Block 2

Concepts of Man and His Basic Human Needs

Introduction

The Concepts of Man forms the first foundational component of Nursing. To be able to provide
individualized, holistic, humane, ethical and quality nursing care, it is primary consideration to understand
MAN.
Each individual has unique characteristics, but certain needs are common to all people. These needs are
called basic human needs. Human needs are physiologic and psychologic conditions, that the individual must
meet to achieve a state of health and well-being.

The 4 Major Attributes of Human Being

1. The capacity to think or conceptualize on the abstract level.
2. Family formation.
3. The tendency to seek and maintain territory.
4. The ability to use verbal symbols as language, a means of developing and maintaining culture.

Nursing Concepts of Man

• Man is a Biopsychosocial and Spiritual being who is in constant contact with the environment. (Roy).
As a biologic being man is like all other men. This is because all men have the same basic
human needs.
As a psychologic being, man is like no other man. This is because man is a unique,
irreplaceable, one- time being No two persons are exactly alike. Man as a psychologic being has the
following characteristics: rational but at times irrational; mature with a core of immaturity; with limited
and unlimited nature; a being of contradictions, a being who is usually at the crossroads of
indecisiveness.
As a social being, man is like some other men. A group of people have common attributes that
make them different from other groups. Some factors that characterize particular groups of people are
culture (including beliefs, practices, norms, taboos, religions, language, etc.), age groups, social status,
educational status, en
As a spiritual being, man is like all other men. All men are spiritual in nature. This is because
all men have intellect and will; all men are endowed with virtues of faith, hope, and charity. All men
beheve in the existence of a Supreme Peter who guides our fate and dusting; who is the source of
meaning and purpose of life; to whom we seek console in case of difficulties in life, like in illness or
hospitalization.

• Man is an Open system in constant interaction with a changing environment. (Roy).

An open system is one that allows input and output to and from its boundaries; one that allows
exchange of, or is constantly affected by matter, energy, and information. Examples of matter that may
affect man are foods, medicines, microorganisms, etc. Examples of energy that may affect man are pain,
fever, inflammation, etc. Examples of information that may affect man are diagnosis of an illness,
pregnancy, the need to undergo surgery or other treatments, death of a loved one, etc.
 A closed system is one that will not allow inputs and outputs. It is one that will not allow exchange
of matter, energy and information. Example, a lighted candle covered with a glass. Once the oxygen within
the glass is exhausted, then the flame is extinguished

• Man is a unified whole composed of parts which are interdependent and interrelated with each other.
(Rogers)
The different organs and organ systems function together to achieve a particular purpose.
Example, to have adequate oxygenation, there should be normal functioning of the respiratory system,
cardiovascular system, and nervous system. N organ or organ system functions on each own. Therefore,
no single organ or organ system is affected without affecting other organs or organ systems

• Man is composed of parts which are greater than and different from the sum of all his parts.
(Rogers)
Man is greater than the sum of all his parts because he is not simply a composite of
physiologic body parts. He is endowed with intellect, will, judgment ability, decision-making ability,
talents strengths, and other numerous enabling powers.
Man is different from the sum of all his parts because at times his responses are predictable,
but at times unpredictable. He is a creature of contradictions. Sometimes he responds favorably to some
factors like food, medications, treatments; but at times he responds unfavorably to these factors like
developing diarrhea after eating a certain food, developing allergies to certain medications, developing
adverse reactions to treatments like surgery and anesthesia

• Man is composed of subsystems and suprasystems. (Rogers)

Man's subsystems are the cells, tissues, organs, organ systems. Man's suprasystems are his
family, community, and the society. All of these subsystems and suprasystems affect man as a whole.
When certain subsystem of man's body is affected, the entire borly is affected.; example is pain in the
wound on a finger, which affects the entire body.
Man's family, community, and the society profoundly affect him in all dimensions---
physiologic, psychologic, social, cognitive, and spiritual. Man's health practices and health care patterns
are developed from the family. The conditions in the community like sanitation, supply of potable water,
space, availability of health care facilities, etc., greatly affect the health of man and his family. The
societal conditions like availability of basic health care facilities and services, laws that ensure adequate
and equitable health care delivery, political climate that considers health as a right of every man, etc.
likewise affect man, his family, the community, and the society as a whole.

