balloon mitral valvuloplasty is an alternative
to surgical commissurotomy.
 7

c) Prosthetic Valve Replacement

Mitral valve replacement (MVR) is indicated in
symptomatic, severe mitral stenosis when he valve is not
amenable to open commissurotomy or percutaneous
balloon mitral valvuloplasty.
⇒ Mitral valve replacement is associated with greater
preioperative mortality and long-term morbidity
compared to other mitral procedures.
⇒ In most cases, mitral valve replacement requires life-
long anticoagulation.

Other Valvular Disorders

Valve Assessment Data Diagnostic Findings Nursing and

Disorder Medical
Intervention
Mitral Pansystolic, Chest X-ray: Antibiotic
regurgitation blowing, high- Left atrial and ventricular prophylaxis;
(Insufficiency) pitched murmur – at enlargement; Pulmonary Activity
apex, radiating to vascular congestion. limitations;
axilla; Weak-ness, Sodium
Electrocardiogram:
fatigue; Left restriction;
ventricular failure: Left atrial hypertrophy; Diuretics;
Dyspnea, orthopnea, P-mitrale; Atrial fibrillation; Digitalis;
PND, pulmonary Left ventricular Vasodilators;
crackles, S3 and S4; hypertrophy. Anticoagulation
Palpitations; Right Echocardiogram:
ventricular failure: Bizarre motion of mitral
Neck vein distention, leaflets; Hyperdynamic left
peripheral edema, ventricle; Enlarged left
hepatomegaly. atrium and ventricle.
Cardiac catheterization:
Increased left atrial
pressure; Increased
amount of regurgitant
flow; Rule out prolapse
and congenital disorders;
Increased left ventricular
end-diastolic pressure
(preload); Increased
pulmonary artery wedge
pressure; Decreased
cardiac output.
Continued
 8

Valve Assessment Data Diagnostic Findings Nursing and

Disorder Medical
Intervention
Aortic Systolic, harsh, Chest X-ray: Antibiotic
stenosis crescendodecrescendo Calcification of aortic prophylaxis;
murmur – right sternal valve; Left ventricular Digitalis;
border radiating to enlargement; Prominent Diuretics;
neck; Dyspnea, ascending aorta. Sodium
orthopnea, PND S3 and restriction;
S4; Fatigue; Vertigo and Electrocardiogram: Activity
syncope; Chest pain; Left ventricular restrictions;
Ventricular hypertrophy; Sinus Vasodilators;
tachycardia; tachycardia, atrial Oxygen (p.r.n.).
Bradycardia; Low pulse fibrillation; AV
pressure; Palpable conduction delay; Left
thrill at second right and right bundle branch
intercostals space block (BBB).
Echocardiogram:
Limited aortic valve
movement; Thickened
left ventricular wall.
Cardiac catheterization:
Increased pressure
gradient in systole
across aortic valve;
Decreased size of aortic
orifice; Increased left
ventricular end-diastolic
pressure.
Aortic Diastolic, blowing, Chest X-ray: Antibiotic
regurgitation decrescendo murmur – Calcification of aortic prophylaxis;
(insufficiency) left sternal border, valve; Left ventricular Digitalis;
increases with enlargement; Dilation of Diuretics;
inspiration; Loud S2; ascending aorta. Vasodilators;
Dyspnea, orthopnea, Sodium
PND; Fatigue, Electrocardiogram: restriction;
weakness; Syncope; Left ventricular Oxygen (p.r.n.);
Palpitations (water- hypertrophy; Sinus Activity
hammer pulse); tachycardia, PVCs. restrictions..
Pulmonary congestion, Echocardiogram:
S3 and S4; Sinus Dilated and
tachycardia, PVCs; hyperdynamic left
Wide pulse pressure; ventricle; Enlargement
Large and diffuse of aortic root and left
diastolic thrill, left atrium; Early closure of
sternal border; Neck mitral valve; Diastolic
vein distention, ankle fluttering of aortic valve.
edema; hepatomegaly,
ascites. Cardiac catheterization:
Decreased aortic
diastolic pressure;
Increased left
ventricular end-diastolic
pressure; Decreased
regurgitant flow; Reflux
through aortic valve.
 Continued
9

Valve Assessment Data Diagnostic Findings Nursing and

Disorder Medical
Intervention
Tricuspid Diastolic, rumbling Chest X-ray: Antibiotic
stenosis murmur – left sternal Right atrial prophylaxis;
border, increases with enlargement. Digitalis;
inspiration; Signs of Diuretics;
right ventricular failure: Electrocardiogram: Sodium
neck vein distention, Tall, peaked P wave – restriction.
peripheral edema, right atrial hypertrophy;
hepatomegaly, RUQ Atrial arrhythmias.
pain. Echocardiogram:
Thickening and
abnormal motion of
tricuspid valve.
Cardiac catheterization:
Increased pressure
across tricuspid
valvegradient in systole
across aortic valve;
Decreased size of aortic
orifice; Increased left
ventricular end-diastolic
pressure.
Tricuspid Same as for tricuspid Chest X-ray: Same as for
regurgitation stenosis Right atrial and tricuspid
(insufficiency) ventricular enlargement. stenosis.
Electrocardiogram:
Tall, peaked P wave;
Right ventricular
hypertrophy.
Echocardiogram:
Right ventricular
dilation; Paradoxical
septal motion; Tricuspid
valvular thickening and
abnormal motion.

Nursing Management in Valvular Heart Disease

1. Nursing Assessment
Nursing assessment involves gathering subjective and objective
data concerning (a) the type, severity and progress of the
valvular disorder; (b) the degree of heart failure; (c) the person’s
tolerance to activity; (d) the person’s support systems; and (e)
the degree of knowledge that the person and significant others
have concerning the nature of and intervention for the disorder.
 10

2. Nursing Diagnoses
Nursing diagnoses that may apply to people with valvular
disease include the following:

⇒ Alteration in cardiac output: decreased, due to valvular

abnormalities and/or arrhythmias.

⇒ Knowledge deficit regarding the nature of the valvular

disorder and its intervention.

