AKSUM UNIVERSITY

COLLEGE OF HEALTH SCIENCES

DEPARTMENT OF NURSING

MEDICAL NURSING PRACTICE GUIDE FOR 3RD YEAR REGULAR NURSING

STUDENTS

CONTENTS

 Approach of Nursing Health Assessment (Functional Health Pattern)

 Content of Group Seminar Presentation
 Main Activities of Medical Nursing
 Sample For Preparing Nursing Care Plan
 Sample For Writing Activity Report (Submitted at the end of each week)

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 Approaches of Health Assessment in Nursing

Functional Health Pattern

The North American Nursing Diagnosis Association (NANDA 1994) defines a nursing diagnosis
as “A clinical judgments about individual, family or community response to actual and potential
health problems and life responses”

It measures a person’s self care ability in the areas of physical health, activities of daily living,
nutritional status, and psychosocial status. This means organizing the entire assessment around
functional ‘‘pattern areas”. These include:-

1. Health Perception and Management Pattern

Determine how the client perceives and manages his or her health, compliance with
current and past nursing and, medical recommendations and the client's ability to
perceive the relationship between activities of daily living and health.
Subjective Data
Client's Perception of Health:
Describe your health.
Client's Perception of Illness
Describe your illness or current health problem.
Health Management and Habits
Tell me what you do when you have a health problem.
Compliance with Prescribed Medications and Treatments
Have you been able to take your prescribed medications?
If not, what caused your inability to do so?
Objective Data
Refer to General Physical Survey
Associated Nursing Diagnoses
Actual Diagnoses
Altered Growth and Development
Ineffective Management of Therapeutic Regimen
Risk Diagnoses

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 Risk for injury, risk for trauma
2. Nutritional and Metabolic Pattern
Assessing the client's nutritional-metabolic pattern is to determine the client's dietary
habits and metabolic needs. The conditions of hair, skin, nails, teeth and mucous
membranes are assessed.
Subjective Data
Dietary and Fluid Intake
Describe the type and amount of food you eat at breakfast, lunch, and supper on an
average day
Do-you take any vitamin supplements? Describe.
Do you find it difficult to tolerate certain foods? Specify.
Do you ever experience nausea and vomiting? Describe.
Do you ever experience abdominal pains? Describe
Condition of Skin
Describe the condition of your skin.
How well and how quickly does your skin heal?
Do you have any skin lesions? Describe-
Do you have any itching? What do you do for relief?
Condition of Hair and Nails
Have you had difficulty with scalp itching or sores?
Do you use any special hair or scalp care products?
Have you noticed any changes in your nails? Color Cracking? Shape? Lines?
Metabolism
What would you consider to be your "ideal weight"?
Have you had any recent weight gains or losses?
Do you have any intolerance to heat or cold?
Have you noted any changes in your eating or drinking habits? Explain.
Have you noticed any voice changes?
Objective Data
Assess the client's temperature, pulse, respirations, and height and weight.
Associated nursing diagnosis

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 Risk Diagnoses
Risk for Altered Body Temperature
Risk for Infection
Risk for altered nutrition less than body requirements.
Risk for Aspiration
Actual Diagnoses
Fluid Volume Deficit, Fluid Volume Excess, Altered Nutrition: Less than body
requirements, Altered Nutrition: More than body requirements, Ineffective Breastfeeding
Altered Oral Mucous Membrane, and Impaired Skin Integrity.
3. Elimination Pattern
It includes assessment of adequacy of the client's bowel and bladder, the client's bowel
and urinary habits, bowel or urinary problems, and use of urinary or bowel elimination
devices.
Subjective Data
Bowel Habits
How frequent are your bowel movements?
Do you use laxatives? What kind and how often do you use them?
Do you use enemas or suppositories? How often and what kind?
Do you have any discomfort with your bowel movements? Describe.
Bladder Habits
How frequently do you urinate?
What is the amount and color of your urine?
Do you have any of the following problems with urinating: Pain? Blood in urine?
Difficulty starting a stream? Incontinence? Voiding frequently at night? Voiding
frequently during day? Bladder infections?
Have you ever had a urinary catheter? Describe. When? How long?
Objective Data
Refer to abdominal assessment, and the rectal assessment.
Associated nursing-Diagnoses
Actual Diagnoses
Altered Bowel Elimination