• Man is an individual with vital reparative processes to deal with disease and desirous of health but
passive in terms of influencing the environment or nurse. (Nightingale)

• Man is a whole, complete and independent being who has 14 fundamental needs to: (Henderson)
Breath Keep Clean
Eat and drink Avoid Danger
Eliminate Communicate
Move and maintain posture Workship
Sleep and rest Work
Dress and undress Play
Maintain body temperature Learn
 • Man is a unity who can be viewed as functioning biologically, symbolically and socially and who
initiates and performs self-care activities on own behalf in maintaining life, health, and well-being.
(Orem)

The Basic Human Needs

• Each individual has a unique characteristic, but certain needs are common to all people.
• A need is something that is desirable, useful or necessary.
• Human needs are physiologic or psychologic conditions that an individual must meet to achieve a state
of health or well-being.
• Maslow ranks basic human needs according to what is crucial for survival. He avers that physiologic
needs are to be given highest priorities over a higher-level need.

Self-
Actualitation

Self-esteem

Love and Belonging

Safety and Security

Physiologic

ABRAHAM MASLOW’S HIERARCHY OF BASIC HUMAN NEEDS

According to Maslow's Hierarchy of Basic Human Needs:

1. Physiologic Needs are as follows:
• Oxygen
• Fluids
• Nutrition
• Body Temperature
• Elimination
• Rest and Sleep
• Sex
(Note: Sex is not necessary for individual survival but it is necessary for survival of mankind.)
2. Safety and Security Needs are as follows:
• Physical Safety
 • Psychological Safety
• The need for shelter and freedom from harm and danger.

3. Love and Belongingness Needs are as follows:

• The need to love and be loved.
• The need to care and be cared for.
• The need for affection; to associate or to belong.
• The need to establish fruitful and meaningful relationships with people, institution, or organization.
4. Self-Esteem Needs are as follows:
• Self-worth
• Self-identity
• Self-respect
• Body image
(Need to be well thought of by oneself as well as by others.)
5. Self-Actualization Needs are as follows:
 The need to learn, create and understand or comprehend.
 The need for harmonious relationships.
 The need for beauty or aesthetics.
 The need to be self- fulfilled.
 The need for spiritual fulfillment.

Characteristics of Basic Human Needs

 Needs are universal. All human beings have the same basic human needs.
 Needs may be met in different ways. Example: if a person is unable to eat through the mouth, nutrition
may be administered through nasogastric tube, or intravenous route (total parenteral nutrition)
 Needs may be stimulated by external and internal factors Example: external factor like smelling a
seemingly delicious food will trigger hunger in a person; internal factor ke low blood glucose level will
stimulate sensation of hunger.
 Priorities may be altered Example: the adolescent nursing student gives higher priority to her studies
to achieve self-esteem over her need for love and belongingness. So she sacrifices to be away from her
parents who live in a far province.
 Needs may be deferred. Example: a person who is confined in the hospital has to forego his need for
independence and privacy
 Needs are interrelated. Example: when physiologic needs of an infant are adequately met, he
associates this with satisfaction of his need for love and belongingness. When a person is loved and
appreciated by many people, his self-esteem is enhanced, likewise when a person has high self-esteem,
he is more capable of loving and appreciating other people.

Maslow's Characteristics of a Self-Actualized Person

 Is realistic, sees life clearly, and is objective about his or her observations.
 Judges people correctly.
 Has superior perception, is more decisive.
 Has clear notion to what is right or wrong.
  Is usually accurate in predicting future events.
 Understands art, music, politics, and philosophy.
 Possesses humility, listens to others carefully.
 Is dedicated to some work, task, duty, or vocation.
 Is highly creative, flexible, spontaneous, courageous, and willing to make mistakes.
 Is open to new ideas.
 Is self-confident and has self-respect.
 Has low degree of self-conflict, personality is integrated
 Respects self, does not need fame, possesses a feeling of self-control.
 Is highly independent, desires privacy.
 Can appear remote and detached.
 Is friendly, loving, and governed more by inner directives than by society.
 Can make decisions contrary to popular opinion.
 Is problem-centered rather than self centered.
 Accepts the world for what it is

A self-actualized person is basically a mentally healthy person.