⇒ Knowledge deficit regarding ongoing home self-care.

⇒ Decreased activity tolerance due to valvular dysfunction

and heart failure.

⇒ Anxiety due to the uncertain nature of the disease and its

intervention.

⇒ Coping deficit due to the chronic nature of the valvular

disease and activity limitations.

3. Nursing Goals
With appropriate and individualized interventions, the nurse can
facilitate accomplishment of the following goals and intervention
outcomes:

i) The person will maintain or restore hemodynamic stability,

as evidenced by clear lungs on auscultation, maintenance
of stable dry weight, urine output averaging greater than
30 ml per hour, no reported (or observed) dyspnea of
orthopnea, normal vital signs, regular heart rhythm,
absence of S3 and 4 heart sounds, and decreased or
absent peripheral edema.

ii) The person and/or significant others will demonstrate

understanding of the underlying valvular disorder and
prescribed treatment as evidenced by ability to describe
(a) the disease process, (b) factors contributing to
symptoms and (c) rationale for intervention. They will
actively participate in the prescribed health behaviors that
enhance success of intervention.
 11

iii) The person will demonstrate progression toward an

optimal level of physical activity tolerance, based on
underlying cardiovascular status and psychosocial
readiness. The person will demonstrate the ability to pace
activity, verbalize improvement in fatigue, and express
acceptance of any imposed activity restrictions.

iv) The person will show few behavioral and physical

symptoms of anxiety and will use anxiety relief techniques.

v) The person will use adaptive coping strategies, as

evidenced by the ability to recognize personal coping
patterns and identify appropriate support systems and
personal strengths.

Nursing Intervention
1. Nursing Diagnosis: Alteration in Cardiac
Output: Decreased, Due to Valvular
Abnormalities and/or Arrhythmias
 The main goal of nursing intervention for valvular heart
disease is to help the person maintain a normal cardiac
output, thereby preventing manifestations of heart failure,
venous congestion, and inadequate tissue perfusion.
 To evaluate the effectiveness of therapeutic interventions,
perform ongoing hemodynamic assessment.
 Monitor vital signs closely.
 A decrease in cardiac output manifests in a compensatory
rise in heart rate, a drop in blood pressure, or a decrease
in urinary output.
 Carefully auscultate the chest to identify the presence of
adventitious breath sounds (crackles, rhonchi) or heart
gallops (S3, S4).
2. Nursing Diagnosis: Knowledge Deficit
Regarding Ongoing Home Self-care
 Before discharge, prepare detailed learning/teaching
guidelines for the person and significant others concerning
the therapeutic regimen.
 Give information concerning prescribed medications.
 12

 Medications frequently prescribed include digoxin,

diuretics, potassium supplements, anticoagulants, and
prophylactic antibiotics.
 Clearly explain their rationale, dosages, side effects and
special considerations in their use.
 You must also review exercise prescriptions with the
person.
 Aortic stenosis often requires activity restrictions, whereas
other valve problems usually are self-limiting.
 In addition, address dietary restrictions, and plan
interdisciplinary follow-up.
 Make sure the person knows whom to call when questions
arise.

Preventing Valvular Heart Disease

Rheumatic heart disease, the most common cause of valvular
heart disease, is preventable. Community nurses working in
health care centers or schools can often detect individuals with
beta-hemolytic streptococcal infections (the precursor to
rheumatic heart disease). The nurse needs to refer these
individuals for appropriate diagnosis and intervention.

References
1. Nursing people experiencing cardiovascular structural
disorders; pp 991-1001.

2. Chung, EK and Tighe DA (1999). Valvular Heart Disease

In: Pocket Guide to Cardiovascular Diseases. Blackwell
Science Inc; pp 229-238.
 LIAQUAT UNIVERSITY OF
MEDICAL & HEALTH SCIENCES
JAMSHORO SINDH

Bladder Cancer

Farzana Kouser
(BScN Part I Student)

ACN-II

Mrs. Munira A. Ali

 Contents

Bladder Cancer

 Definitions

 Types

 Pathophysiology

 Etiology and Incidence

 Clinical manifestation.

 Investigation.

 Management.

 Nursing Diagnosis.

 Nursing Intervention

 References.
 1

BLADDER CANCER
Cancer

It is a general term to describe malignant growth in the

tissue of which carcinoma is of epithelial and sarcoma of
connective tissue, origin as in bone and muscle.
Types of Cancer
Cancer are classified by their microscopic appearance and
the body site from which they arise. The name of cancer is
derived from the type of tissue in which develops, most
common are:
1. Carcinomas (Cancer Tumor)
Malignant tumors arise from epithelial cells.
2. Melanomas (Melano-Black)
Cancerous growth of melanocytes, skin cell produces
pigment melanin.
3. Sarcoma
Any cancer arises from muscle cell or connective
tissues.
i) Osteogenic Sarcoma (Bone origin)
Destroy the bone tissues.
4. Leukemia
Cancer of blood.
5. Lymphoma
Malignant disease of lymphatic tissue.
 2

Pathophysiology

Cancer is disease process that began

Abnormal cell arise from normal body cell

Result from poorly understood mechanism of change

As disease progresses locally

Abnormal cell proliferate

Ignoring growth – regulating signals in the

microenvironment surrounding cell

Cell acquire invasive characteristics

Change occur surrounding the tissue

Cell infiltrates these tissue and access to lymph and blood vessels

By which blood transported metastasis

To other part of body

Cancer is not a single disease with a single cause rather it

is a group of distinct disease with different causes,
manifestations, treatments and prognoses.
 3
Bladder
Urinary bladder is a hallow muscular organ, which acts as a
reservoir.
Etiology
1. Cigarette smoking.
2. Carcinogens work environment such as dyes, rubber,
leather, ink or paint.
3. Coffee drinking.
4. Chronic parasitic infection.
Incidence
Age: More common after 50 years.
In man than woman (3:1).
Clinical Manifestions
 Hematuria.
 UTI.
 Producing frequency.
 Urgency.
 Dysuria.
 Alteration in voiding.
 Pelvic or back pain.
Investigation
 Urography.
 Tomography.
 Ultrasonography.
 Biopsies.
 4
Management
Treatment of Bladder cancer depends on the grade of
tumor.
1. Transurethral resection or fulguration (superficial
bladder cancer).
2. Chemotherapy.
3. Cystectomy.
Nursing Diagnosis
1. Alteration in urinary elimination pattern.
2. High risk for infection.
3. High risk for injury.
4. Alteration in nutrition.
5. Alteration in comfort (pain).
Nuring Intervention
1. Prevention of infection.
2. Prevention of injury related to bleeding disorder.
3. Maintenance of tissue integrity.
4. Relief of pain.
5. Decreasing fatigue.
6. Rehabilitation.
 5