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 Constipation
Diarrhea
Bowel Incontinence
Altered Urinary Elimination Patterns of Urinary Retention
Total Incontinence
Stress Incontinence
Risk Diagnoses
Risk for constipation
Risk for altered urinary elimination
4. Activity and exercise pattern
An assessment is made of any factors that affect or interfere with the client's routine
activities of daily living which includes routines of exercise, leisure, and recreation.
Activities necessary for personal hygiene, cooking, shopping, eating, maintaining the
home, and working should be asked.
Subjective Data
Describe your activities on a normal day. (Including hygiene activities, eating activities)
Do you have difficulty with any of these self-care activities? Explain.
Does anyone help you with these activities? How?
Do you use any special devices to help you with your activities?
Does your current physical health affect any of these activities e.g. dyspnea, shortness of
breath, palpations, chest pain. pain, stiffness, weakness)? Explain.
Occupational Activities
Describe what you do to make a living.
Do you feel it has affected your health?
How has your health affected your ability to work?
Objective Data
Refer to Thoracic and Lung Assessment
Cardiac Assessment
Peripheral Vascular Assessment
Musculoskeletal Assessment
Associated Nursing Diagnoses

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 Risk Diagnoses
Risk for Disorganized Infant Behavior
Risk for Peripheral Neurovascular Dysfunction
Risk for altered respiratory function
Actual Diagnoses
Activity Intolerance
Impaired Gas Exchange
Ineffective Airway Clearance
Ineffective Breathing Pattern
Disuse syndrome
Impaired Physical Mobility
Inability to Sustain Spontaneous Ventilation
Altered Tissue Perfusion
5. Sexuality-Reproduction Pattern
Subjective Data
1- Female
Menstrual history:
Last cycle begin?
Duration?
Any change or abnormality?
Describe any mood changes or discomfort before, during, or after your cycle
Obstetric history
How many times have you been pregnant?
Describe the outcome of each of your pregnancies.
If you have children, what are the ages and sex of each?
Explain any health problems or concerns you had with each pregnancy. If pregnant now .
Contraception
What do you or your partner do to prevent pregnancy?
Describe any discomfort or undesirable effects this method produces.
Have you had any difficulty with fertility? Explain
Special problems

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 Do you have or have you ever had a sexually transmitted disease? Describe.
Describe any pain, burning, or discomfort you have while voiding.
Objective Data
Refer to Breast Assessment, Abdominal Assessment, and Urinary and Reproductive
Assessment.
Associated nursing Diagnoses
Risk-Diagnosis
Risk for altered sexuality pattern
Actual Diagnoses
Sexual Dysfunction, Altered Sexuality Patterns
6. Sleep-Rest Pattern
Subjective data
Sleep Habits:
How would you rate the quality of your sleep?
Special Problems
Do you ever experience difficulty with falling asleep? Remaining asleep? Do you ever
feel fatigued after a sleep period?
Sleep Aids
What helps you to fall asleep? medications? reading? relaxation technique? Watching
TV? Listening to music?
Objective Data
1. Observe appearance
a. Pale b. Puffy eyes with dark circles
2. Observe behavior
a. Yawning
b. Dizzying during day
c. Irritability
d. Short attention span
Associated nursing Diagnoses
Risk Diagnosis
Risk for sleep pattern disturbance

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 Actual Diagnosis:
Sleep Pattern Disturbance.
7. Sensory-Perceptual Pattern
Subjective Data
Describe your ability to see, hear, feel, taste, and smell.
Describe any difficulty you have with your vision, hearing, and ability to feel (e.g., touch,
pain, heat, cold), taste (salty, sweet, bitter, sour), or smell.
Pain Assessment
Complete Symptom Analysis
Special Aids:
What devices (e.g., glasses, contact lenses, hearing aids)
Describe any medications you take to help you with these problems.
Objective Data
Refer to the section on Nose and Sinus Assessment, Eye Assessment, and Ear
Assessment.
Associated Nursing Diagnoses
Risk Diagnoses
Risk for pain
Actual Diagnoses
Pain
8. Cognitive Pattern
Subjective Data
Ability to Understand:
Explain what your doctor has told you about your health.
Ability to Communicate:
Can you tell me how you feel about your current state of health?
Ability to Remember:
Are you able to remember recent events and events of long ago? Explain.
Ability to Make Decisions:
Describe how you feel when faced with a decision.
Objective Data

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 Refer to the Mental Status Assessment
Associated nursing Diagnoses
Risk Diagnosis: Risk for altered thought processes
Actual Diagnoses:
Acute confusion
Chronic Confusion
Knowledge Deficit (Specify)
Impaired Memory
9. Role and Relationship Pattern
Subjective Data
Perception of Major Roles and Responsibilities in Family
Describe your family.
Are there any major problems now?
Perception of Major Roles and Responsibilities at Work
Describe your occupation.
What is your major responsibility at work?
Perception of Major Social Roles and Responsibilities
Describe your neighborhood and the community in which you live.
Objective Data
1. Outline a family genogram for your client.
2. Observe your client's family members.
Associated Nursing Diagnoses
Risk Diagnoses:
High risk for Loneliness
Risk for Altered Parent/Infant/Child Attachment
Actual Diagnoses:
Impaired Verbal Communication
Impaired Social Interaction: Social Isolation
10. Coping-Stress Tolerance Pattern
Subjective Data
Perception of Stress and Problems in Life