Marie Jahoda suggests the following criteria of mentally healthy person:

1. The attitude of person towards himself is positive. That is, the person is self-reliant, self-confident, and self-
accepting.
2. The person can become aware of the meanings of his actions through introspection. By this, the person's
behavior is accessible to the consciousness.
3. A person's self concept is similar to that which others have of the person.
4. The person can accept himself.
5. The person has sense of identity, that is he knows who he is and at the same time has few doubts about it.
6. The person changes and grows throughout life.
7. The person acts in a unified manner, that is, his behavior is consistent throughout his life. The person acts in a
unified manner, that is, his behavior is consistent throughout his life.

William Glasser states that there are two needs that are fulfilled by the mentally healthy person: the need to
love and be loved and the need to feel that one is worthwhile to self and to others.
 A person fulfills these needs by doing that which is realistic, responsible and right.
 Realistic behavior is that which the person chooses by reasoning and by considering the remote as well
as the immediate consequences to self and others.
 Responsibility is the ability to fulfill personal needs and at the same time not deprive others of being
able to fulfill their needs.

On the whole, self actualization is the essence of mental health.

 Block 3
Health and Illness
3.1. Concepts of Health and Illness

Introduction
Health is a fundamental right of every human being. It is a state of integration of the body and mind. It is
a much sought after state; a highly desirable state for most people and yet at times, it remains elusive for some
people.

Across the lifespan, man moves from the health spectrum to the illness spectrum. Some people think of
themselves as healthy and well if they are not ill and ill if they are not well. However, there is no exact point at
which health ends and illness begins as both are relative in nature.

Health and illness are highly individualized perceptions. Meanings and descriptions of health and illness
vary among people, in relation to geography and to culture.
This Block will help you, to have a better notion and perspective of health and illness.

Concepts of Health and Illness

 Health is a state of complete physical, mental and social well-being, and not merely the absence of
disease or infirmity. (WHO)
 Health is the ability to maintain the internal milieu. Illness is the result of failure to maintain the
internal environment.(Claude Bernard)
 Health is the ability to maintain homeostasis or dynamic equilibrium. Homeostasis is regulated by the
negative feedback mechanism.(Walter Cannon)
 Health is being well and using one's power to the fullest extent. Health is maintained through prevention
of disease via environmental health factors. (Nightingale)
 Health is viewed in terms of the individual's ability to perform 14 components of nursing care unaided.
(Henderson)
 Positive health symbolizes wellness. It is a value term defined by the culture or individual. (Rogers)
 Health is a state and a process of being and becoming an integrated and whole person. (Roy)
 Health is a state that is characterized by soundness or wholeness of developed human structures and
of bodily and mental functioning. (Orem)
 Health is a dynamic state in the life cycle; illness is an interference in the life cycle. (King)
 Wellness is the condition in which all parts and subparts of an individual are in harmony with the
whole system. (Neuman)
  Health is an elusive, dynamic state influenced by biologic, psychologic, and social factors. Health is
reflected by the organization, interaction, interdependence and integration of the subsystems of the
behavioral system. (Johnson)

Wellness and Well Being

 Wellness is well-being. It involves engaging in attitudes and behaviors that enhance quality of life and
maximize personal potential (Anspaugh, et al. 1991.p.2).
 Well-being is a subjective perception of balance, harmony and vitality (Leddy and Pepper, 1993, p.
221).
 Wellness is a choice.
 Wellness is a way of life.
 Wellness is the integration of body, mind and spirit.
 Wellness is the loving acceptance of one's self.

Models of Health and Illness

The Health - Illness Continuum

Health Belief Model (HBM)
Smith's Models of Health
Leavell and Clark's Agent - Host - Environment Model (Ecologic Model)
Heath Promotion Model

+
THE HEALTH-ILLNESS CONTINUUM (Dunn)
Dunn’s theory on Health-illness Continuum” describes the interaction of the environment with well-being and
illness.

ENVIRONMENT

ILLNESS
HEALTH

Death Poor Health Good Health

High Level
Precursor of Illness Wellness

Poor health is unfavorable Emergent LBW in unfavorable

environment environment
High level wellness (HLW). An integrated method of functioning that is oriented towards maximizing one's
potentialities within the limitations of his environment.
This concept connotes ability to perform ADL or to function independently.