References

 Smeltzer SC and Bare BG. Oncology: Nursing the

Patient with Cancer In: Brunner and Suddaraths
Text Book of Medical and Surgical Nursing.
7th Edition. JB Lippincott Co 1992.

 Tertora-Grabowski. Principles of Anatomy and

Physiology. 7th Edition.
Estimated Cancer Deaths by Site and Sex
Liaquat University of Medical & Health Sciences
Jamshoro Sindh

Diabetes Mellitus

ACN-II

Maqbool Ahmed
M. Farooq Saeed
Kamla Kumari
(BScN Part-I Students)

Mrs. Munira A. Ali

OBJECTIVES

At the end of this session the learners will be able to:

8. Define Diabetes mellitus.

9. Enlist types of Diabetes mellitus.

10. Describe pathophysiology.

11. Enlist causes of Diabetes mellitus.

12. Explain clinical manifestation of Diabetes mellitus.

13. Enlist investigation for diagnosis of Diabetes mellitus.

14. Manage Diabetes mellitus.

15. Explain complications of Diabetes mellitus.

16. Demonstrate sites of insulin administration.

17. Enlist nursing diagnosis of Diabetes mellitus.

18. Explain necessary nursing intervention regarding Diabetes mellitus.

 1

DIABETES MELLITUS

Definition

 Diabetes mellitus is a clinical syndrome characterized by hyperglycemia

due to absolute or relative deficiency of insulin.

 Diabetes mellitus is a group of chronic endocrine (pancreatic) metabolic

disorder caused by deficiency, absence or resistance to the action of insulin

characterized by hyperglycemia.

Types of Diabetes mellitus

The types of diabetes mellitus is describe by National Data Group in 1979 as

follow:

1. Type 1 or Insulin Dependent Diabetes Mellitus

In this type of diabetes, the beta cell of islet of Langerhans in pancreas could not

produce insulin. It occurs in any age, mostly before 30 years. It is also called

“Juvenile Diabetes Mellitus”.

2. Type 2 or Non-Insulin Dependent Diabetes Mellitus

It was formally called “Adult-Onset” or “Maturity-Onset” diabetes. In this type

insulin are present but there is a resistance to the biologic activity of insulin in liver

and peripheral tissues. This is mostly occurred after 35 years of age.

3. Diabetes Mellitus Associated With Other Condition or Syndrome

Secondary diabetes condition known or suspected to cause the disease like

pancreatic disease, hormonal abnormalities.

4. Gestational Diabetes
Gestational diabetes onset during pregnancy usually in the second or third

trimester due to hormones secreted by the placenta, which inhibit the action of

insulin.

Pancreas

The pancreas is a pale grey gland weighing about 60 grams. It is about 12 to 15 cm

long and is situated in the epigastric and left hypochondriac regions of the

abdominal cavity. It consists of a broad head, a body and a narrow tail. The head

lies in the curve of the duodenum, the body behind the stomach and the tail lies in

front of the left kidney and just reaches the spleen. The abdominal aorta and the

inferior vena cava lie behind the gland.

Structure

The pancreas is both an exocrine an endocrine gland. The exocrine part consists of

a large number of lobules made up of small alveoli, the walls of which consist of

secretory cells. Each lobule is drained by a tiny duct and these unite eventually to

form the pancreatic duct that extends the whole length of the gland and opens into

the duodenum at its midpoint. Just before entering the duodenum the pancreatic

duct joins the common bile duct to form the ampulla of the bile duct. The duodenal

opening of the ampulla is controlled by the sphincter of Oddi.

The islets of Langerhans are the endocrine part, consisting of groups of specialized

cells distributed throughout the gland. They secrete the hormones glucagon and

insulin. The islets have no ducts sot he hormones pass directly into the blood.
The pancreas in relation to the duodenum and biliary tract
Part of the anterior wall of the duodenum removed
 5

Physiology

1. Endocrine Pancreas Hormones

The endocrine pancreas produces hormones necessary for the metabolism and

cellular utilization of carbohydrates, proteins and fats. The cells that produce these

hormones are clustered in groups of cells called the “Islets of Langerhans”. There

are three different types of cells in these islets.

i) Alpha Cells

These cells produce the hormone “Glucagon”. Glucagon stimulates the

breakdown of glycogen in the liver, the formation of carbohydrates in the

liver and the breakdown of lipids in the liver and in the adipose tissue. The

primary function of glucagon is to decrease glucose oxidation and to

increase blood glucose levels.

ii) Beta Cells

Beta cells secrete the hormone insulin. Insulin facilitates the movements of

glucose across the cell membranes into cells, decreasing blood glucose

levels. Insulin prevents the excessive breakdown of glycogen in the liver

and in muscle, facilitates lipids formation, inhibiting the breakdown of

stored fats and helps move amino acids into cells for proteins synthesis.

iii) Delta Cells

These cells produce a substance called “Somatostatin”. Somatostatin is a

neurotransmitter, and inhibits the production of both glucogan and insulin.

Pathophysiology

Type 1 (IDDM)

Insulin dependent diabetes mellitus/Type 1 or Juvenile diabetes can occurs at any

age but most commonly before the age of 30 years. It is the result of the

destruction of the beta cells of the islets of the Langerhans. When beta cells are

destroyed, then insulin is no longer produced. The destruction of the beta cells is

result from a combination of three factors:

1. Genetic predisposition.

2. Viral or toxic chemical.

3. Autoimmune attack.

The disease develops in five stages.

i) Genetic predisposition.

ii) Environmental trigger.

iii) Active autoimmunity.

iv) Progressive beta cells dysfunction.

v) Overt diabetes mellitus.