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 Describe what you believe to be the most stressful situation in your Life.
How has your illness affected the stress you feel?
Coping Methods and Support Systems:
What do you usually do first when faced with a problem?
What helps you to relieve stress and tension?
Do you use medication, drugs, or alcohol to help relieve stress? Explain.
Objective Data
Refer to the Mental Status Assessment.
Associated nursing Diagnoses
Risk Diagnoses:
Risk for self-harm
Risk for suicide
Actual Diagnoses:
Ineffective Individual Coping
Ineffective Family Coping: Disabling
11. Value and Belief Pattern
Subjective Data
Values, Goals, and Philosophical Beliefs
Religious and Spiritual Beliefs:
Are there certain health practices or restrictions that are important for you to follow
while you are ill or hospitalized? Explain.
Objective Data
Observe religious practices
Bible, clergy
Observe client's behavior for signs of spiritual distress
Anxiety, Anger, Depression, Doubt, Hopelessness and Powerlessness
Associated Nursing Diagnoses
Risk diagnosis:
Risk for spiritual distress
Actual Diagnosis:
Spiritual disturbance (distress of the human spirit).

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Contents of Seminar Presentation

 Bibliography of the patient

 Chief complaint, HPI
 Key physical findings
 Key lab results
 Definition of the disease
 Epidemiology
 Clinical manifestation
 Medical Management (what & why is the patient taking?)
 One nursing care plan using the above format
 Summary

Selected Topics for Seminar Presentation

Visceral Leshmaniasis, CHF, Anemia, HIV, Ascites, PTB, DM?, Stroke, DVT?

Key Activities of Medical Nursing (Medical Ward)

 Routine nursing cares (bed making, oral care, V/S taking, admitting and discharging
patient ….)
 Advanced nursing care (catheterization, enema, O2 administration, NGT insertion, )
 Medication administration (PO, IM, IV, SC)
 Acquire practical knowledge of common medical disorders by discussing on real patients
(reflection)
 Assess a patient using the functional approach and Prepare one nursing care plan
individually
 Submiting activity reports at the end of each week

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 Nursing Care Plan Sample

Patient name: Kinmewal Yibejal

Ward: Surgical (GI unit)

Age: 65 year

Medical diagnosis: Small bowel Obstruction secondary to post op adhesion + Intra-abdominal

mass

Facilitator: Zeleke Aregaw

Assessment Nursing Diagnosis Plan Implementation Evaluation

Subjective  Pain related to To relief  Narcotics like Relived from

 Pain on surgical incision as pain Pethidine pain but he
surgical manifested by administered needs
incision site verbalization during  Reassurance made consistent Rx
 Difficulty of wound care
passing stool Fiber diet were He starts to
and flatus  Constipation related To prevent suggested pass flatus
Objective data to immobility and and treat Ambulation tried and stool one
 Oozing of lack of fiber diet as constipation Laxatives like times per day
blood on site manifested by bisacodyl given
of incision difficulty of passing
stool
 Prolonged  Antibiotics like
staying in bed To prevent cloxacillin and Still there is
 Risk for infection
 Long related to long infection metronidazole no sign of
laparotomy incision on abdomen administered infection
incision  Wound care daily with
 Lower BP staff nurses given
 A Pad which was
inside the abdomen
was changed by
surgeon

 Risk for thrombosis To prevent Prophylactic heparin

related to immobility thrombo and aspirin was Lower
embolism given to prevent extremities
thrombosis have no sign
Active and passive of DVT
range of motion
implemented
Assessment Nursing Goals Implementation Evaluation
diagnosis

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Wt loss of 7kg in 10 day Altered nutrition Client will Weight daily at Weight remains at 70
less than body maintain wt 7am kg
Eats only 10% of meal requirement Eats 100% of Small and Client consumes all
due to feeling of fullness related to meals frequent meal food on meal try
immediately after sensation of
beginning of food fullness with
meals
Fever higher than 390c, High risk for Skin remains intact Turn the client Skin remains dry and
sweating, incontinence impaired skin Skin is free from every 2 hours intact
of urine integrity related pressures Keep clients skin
to immobility dry at all time
Frowned face, frequent Anxiety related Decrease anxiety Explain condition The client is free from
verbalization of to knowledge to patient and anxiety
apprehension deficit family
Provide time for
questions,
expression of
concerns & fears
Offer reassurance
and document
interventions

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 Activity Report Sample (if necessary)

Course: Adult Health Nursing Practicum two

Duration of attachment: two months

Place: TikurAnbesa Hospital (orthopedic ward, oncology unit, surgical ward and diabetes unit)

Student Name: Awel & Almaz

Facilitator: Zeleke Argaw

Below listed are all the activities we observed and performed during the two month course of
clinical attachment inTikurAnbesa Hospital.