Precursor of Illness
These are the factors which impinge on the individuals to lead towards the illness spectrum:
1. Heredity. e.g. family history for diabetes mellitus, hypertension, cancer.
2. Behavioral factors. e.g. cigarette smoking, alcohol abuse, high animal fat intake.
3. Environmental factors. e. g. overcrowding, poor sanitation, poor supply of potable water.
Health Belief Model (HBM) Becker, 1975
 Describes the relationship between a person's belief and behavior.
 Individual perceptions and modifying factors and preventive health behavior. may influence health
beliefs
 Individual perceptions include the following:
1. Perceived susceptibility to an illness. E.g. family history to diabetes mellitus increases risk to
develop the disease.
2. Perceived seriousness of an illness. E.g. Diabetes mellitus is a lifelong disease.
3. Perceived threat of an illness. E.g. Diabetes mellitus causes damage to the brain, heart, eyes,
kidneys, blood vessels.
 Modifying factors include the following:
1. Demographic variables (age, sex, race, etc.)
2. Sociopsychologic variables (social pressure or influence from peers, etc.)
3. Structural variables (knowledge about the disease, and prior contact with it)
4. Cues to action. (internal: fatigue, uncomfortable symptoms; external; mass media, advice from
others)
 Likelihood of taking recommended preventive health action depends on:
1. Perceived benefits of preventive action.
2. Perceived barriers to preventive action
1. Preventive health behavior may include lifestyle changes, increased adherence to medical
therapies, search for medical advice or treatment.
2. Perceived barriers to preventive action may be due to difficulty in adhering to lifestyle changes;
social pressures; physical symptoms such as fatigue, joint pains, etc.; economic factors; accessibility of
health care facilities.

Smith's Model of Health

1. Clinical Model. Views people as physiologic system with related functions and identifies health as the
absence of signs and symptoms of disease or injury.
2. Role Performance Model. Defines health in terms of individual's ability to fulfill societal roles such as
performing work.
3. Adaptive Model. Focuses on adaptation. Views health as creative process; and disease as a failure in
adaptation or mal-adaptation. This model believes that the aim of treatment is to restore the ability of the
person to adapt, that is to cope.
4. Eudaemonistic Model. Conceptualizes that health is a condition of actualization or realization of a
person's potential. This model avers that the highest aspiratio of people is fulfillment and complete
development- -- actualization.
Leavell and Clark's Agent-Host-Environment Model (Ecologic Model)
Avers that there are three interactive factors that affect health and illness. The three factors are as
follows: (1) Agent. Any factor or stressor that can lead to illness or disease. (2) Host. Persons who may or may
not be affected by a disease. (3) Environment. Any factor external to the host that may or may not predispose
the person to a certain disease.

Health Promotion Model (Pender, 1982, 1993, 1996)

The Health Promotion Model (Pender) describes the multi-dimensional nature of persons as they interact
within the environment to pursue health. The model focuses on the areas:
1. Individual Perceptions (client's cognitive perceptual factors).
2. Modifying Factors (demographic and social factors)
3. Participation in health-promoting behaviors (likelihood of action).
This model attempts to explain the reasons why individuals engage in health activities.

Pender advocates that health promotion involves activities that are directed toward increasing the level of well
being and self-actualization

1. Includes efforts to assist individuals in taking control of and responsibility for their health risks and
ultimately improve quality of life.
2. Encompasses activities to improve the health of those who are not initially healthy as well as the healthy
individuals
3. Includes individual and community activities to promote healthful lifestyles.
4. Includes the principles of self responsibility, nutritional awareness, stress reduction and management
and physical fitness.
5. Health promotion activities such as routine exercise and good nutrition, help clients maintain or enhance
their present level of health. L
6. Illness prevention activities such as immunization programs protect clients from actual or potential
threats to health.

ILLNESS AND DISEASE

Illness
 Illness is a personal state in which the person feels unhealthy.
 Illness is a state in which a person's physical, emotional, intellectual, social, developmental or spiritual
functioning is diminished or impaired compared with previous experience.
 Illness is not synonymous with disease; although nurses must be familiar with different kinds of
diseases and their treatments, they are concerned more with illness, which may include disease but also
the effects on functioning and well-being in all dimensions.
Disease
An alteration in body functions resulting in reduction of capacities or a shortening of the normal life
span.