1. Genetic Predisposition

There is a relationship between the occurrence of IDDM and genetic

predisposition. The general risk of IDDM ranges from 1 in 400 to 1 in 1000. The

children of a person with diabetes have 1 in 20 to 1 in 50 risks. The genetic

markers that determine immune response have been found in 95% of people

diagnosed with IDDM are DR3 and DR4 histocompalibality. Further, if the father

have DM, then the risk is 2.5%, if mother then 2%, if both then 15% and if sibling,

then 3%.
2. Viral or toxic chemical (Environmental)

The environmental factors precipitate rather than initiate the diabetes mellitus and

also trigger the development of DM. The triggers are infections as mumps, rubella

or coxsachie virus BA, or chemical toxin such as those found in smoked and cured

meats. An exposure to the virus or chemical, an abnormal autoimmune response

occurs in which antibodies respond to normal islet beta cells as though they were

foreign substances, destroying them. The symptoms of IDDM appear when about

90% of the beta cells are destroyed or in the acute stage of the process. When an

illness or stress increase the demand of insulin beyond the reserves of the damaged

cells.

3. Autoimmune Attack

(HLA-DR-3 and B-15 known to be associated with immune endocrinopathy are

found with increased frequency in IDD patient). There is a co-existence of IDDM

and other forms of autoimmune endocrinopathy such as adrenal insufficiency,

hoshimotois thyriditis, hyperthyroidism, pernicious anemia and collagen vascular

disease.

Type 2 (NIDDM)

There are two main problems related to insulin:

 Insulin resistance.

 Impaired insulin secretion.

Insulin Resistance

Insulin resistance to a decreased sensitivity of the tissue to insulin normality.

Insulin binds to special receptors on cell surfaces due to this binding a series of

reaction involved in glucose metabolism occurs with the cell.

Causes of Diabetes Mellitus

Type 1 is characterized by destruction of the pancreatic beta cell. Currently, it is

thought that a combination of genetic, immunologic and possibly environmental

factors contribute to beta cell destruction.

1. Immunological Factors

In diabetes, there is evidence of an autoimmune response. This is an abnormal

response in which antibodies are directed against normal tissue of a body.

2. Environmental Factors

It has been proposed that certain viruses or toxins may precipitate the autoimmune

process that leads to beta cell destruction.

3. Genetic Factors

Genetic factors are thought to play a role in the development of insulin resistance.

In addition, these certain risk factors that are known to be associated with the

development of type 2 diabetes is included.

Signs and Symptoms

Type 1 (IDDM)

♦ Hyperglycemia/Glucose urea.

♦ Polyuria.

♦ Polydipsia.

♦ Polyphagia.

♦ Weight loss.

♦ Malaise.

♦ Fatigue.

♦ Abrupt and rapid onset of hyperglycemia.

♦ Postural hypotension.
Type 2 (NIDDM)
♦ Slow onset of manifestation.

♦ Polyuria.

♦ Polydipsia.

♦ Polyphagia.

♦ Weight is mostly gained/obese.

♦ Blurred vision.

♦ Fatigue.

♦ Paresthesias.

♦ Skin infection (pruritis, vaginitis).

♦ Lack of energy.

♦ Delay wound healing.

Diagnostic Tests

Blood test is a major test, which is employed to diagnose the presence and severity

of diabetes and includes:

 Fasting blood sugar.

 Random blood sugar.

 Glucose tolerance test.

 Urine ketoacetosis (Urine test for glucose).

Management

There are three methods of management of diabetes.

1. Diet alone.

2. Diet and oral hypoglycemic drug.

3. Diet and insulin.

1. Diet

The patient of diabetes mellitus needs balance and special diet as mention below:

 Foods to be avoided altogether include sucrose, glucose and foods high in

sucrose/glucose.

 Carbohydrate foods to be eaten in moderation such as breads of all kinds,

rolls, scones, biscuits, crisp breads; breakfast cereals and porridge,

potatoes, peas, baked beans; all fresh and dried fruit; pasta, custard, thick

soups; ‘diabetic foods’, milk; meat, fish, eggs, cheeses.

 Foods, which can be eaten, as desired include green vegetables, clear soups,

meat extracts, tomato or lemon juice, tea and coffee.

 Beside this, routine should be made for regular exercise and daily walk to

induce weight loss and to reverse the insulin resistance.

2. Oral Hypoglycemic Drugs

These drugs are valuable in the treatment of patient with NIDDM who fail to

respond to simple dietary restriction. There are two groups of oral hypoglycemic

drugs.

a) Sulphonylureas - Non-obese.

b) Biguanides - Obese.
3. Insulin

Types of Insulin

a) Regular (R) (Humiten R)

i) Clear solution.

ii) Rapid onset.

iii) Short duration.

Indication

 New cases of diabetes with dehydration and or ketoacidosis.

 In emergencies e.g., ketoacidosis or surgical procedure.

 In all IDDM in combination with depot insulin.

b) Modified or Intermediate and long acting Insulin

(Mixtard – 70% N + 30% R)

i) Cloudy solution.

ii) Delayed onset.

iii) Prolong duration because insulin is pre-mixed with retarding agents e.g.,

protamine or zinc.

Indication

 In IDDM along with unmodified insulin.

c) NPH (N) Intermediate Acting (Isophane)

Sites of Injection

Any areas of the body with subcutaneous tissue may be used for injection of

insulin. The sites that allow the most rapid absorption are:

1. Abdomen (around umbilicus – 2 inch diameter).

2. Deltoid muscles.

3. Thigh.

4. Hip.

Sites of Insulin Injection

Preparation of Insulin

Administration of Insulin

1. Select site.

2. Clean with spirit swab.

3. While administrating insulin gently pinch a fold of skin and inject the

needle at 90 degree angle.