Orthopedic ward

We observed the following procedures

 How POP is applied, and precautions about complications

 How Traction is applied using sand bag and its weight estimation (10% of body weight)
 Fixation (external & internal) with its indication and pin site care
 We identified some patients who have multiple fractures as having psychosocial
problems like delirium and depression which needs psychotherapy
 Splinting patients with gutter
 Different prosthetic materials used to rehabilitate amputated extremities
 Physiotherapy set up and identified what type of cases need it. We also appreciate some
devices like electrotherapy and radiations used to treat back pain (inflammatory and
neurogenic)
 Acquire knowledge on different type fractures and dislocations as. Because most patients
admitted are with those causes.
 Discuss some nursing management of a patient diagnosed as floating elbow with our
instructor
 Antipains (NSAIDs, narcotics), and antibiotics are usually prescribed
 We observed nutritional therapy typically high protein diets are prescribed for
traumatized patients
 By far and most importantly, we attended a full procedure of major Amputation in
orthopedic OR.
Shortly the procedure looks as follows:
 The patient had right leg gangrene started as diabetic foot ulcer
 Once the patient entered in OR, anesthetists gave him spinal anesthesia instead of
general anesthesia

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  The sterile team (scrub nurse, surgeon, asst. surgeon) scrub and put on sterile
gloves and gown
 They started to cut the skin with cautery at distal femur, then fascia, muscle, and
bone with bone sow
 Finally they stitched arteries, nerves, skins, fascia, and muscles together!!!!!

ONCOLOGY UNIT

 Generally we observed a lot of cases in inpatient and outpatient department of

oncology. Among the cases we observed are:
Male and female breast cancer
Retinoblastoma
Cervical cancer with vesico-vaginal fistula- with chief compliant of vaginal bleeding of 6
months duration
Colon and colorectal cancer
Cancer of parotid gland that metastasize to ear
Submandibular cancer
Cancer of scalp
Ovarian cancer
Lung cancer
Sarcoma which usually respond to radiation therapy only
 In outpatient department of chemotherapy for breast cancer we appreciate the
following chemotherapeutic regimens
Cyclophosphamide, 5-flouro uracil, Adriamycin, and Zofran for vomiting
Before the above chemotherapy are administered nurses:
Ensure RFT, LFT, CBC and weight are in the normal range
Administer normal saline to ensure adequate hydration, and to prevent
drug induced renal failure
Administer dexamethasone as premedication
The regimen is given every 21 days for 6 cycles and can be given before
or after mastectomy
In outpatient chemo follow up, we observed that the most common complain of patients
were vomiting and constipation. There are a number of cases with recurrence even during
and post chemo. Therefore, nutritional therapy is main components of managing cancer
patients.
Palliative care is another issue in cancer care. Patients are palliated through radiation
therapy, chemotherapy and psychosocial support
We made major rounds with oncologists
Additionally, we observed different types leukemia like ALL, CLL, AML, CML patients

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 Diabetic Unit

Even though we encountered beaurocratic problems and inconvenience, we had a chance

to saw the following cases
 Diabetic foot ulcer
 Diabetic associated heart failure
 Retinal screening camera used to diagnose Diabetic Retinopathy
 Diabetic neuropathy
 Regular and NPH insulin for DM patients
 Oral Hypoglycemic Agents like metformin, Glibenclamide prescribed for Type 2
DM patients
 Athlete foot and atopic dermatitis in DM patients

Surgical ward

 We read the informed consent utilized in OR of Tikur Anbesa Hospital and analyzed
using the principles of respect, autonomy, and beneficence/ non-maleficence
 We attended a procedure of permanent colostomy, and removal of mass of esophageal
cancer in OR
 We observed chest tube inserted to drain pleural effusion and pneumothorax
 Wound care given for a patient undergoing laparotomy secondary to small bowel
obstruction which is again secondary to adhesion
 We observed tubes inserted to drain perinephric abscess
 Antibiotics and analgesics are commonly administered in surgical ward

Over all during the course of attachment we encounter the following opportunities and problems
as described below

Opportunities
 Good facilitator
 Cooperative nurses specially working at OR
 Rounds were educative
 There are variety of cases which is ideal for learning
 We didn’t have communication difficulty with staffs because one of us were member
previous Tikur Anbesa Hospital staff
Problems encountered
 Renal procedures like dialysis were absent
 Some exaggerated beurocratic issues were encountered in Diabetes Clinic
 Research methodology course bombarded us not to practice freely
 Our practice in some departments were clashed with exam schedule of medical students

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