Common Causes of Disease

1. Biologic agents (e.g. microorganisms)
2. Inherited genetic defects (e.g. cleft palate)
 3. Developmental defects (e.g. imperforate anus)
4. Physical agents (e.g. hot and cold substances, radiation, ultraviolet
5. Chemical agents (e.g. lead, emissions from smoke-belching cars) rays)
6. Tissue response to irritation/injury (e.g. fever, inflammation)
7. Faulty chemical/metabolic process (e.g. inadequate insulin in diabetes mellitus, inadequate iodine
causing goiter)
8. Emotional/physical reaction to stress (e.g. anxiety, fear)

Stages of Illness
1. Symptom Experience
 transition stage.
 the person believes something is wrong.
 experiences some symptoms.
 3 aspects:
• physical (fever, muscle aches, malaise, headache)
• cognitive (perception of "having flu")
• emotional (worry on consequence of illness)

2. Assumption of Sick Role

• acceptance of the illness.
• seeks advice, support for decision to give up some activities.

3. Medical Care Contact

• seeks advice of health professionals for the following reasons:
• validation of real illness
• explanation of symptoms
• reassurance or prediction of outcome

4. Dependent Patient Role

 the person becomes a client dependent on the health professional for help.
 accepts/rejects health professional's suggestions.
 becomes more passive and accepting
 may regress to an earlier behavioral stage.

5. Recovery/Rehabilitation
 gives up the sick role and returns to former roles and functions.

Aspects of Sick Role

• One is not held responsible for his condition. The person did not cause his illness.
• One is excused from social roles. The person is allowed to rest by seeking sick leave or leave of
absence.
• One is obliged to get well as soon as possible. The person is expectedto cooperate and comply with
recommended therapies.
 • One is obliged to seek for competent help. The person is expected to seek help from health
professionals.

Risk Factors
• A risk factor is any situation, habit, social or environmental condition, physiological or psychological
condition, developmental or intellectual condition, or spiritual or other variable that increases the
vulnerability of an individual or group to an illness or accident.
• The presence of risk factors does not mean that a disease will develop, but risk factors increase the
chances that the individual will experience a particular dysfunction.

Risk Factors of a Disease

1. Genetic and Physiological Factors
• Heredity, or genetic predisposition to specific illness, is a major physical risk factor. For example, a
person with a family history of diabetes mellitus is at risk for developing the disease later in life.

2. Age
 Age increases or decreases susceptibility to certain illnesses (e.g. the risk of heart diseases increases
with age for both sexes)
 The risk of birth defects and complications of pregnancy increase in women bearing children after
age 35

3. Environment
• The physical environment in which a person works or lives can increase the likelihood that certain
illnesses will occur. For example, some kinds of cancer and other diseases are more likely to develop
when industrial workers are exposed to certain chemicals or when people live near toxic waste
disposal sites.

4. Lifestyle
• Many activities, habits and practices involve risk factors. Lifestyle practices and behaviors can also
have positive or negative effects on health.
• Other habits that put a person at risk for illness include tobacco use, alcohol or drug abuse and
activities involving a threat of injury, such as skydiving or mountain climbing.
• Stress can be a lifestyle risk factor if it is severe or prolonged, or if the person is unable to cope with
life events adequately.
• Stress can threaten mental health (emotional stress), as well as physical well-being (physiologic
stress)
• The goal of risk factor identification is to merely assist clients in visualizing those areas in their life
that can be modified or even eliminated to promote wellness and prevent illness.

Terminologies

Disease. Disturbance of structure or of function of the body or its constituent parts.

• Lack of or faulty or inadequate adaptation of the organism to his environment.
 • Failure of the adaptive mechanism to adequately counteract the stimuli or stresses to which it is subject
resulting in disturbances in function and structure of any part, organ or system of the body.
Morbidity. Condition of being diseased.

Morbidity rate. The proportion of disease to health in a community.

Mortality. Condition or quality of being subject to death.

Ecology. The science of organisms as affected by factors in their environment; deals with the relationship
between disease and geographical environment.