4. Do not massage after injected insulin.

5. Rotation of injection sites is recommended, distance about one inch.

Complications of Diabetes Mellitus

 Hypoglycemia.

 Hyperglycemia.

 Macrovascular disease.

 Microvascular disease.

 Retinopathy.

 Nephropathy.

 Coronary artery disease (Myocardial Infarction).

 Cardiovascular disease (Stroke).

 Peripheral vascular disease.

 Neuropathy (Nerve damage).

 Sensorimotor.

 Autonomic neuropathy.

 Foot ulcers.

Nursing Diagnosis

 Risk for injury.

 Anxiety.

 Fatigue.

 Ineffective management of therapeutic regimen.

 Risk for fluid volume deficit.

 Sexual dysfunction related to vaginitis.

 Altered nutrition.
Nursing Intervention

 Maintenance of fluid and electrolyte balance. Intake and output are

measured.

 Vital signs are monitored to detect signs of dehydration, tacychardia,

orthostatic, hypertension, etc.

 Correction of metabolic abnormalities, glucose monitoring is performed

before meal and at bedtime. Insulin is administered as ordered.

 In patient educational patient is taught survival skills including simple

pathophysiology, treatment modalities (insulin administration), monitoring

of blood glucose, urine ketones and prevention from complications.

 Regular visit to the physician.

 Teaching about appropriate preventive behavior (e.g., foot care and eye

care).

 Normal range of blood glucose, the patient should know it.

 Low literacy information is used as needed.

 Family should be instructed to assist in diabetic management.

References

 Smeltzen SC and Bare BG (1992). Text Book of Medical and Surgical

Nursing. Brunner and Suddarath (ed.). 7th Edition. JB Lippincott Co.

 Kumar PJ. Clinical Medicine. 2nd Edition.

 Edward CRW. Davidson’s Principles and Practice of Medicine. 16th

Edition.

 Andeoli, Plum and Smith. Cecil Essentials of Medicine. 2nd Edition.

 Schroeder SA. Current Medical Diagnosis and Treatment. 32nd Edition.

 Baunwald and Wilson. Harison’s Principles of Internal Medicine. 12th

Edition.
 LIAQUAT UNIVERSITY OF
MEDICAL & HEALTH SCIENCE
JAMSHORO SINDH

Health Perceptions / Management Pattern

Aster Ghulam
Mahmood Ahmed
Maqbool Ahmed
Rukhsana Perveen

ACN-I

Miss. Yasmin Parpio

 OBJECTIVES

By the end of this session the learners will be able 

to:

19. Define the terms health, wellness and illness.
20. Explain the Health Belief Model (HBM).
21. Identify the risk factors affecting health.
22. Describe   implementation   of   nursing 
measures   for   promotion   of   health   behavior, 
lifestyle and elderly care.
23. Explain   nursing   care   process   related   to 
altered health maintenance.
 1

Definitions

1. Health

Health   is   a   state   of   complete   physical,   mental   and 

social well being and not merely the absence of disease or 

infirmity (WHO 1947).

2.. Wellness

Wellness   is   a   level   of   well   being   in   which   a   person 

perceives of being healthy.

3. Illness

Illness is a highly personal state in which the person 

feels   unhealthy   or   ill.   Disease   alters   body   function   and 

results in a reduction of capacities or a shortened life span.

Models of Health and Wellness

Health  is  such a complex concept  for  which various 

researchers have developed models or paradigms to explain 

health and its relationship to illness or injury. Models help 

health professionals to meet health and wellness needs.
 2

Smith’s Model of Health

Judith Smith (1981) describes four models of health.

1. Clinical Model

Health is identified by the absence of sign/symptoms 

of   disease   and   injury.   When   sign/symptoms   disappear,   a 

person is considered healthy.

2. Role Performance Model

In this model a person is considered healthy if he can 

perform   work,   although   he   may   possess   any   potential 

problem (e.g., lung tumor).

3. Adaptive Model

In this model health is a creative process, disease is a 

failure in adaptation. The aim of treatment is to restore the 

ability to adapt and to cope.

4. Eu­daemonistic Model

When people fulfill their requirements and complete 

development   that   is   actualization.   Actualization   is   fully 

developed   personality.   In   this   model   health   is   seen   as   a 

condition   of   actualization   or   realization   of   a   person’s 

potential.
 3

Leavell and Clark’s (1965) Agent Host Environment

This is also called ecologic model. It is used to identify 

the risk factors that result from interaction of environment, 

host and agent.

1. Agent  –   any   environmental   factor   or   stressor, 

biochemical,   physical,   mechanical   or 

psychological.

2.  Host  – a person who is caused family.

3.  Environment   –   all   factors   external   to   the   host, 

climate, sound, economic.

Health Illness Continuum

a) Dunn’s High Level Wellness Grid

Dunn describes a health grid. The gird demonstrates 

the   interaction   of   environment   with   wellness­illness 

continuum.

i) High level wellness in a favorable environment – 

a person implements to support his lifestyle by 

using all resources.
 ii) Emergent high level wellness in an unfavorable 

environment – a person has knowledge but does 

not implement adequate self­care.

iii) Protected poor health in a favorable environment 

– an ill person (multiple fracture) or hypertensive 

who meets health care system.

iv) Poor   health   in   unfavorable   environment   e.g.,   a 

young   child   starving   in   a   drought   stricken 

country.

b) Travis Illness­Wellness Continuum

According to this continuum health is not a state but 

an   ability   to   function   with   different   levels.   Health   is 

dynamic process with one end to death and other to highest 

level of wellness and the individuals can place themselves at 

different   locations   at   one   point   a   time.   Just   like   different 

culture had their own norms and standards, health has its 

levels.

Illness­wellness Continuum

Wellness model

Death Wellness
Disability Symptoms Signs Awareness Education Growth
Neutral point
Treatment model
 5

Elder Client Problems and Care

Physiologic changes such as decreased vision, loss of 
hearing,   diminished   sense   of   smell   and   taste,   tooth   loss, 
poor   reflex   reactions,   memory   impairment,   skin   lost 
effectiveness as barrier, general hair loss, range of motion of 
joints   decreases   may   be   incontinence   of   urine,   food 
absorption disturbance and constipation may occur.