Epidemiology. Study of the patterns of health and disease, its occurrence and distribution in man, for the
purpose of control and prevention of disease.

Susceptibility. The degree of resistance the potential host has against the pathogen.

Etiologic agent. One that possesses the potential for producing injury or disease. (e.g. Streptococcus,
Staphylococcus)

Virulence. Relative power or the degree of pathogenicity of the invading microorganism, the ability to produce
poisons that repel or destroy phagocytes.

Symptomatology. Study of symptoms.

Symptom. Any disorder of appearance, sensation or function experieced by the patient indicative of a certain
phase of a disease.

• Manifestation of perceptible changes in the body which indicate the presence of a disease or disorder. It
is subjective in nature.

Sign. An objective symptom or objective evidence or physical manifestation made apparent by special methods
of examination or use of senses,

Syndrome. A set of symptoms, the sum of which constitutes a disease.

• A group of symptoms which commonly occur together.

• A group of signs and symptoms which when considered together characterize a disease. Eg, fever,
rashes, Koplik's spot in measles.
Pathology. The branch of medicine which deals with the cause, nature, treatment and resultant structural and
functional changes of disease.

Pathogenesis. Method of origin and development of a disease, including sequence of processes or events from
inception to the development of characteristic lesion or disease.

Diagnosis. Art or act of determining the nature of a disease, recognition of a diseased state.

Sequela. The consequence that follows the normal course of an illness.

Complication. A condition that occurs during or after the course of an illness.

Prognosis. Prediction of the course and end of a disease, medical opinion as to the outcome of a disease
process. Good prognosis means that there is great possibility to recover from the disease and poor prognosis
means that there is great risk for morbidity or mortality.

Recovery, Implies that the person has no observable or known after effects from his illness; there is apparent
restoration to the pre-illness state.

Classification of Diseases
A. According to Etiologic Factors
1. Hereditary. Due to defect in the genes of one or other parent which is transmitted to the offspring.
(e.g. diabetes mellitus, hypertension)
2. Congenital. Due to a defect in the development, hereditary factors, or prenatal infection; present at
birth. (e.g. cleft lip, cleft palate)
3. Metabolic. Due to disturbances or abnormality in the intricate processes of metabolism. (e.g.
diabetes mellitus, hyperthyroidism)
4. Deficiency. Results from inadequate intake or absorption of essential dietary factors. (e.g.
osteomalacia, which is Vitamin D deficiency in adults)
5. Traumatic. Due to injury. (e.g. fractures)
6. Allergic. Due to abnormal response of the body to chemical or protein substances or to physical
stimuli. (e.g. asthma, skin allergy)
7. Neoplastic. Due to abnormal or uncontrolled growth of cells. (e.g. cancer)
8. Idiopathic. Cause is unknown; Self-originated; of spontaneous origin. (e.g. cancer)
9. Degenerative. Results from the degenerative changes that occur in tissue and organs. (e.g.
osteoporosis, osteoarthritis)
10. Iatrogenic. Results from the treatment of a disease. (eg. hypothyroidism after thyroid surgery;
alopecia [hair loss) after chemotherapy)

B. According to Duration or Onset

1. Acute illness: An acute illness usually has a short duration and is severe. The signs and symptoms
appear abruptly, are intense and often subside after a relatively short period. An acute illness may
affect functioning in any dimension. (e. g acute appendicitis)
2. Chronic illness. A chronic illness persists, usually longer than 6 months, and can also affect
functioning in any dimension. The client may fluctuate between maximal functioning and serious
relapses that may be life threatening. (eg, hypertension). It is characterized by remission and
exacerbation.
• Remission. Period during which the disease is controlled and symptoms are not obvious.
• Exacerbation. The disease becomes more active again at a future time, with recurrence of
pronounced symptoms
3. Sub-acute. Symptom's are pronounced but more prolonged than in acute disease. (e.g. sub-acute
endocarditis)
C. Others. Diseases may also be described as:
1. Organic. Results from changes in the normal structure, from recognizable anatomical changes in an
organ or tissue of the body.
2. Functional. No anatomical changes are observed to account for the symptoms present, may result
from abnormal responses to stimuli (e.g. psychiatric illnesses)
 3. Occupational. Results from factors associated with the occupation engaged in by the patient. (e.g.
cancer among chemical factory workers) 4. Familial. Occurs in several individuals of the same
family. (e.g. hypertension, cancer)
4. Venereal. Usually acquired through sexual relation. (e.g. AIDS, gonorrhea)
5. Epidemic. Attacks a large number of individuals in a community at the same time. (e.g. SARS/
Severe Acute Respiratory Syndrome)
6. Endemic. Present more or less continuously or recurs in a community. (e.g. Malaria in Palawan,
Goiter in Mountain Province)
7. Pandemic. An epidemic disease which is extremely widespread involving an entire country or
continent.
8. Sporadic. A disease in which only occasional cases occur. (eg. Dengue during rainy season,
leptospirosis during floods).