Nursing Care

Focus especially on known problems, check nutritional 
status,   disability   and   establish   supportive   relationship. 
Teach activities of daily living, any associated disease such 
as arthritis, COPD and CHF should be monitored carefully. 
Be careful when take a sample of specimen of elder client.

Smoking

Smoking is a dangerous and risky habit for health. It 
drains   economically   and   affects   the   respiratory   system, 
which may cause respiratory problems and lung cancer in a 
client. Many deaths occur in world due to smoking every 
year.

Teach a client the effects of smoking and its results in 
future.   Counsel,   if   a   client   is   interested   himself   to   stop 
smoking.
 6

Obesity
Obesity is a common problem of our society, which is 
a main cause of disease of cardiovascular system. Increased 
level of cholesterol suffers a client for it.

Provide   food   pyramid   guide   to   an   obese   client   and 

teach him to walk, jogging, and exercise and to participate 
social activities to control his weight.

Infection
Establishment   of   a   disease   process   that   involves 
invasion   of   the   body   tissue   by   microorganisms   and   the 
reaction  of  the  tissues  to  their  presence  and  to the toxins 
generated by them.

Infectious Agent
Bacteria, virus and fungi.

Mode of Transmission

Direct, indirect and airborne.

a) Direct   Transmission  –   by   coughing,   sneezing, 

kissing, sexual intercourse.

b) Indirect   Transmission  –   using   patient’s   utensils, 

clothes,   needles,   soiled   dressing,   contaminated 
food, water, by vectors.

c) Airborne  –   by   droplet   infection   like   tuberculosis, 

whooping cough, etc.
 7

Barrier to Infection

Body   is   protected   against   infection   by   immunities. 

Body’s   natural   immunity,   antitoxins,   vaccines   and 

phagocytosis.

Conditions Predisposing to Infection

1. Surgical   wound  –   microorganisms   can   enter   during 

post­surgical procedures.

2. Anti­bacterial Immune Mechanisms  – abnormalities 

limited,   prohibited,   synthesis   of   antibodies   against 

foreign bodies (microorganisms).

Entrance of microorganisms in these route can cause 

infection through procedures.

3. Respiratory Tract.

4. Genito­urinary Tract

5. Invasive   Drugs  –   contaminated   drugs   I/V   solutions 

can be infective cause.

24. Vein   Puncture   Site  –   I/V   canula,   syringe   can   enter 

bacteria to vein.
25. Implanted Prosthetic Devices – PPM shunts, etc.
 8

Standard Precaution to Control Infection

1. Hand washing before and after every procedure.

2. Gloves (sterilize).

3. Mask eye protection face shield.

4. Gown.

5. Linen   (clean,   dry   linen)   (remove   soiled   and 

contaminated linen).

6. Discard   syringe   needles   in   a   container   and   place 

contaminated articles in a leak proof bags/containers.

7. Place   client   in   isolation   room   if   have   communicable 

disease.

8. Prepare   a   sterile   field   e.g.,   an   operation   theatre   by 

fumigation by carbolizing, etc. and by supplying pre­

packed supplies.
Scenario

Zahid Ali age 54 years old admitted with a complaint 

of dyspnea and cough. He is a known asthmatic patient. His 

recent investigation report of CBC shows decreased Hb 4.0 

g/dl, WBC 3.7 and Plt is 49.

Nursing Diagnosis

 Altered breathing pattern.

 Altered health maintenance i.e., high risk for infection.

 Altered health maintenance i.e., high risk for injury.
 11

References

1. Erb and Kozier. Fundamental of Nursing. 5th  Edition. 

Blaise Wilkinsin California.

2. White L. Fundamental of Nursing. 1995
3. Smith and Duell.  Clinical Nursing Skills. 4th  Edition. 

Appleton and Lange 1996.
 Role Relationship Pattern 66
STANDARD NURSING CARE PLAN
TITILE: HIGH RISK FOR INFECTION
PATENT’S NAME: Zahid Ali
D.O.A. 10/10/2005
AGE:
54 Years
DIAGNOSIS: Anemia
C.R. NO.
65296
CO-MORBITIES: Asthma
WARD NO.
12
SIGN/DATE/TIME: M. Ahmed/10-10-05
BED NO.
15

Da Assessment Nursing Diagnosis Goal/Planning Nursing

te (Data Statement)
Subjective Data: Altered health mainten- Short-term Goals: • Check
10-10-2005

ance i.e., high risk for hourly.

infection related to Patient will be able to • Wash h
Objective Data: decreased WBC i.e., identify the measures after an
A male patient 54 years old looks pale, weak 3.7 x 103 secondary to to prevent infection wear gl
and with respiratory distess. disease process and within a day. • Encour
neutropnea mentar
Vital Sign: Long-term Goals: patient.
• Blood Pressure 90/70 mmHg • Patient
Till hospitalization
• Temperature 98 °F isolated
patient will remain
• Heart rate 96 per min free from symptoms of • Send a
• Respiratory rate 30 per min infection. reports
Patient will not • Give
Lab. Investigations develop complications proper
4 mg/dl prescrib
3.7 x 103 doctor.
• Hb
49 • Check
• WBC
orders
• Platelet
the pa
blood c
 Role Relationship Pattern 67