Leavell and Clark's Three Levels of Prevention

1. Primary Prevention: To encourage optimal health and to increase the person's resistance to illness.
Seeks to prevent a disease or condition at a prepathologic state; to stop something from ever
happening.
• Health promotion
• Specific protection

2. Secondary Prevention: It is also known as health maintenance. Seeks to identify specific illnesses
or conditions at an early stage with prompt intervention to prevent or limit disability; to prevent
catastrophic effects that could occur if proper attention and treatment are not provided.
• Early diagnosis/detection/screening
• Prompt treatment to limit disability

3. Tertiary Prevention: To support the client's achievement of successful adaptation to known risks,
optimal reconstitution, and/or establishment of high-level wellness. Occurs after a disease or
disability has occurred and the recovery process has begun; intent is to halt the disease or injury
process and assist the person in obtaining an optimal health status.
• Rehabilitation

Behaviors Associated with the Levels of Prevention

Primary Prevention
 Quit smoking.
 Avoid/limit alcohol intake.
 Exercise regularly.
 Eat well-balanced diet.
 Reduce fat and increase fiber in diet.
 Take adequate fluids.
 Avoid over exposure to sunlight.
  Maintain ideal body weight.
 Complete Immunization Program.
 Wear hazard devices in work site.

Secondary Prevention
• Have annual physical examination.
• Regular Pap's test for women.
• Monthly BSE for women who are 20 years old and above.
• Sputum examination for Tuberculosis.
• Annual stool guaiac and rectal examination for clients over age 50 years.

Tertiary Prevention
• Self-monitoring of blood glucose among diabetics.
• Physical therapy after CVA (stroke); participation in Cardiac Rehabilitation after MI (myocardial
infarction or heart attack).
• Attending self-management education for diabetes.
• Undergoing speech therapy after laryngectomy.

Types of Health Promotion Programs

1. Information Dissemination
• Use of variety of media to offer information to the public about the particular lifestyle choices
and personal behavior, the benefits of changing that behavior and improving the quality of life.
2. Health Appraisal and Wellness Assessment Programs
 Appraise individuals of their risk factors that are inherent in their lives in order to motivate them
to reduce specific risk and develop positive health habits.
 Wellness assessment programs are focused on more positive methods of enhancement.
3. Lifestyle and Behavior Change Programs
 Basis for changing health behavior.
 Geared toward enhancing the quality of life and extending the life span.
4. Worksite Wellness Programs
 Include programs that serve the needs of persons in their workplace.
5. Environmental Control Programs
 Developed to address the growing problem of environment pollution- air, land, water, etc.

Activities to Promote Health and Prevent Illness

1. Have regular (yearly) physical examination.
2. Women:
 Regular Pap test
 Monthly BSE (breast self-examination)
3. Men: regular testicular self examination.
4. Annual dental examination and prophylaxis.
5. Regular eye exam (every 1-2 years).
6. Exercise regularly at least 3x per week for 30 minutes.
7. Do not smoke: avoid second hand smoke.
 8. Avoid alcohol and "recreational drugs".
9. Reduce fat and increase fiber in diet.
10. Sleep regularly 7-8 hours/night.
11. Eat breakfast.
12. Eat regular meals with few snacks.
13. Maintain Ideal Body Weight.