LIAQUAT UNIVERSITY OF
MEDICAL & HEALTH SCIENCES
JAMSHORO SINDH

Role Relation Pattern

Muhammad Farooq Saeed

ACN I

Miss. Yasmin Parpio

 Role Relationship Pattern 68

Role is a comprehensive pattern of behaviors that is socially recognized

provides a means of identification and placing an individual in a society. Role is an
interaction point between the individual and society. Roles are responsibilities
including roles in family, work and social relationship. There are three types of role
i.e., acquired roles, achieved roles and interdependent roles.
Family is a structured system of a relationship in which individuals are
bound to one another by complex, interlocking relationship. Such type of
relationship is also known as kinship system. There are several forms of family.
Nuclear family consists of husband, wife and children. Nuclear Dyad family
consists of Husband and wife alone. Single Parent family consists of one head of
household (mother or father). Single Adult Alone family emerged either by chance
or choice, divorce or death of a spouse. Three Generation family consists of three
or more generations living in a single house. In Kin Networking family, nuclear
household or unmarried members live in close geographical proximity. Institution
family depends on children in orphanages or residential schools (hostel), and
Homosexual family depends upon homosexual couple with or without children.
The primary relationship in family members are husband and wife, mother and
daughter, father and son, father and daughter, mother and son, elder and younger
brother, elder and younger sister or brother and sister.
A Genogram resembles a family tree, however, it includes additional
relationships among individuals. The advantages of Genogram uses are to permit
the therapist and the patient to quickly identify and understand patterns in family
history. To map out relationships and traits that may otherwise be missed on family
background chart. To include basic information about number of families, number
of children of each family, birth order and deaths. Some gonograms also include
information on disorders running in the family such as alcoholism, depression,
diseases, alliances and living situations.
The factors affecting role relationship in family include socioeconomic
condition, family dynamics, changing roles (of institution), and gender role
expectation, type of personality and communication skills.
The development considerations according to age in neonate and infant are
attachment behavior such as crying, smiling, clinging, following and cuddling.
Depends on parents for basic needs, reciprocal interaction between infant and
parents, feeling of fear in case of loneliness and behavior in despair. In specific
 Role Relationship Pattern 69

consideration, it includes fulfilling of basic needs, assess infants emotionally

especially when they are alone or in despair, understand crying process and
respond symbolic interaction. In toddler, it includes sense of right or wrong,
confirmation of social demands, depend of mother (parents) and starting of social
interaction. In preschooler, make friends of same sex, capable of internalizing the
social norms and tolerate brief separation of their parents. In terms of school age
child, learn social roles as male and female, enjoy school and peer interaction,
make friends of same sex, capability of expressing feelings, acknowledge
limitations, get allowance for increasing interest outside from the home. In
adolescent, dependence and interdependence, intensive relationship with opposite
sex, spend more time alone, peer and social interaction according to family needs.
Young adults, peak level of biophysical and cognitive skills, meaningful intimate
relationship, primary focus on establishment of family, marriage and parenting,
thinking involves reasoning, consider past experiences, education and possible
outcomes of a situation and learn how to deal with personal and desired needs of
others. In middle age adult, productive years for an individual, parenting role,
mostly secure in a profession/career, initiation of biological and physical changes,
accept the changes of age, prone to chronic diseases/illnesses and finally for older
adult, volunteer role (choice, demand), elder role modeling and depending upon
others.
Manifestation of altered family functions depends on stress, life
disturbance, impaired concentration, effectiveness of performance even at job,
decreased thinking capability and affected decision-making process. Mediators of
roles include role playing skills (symbolic interaction) and self-conception
(values/attitudes, body image, self-esteem and self-awareness about abilities). Role
relationship should be assessed by altered family process,, anticipatory grieving,
dysfunctional grieving, social isolation, impaired social interaction, impaired
verbal communication and altered role performance.
Nursing diagnoses can be made in terms of altered family process by the
state in which a family that normally function effectively experiences a
dysfunction.. A state in which an individual or family experiences a natural
response involving psychosocial, physiological reactions to an actual or perceived
loss (person, object, function, status, relationship) is known as grieving. It further
divided into anticipatory grieving and dysfunctional grieving. Anticipatory
 Role Relationship Pattern 70

grieving is the state in which an individual/group experiences reactions in response

to an expected significant loss or extended, unsuccessful use of intellectual and
emotional responses by which individual attempts to work through the process of
modifying self-concept based up the perception of potential loss. Dysfunction
grieving is the state in which and individual/group experiences prolong unresolved
grief and engage in detrimental (harmful) activities or extended, unsuccessful use
of intellectual and emotional responses by which individual attempts to work
through the process of modifying self-concept based up the perception of actual
loss.
Social isolation or aloneness experienced by the individual and perceived
as imposed by others and as a negative or threatened state. Impaired social
interaction is the state in which an individual participates insufficiently, excessive
quantity, or ineffective quality of social exchange. Impaired verbal communication
is the state in which an individual experiences a desired or absent ability to use or
understand language in human interaction, and altered role performance is
disruption in the way one perceives one’s role performance.
 Role Relationship Pattern 71

LIAQUAT UNIVERSITY OF
MEDICAL & HEALTH SCIENCE
JAMSHORO SINDH

Sexuality and Reproductive Pattern

Mukhtari Sardar
Nabeela Tabassum
Muhammad Yousaf

ACN

Miss. Yasmin Parpio

Role Relationship Pattern 72
 Role Relationship Pattern 73

OBJECTIVES

By the end of this session the learners will be able 

to:

26. Explain   pattern   description   of   sexual 

reproductive aspects of individual.
27. Enlist internal and external genital organs of 
male and female.
28. Define sexuality, sex and gender identity.
29. Describe types of sex.
30. Explain   sexual   concept   and   psychodynamic 
concern.
31. Enlist biological factors influencing sexuality.
32. Explain Nursing diagnosis and intervention.
 Role Relationship Pattern 74

Pattern Description
This   pattern   focuses   on   the   sexual   reproductive 

aspects   of   individual   over   the   entire   life   span.   Sexuality 

pattern involve sex male behavior gender identification and 

physiologic and biology function as well as the cultural and 

societal   expectations   of   sexual   behavior.   An   individual’s 

anatomic structure identifies sexual status, which determine 

the   social   and   cultural   responses   of   other   toward   the 

individual’s responsive behavior toward other.

Reproductive   pattern   involve   the   capability   to 

procreate,   actual   procreation   and   the   ability   to   express 

sexual feeling the success or failure of psychologically and 

physically   expressing   sexual   feeling   and   procreating   can 

effect an individual’s lifestyle, health and self­concepts.

The Nurse may care for client who, because of illness, 

violence or lifestyle experience alteration or disturbance in 

their   sexual   health   and   affect   their   sexuality   and 

reproductive pattern.
 Role Relationship Pattern 75

Internal and External Male and Female Genital Organs
The internal and external genital organs of male and 

female are:

Male Genital Organs Female Genital Organs

1.   Scrotum 1.   Labia majora

2.   Penis. 2.   Labia menora

3.   Perineum 3.   Vestibules

4.   Testes 4.   Glands of biathlon

5.   Epididymis 5.   Prepuce

6.   Vas deference (Ductus) 6.   Clitoris

7.   Seminal vesicles 7.   Vagina

8.   Ejaculatory ducts 8.   Uterus

9.   Prostate glands 9.   Fallopian tubes

10  Bulbourethral gland 10. Ovaries
      (Cowper’s)

11. Male urethra
 Role Relationship Pattern 76

Sexuality
Sexuality includes  all  of those aspects of  the human 
being   that   relate   specifically  to   being   boy   or  girl,   man   or 
woman.   It   is   subject   to   life   long   dynamic   change,   as   a 
function   of   the   total   personality.   It   concerned   with   the 
biologic,   psychologic,   sociologic,   spiritual,   and   cultural 
variable of life.
Sex
It is the term most commonly used to denote biologic 
male and female status balance. It is also used to describe 
specific sexual behavior such as sexual intercourse.
Gender Identity
It is the individual’s persisting inner sense o the being 
male or female. It is development based on biologic sex and 
socio­cultural   reinforcement,   which   is   being   at   birth   with 
identification of the baby as male or female.
Types of Sex
Biologic Sex
It   includes   the   entire   human   being   genetically 
determined   anatomy   and   physiology,   which   is   also 
influenced by intrauterine condition.
Sexual Identity or Sexual Orientation
It is the preference of a person for one sex or the other. 
Examples are:
1. Heterosexual  – one who is sexually attracted to persons 
of the opposite sex (straight).
2. Homosexual – one who is sexually attracted to persons of 
the same sex (gay, both sexes) and lesbian (woman).
 Role Relationship Pattern 77

3.   Rape  –   the  act   of   forcing   of   a  woman  who   has   sexual 

intercourse against her will.
4.   Gender   Role   Behavior  –   is   the   way   a   person   acts   as 
female   or   male,   including   the   expression   of   what   is 
perceived as gender appropriate behavior.
Sexual Concept
The development of sexuality begins with conception 
and   changes   throughout   the   life   span.   Every   society 
develops   expectations   about   acceptable   forms   of   sexual 
expression.
Psychodynamic Concern
It   is   dynamic   entity   that   changes   our   life   span 
sexuality   is   a   basic   human   characteristics   and   cannot   be 
separated from life events.
Biological Factors Influencing Sexuality
Many factors influence a person’s sexuality.
1. Developmental level.
33. Culture.
34. Religion.
35. Values.
36. Personal ethics.
37. Disease processes.
38. Medication.
 Role Relationship Pattern 78

Nursing Diagnosis
1. Sexual Dysfunction
It   is   defined   as   the   state   in   which   an   individual 
experiences a change in sexual function  that is viewed as 
unsatisfied unrewarding or inadequate.
2. Sexuality Pattern Altered
It is the state in  which individual  expresses  concern 
regarding his/her sexuality.
3. Rape Trauma Syndrome
Force   violent   sexual   penetration   against   the   victim’s 
will and consents the trauma syndrome.
Nursing Intervention
(Dysfunction)
a) Assess and monitor the patient and partner’s level of 
knowledge and understanding of his/her dysfunction.
b) Provide   the   patient   (couple)   with   privacy   and 
maintain confidently.
c) Provide   the   patient   with   a   safe   non­judgmental 
atmosphere.
(Pattern Altered)
d) Provide   the   patient   with   accurate   information   to 
increase the level of awareness.
e) Involve the couple in decision about the plan of care.
(Rape Trauma Syndrome)
f) Assess the rape belief pattern and educate as needed.
g) Provide psychotherapy and rape support groups.
 Role Relationship Pattern 79

Scenario

Razia Begum age 45 years old have difficulty in sexual 

desire and stated that, “I have irritation, burning and feeling 

uncomfortable   and   also   unsatisfied   in   sex.

I am depressed and felt change in my interest in others and 

myself. I am unable to achieved desired satisfaction.
 Role Relationship Pattern 80

STANDARD NURSING CARE PLAN

TITILE: UNCOMFORT SEXUAL PATTERN
PATENT’S NAME: Razia Begum
D.O.A. 10/10/2005
AGE: 45 Years
DIAGNOSIS: Sexual Dysfunction
C.R. NO. 67296
CO-MORBITIES: Nil
WARD NO.
SIGN/DATE/TIME: M. Yousuf/11-10-05
BED NO. 15

Da Assessment Nursing Diagnosis Goal/Planning Nursing Interven

te (Data Statement)
Subjective Data: Sexual dysfunction Short-term Goals: • Build the rela
10-10-2005

Patient verbalized that, “I have difficulty in related to sexual desire with patient.
sexual desire and have irritation, burning, and burning during Patient will have • Provide priva
feeling uncomfortable and also unsatisfied in sex. decrease complaint of expressing sexu
sex. I am depressed and change my interest sexual dysfunction • Provide
ourself and other and I am feeling. I am after 3 days. information on
unable to achieve desired satisfaction. of treatment on
Long-term Goals: function.
Objective Data:
• Use adequate am
Female patient 45 years old was admitted with Patient will have
water soluble lu
diagnosis sexual dysfunction change identify and know how
complaining of sex and change in sexual to manage sexual
desire and feeling uncomfortable the during dysfunction. • Use vaginal
sex eue to this she is not satisfied from sexual cream and ta
desire and looking depress. bath.
• Advised
Vital Sign: investigation,
• Blood Pressure 110/75 mmHg Urine C/S.
• Temperature 99.8 °F
• Heart rate 96 per min
• Respiratory rate 20 per min

Lab. Investigations
12 mg/dl
12 mg/dl
• Hb
• ESR