Block 3
Health and Illness
3.2 Asepsis and Infection Control

Introduction

Microorganisms are always present in the environment. Some live on the skin, others are common
inhabitants of the intestinal tract and others are found among other places, in the air, in the soil, in articles and
equipment in the hospital and on our clothes. Therefore, knowledge of asepsis and an awareness of how
microorganisms are transmitted are essential for safe nursing care environment.

Infections pose severe problems to people at home, in the community and in the health care facilities.
They have great impact on the health status of people in varying ages. Furthermore, infections cause great
economic burden because treatments and medications are becoming uncontrollably expensive.

Therefore, ASEPSIS and INFECTION CONTROL in any health care setting should be a onerous effort
among health care workers, especially among us, nurses.

This Block will help you, to develop knowledge, skills and attitude on prevention of transfer of
microorganisms.

Terminologies

Infection. An invasion of the body tissue by microorganisms and their proliferation there.

Asepsis
 The absence of disease-producing microorganisms.
 Being free from infection.

Medical Asepsis
 Practices designed to reduce the number and transfer of pathogens.
 Clean technique.
Surgical Asepsis
 Practices that render and keep objects and areas free from microorganisms.
 Sterile technique

Sepsis. The presence of infection.

Septicemia. Transport of an infection or the products of infection throughout the body or by blood.

Carrier. A person or an animal, who is without signs of illness but who harbors pathogens within his body that
can be transferred to another.

Contact. A person or an animal known or believed to have been exposed to a disease

Reservoir. The natural habitat for the growth and multiplication of microorganisms.

Transient flora or bacteria. The microorganism picked up by the skin as a result of normal activities that can
be removed readily.

Resident flora or bacteria. The microorganism that normally live on a person's skin.

Sterilization. The process by which all microorganisms including their spores are destroyed.

Disinfectant
 A substance, usually intended for use on inanimate objects, that destroys pathogens but generally not the
spores.
 Examples of items that are disinfected: surgical instruments, thermometers.

Antiseptic
 A substance, usually intended for use on persons that inhibit the growth of pathogens but not necessarily
destroy them.
 Example is the substance used for surgical wounds.

Bactericidal. A chemical that kills microorganisms.

Bacteriostatic. An agent that prevents bacterial multiplication but does not kill all forms of organisms.

Contamination. The process by which something is rendered unclean or unsterile.

Disinfection. The process by which pathogens but not their spores are destroyed, from inanimate objects.

Communicable Disease. Results if the infectious agent can be transmitted to an individual by direct or indirect
contact through a vector or vehicle, or as an airborne infection.

Infectious Disease. Results from the invasion and multiplication of microorganisms in a host.

Pathogen. A disease-producing microorganism.

Pathogenecity. The ability to produce a disease.

Virulence. The vigor with which the organism can grow and multiply.
Specificity. The organism's attraction to a specific host, which may include humans.

Opportunistic Pathogen. Causes disease only in susceptible individual.

Nosocomial Infection. Hospital-acquired infection.

Isolation. The separation of persons with communicable diseases from other persons so that either
direct/indirect transmission to susceptible persons is prevented.

Isolation Techniques. Practices designed to prevent the transfer of specific microorganisms.

Etiology. The study of causes.

Stages of Infectious Process

 Incubation Period. Extends from the entry of microorganisms into the body to the onset of signs and
symptoms.
 Prodromal Period. Extends from the onset of non-specific signs and symptoms to the appearance of
specific signs and symptoms.
 Illness Period. Specific signs and symptoms develop and become evident.
 Convalescent Period. Signs and symptoms start to abate until the client returns to normal state of
health.

The Chain of Infection

(1) Etiologic/Infectious Agent: (microorganisms): Bacteria, fungi, virus, parasites

(2) Reservoir (source): Human beings, animals, inanimate objects, plants, general environment such as air,
water and soil
(3) Portal of Exit Sputum, emesis, stool, blood
(4) Modes of Transmission Contact, vehicle, airborne, vectorborne
(5) Portal of Entry Mucous membrane, nonintact skin, GI tract, GU tract, Respiratory Tract
(6) Susceptible Host Immunosuppressed children/ elderly, chronically ill, those with trauma or surgery

1. Etiologic Agent (microorganism).

 These may be bacteria, virus, fungi or parasites. The ability of the infectious agent to cause a disease
depends on its pathogenecity, virulence, invasiveness and specificity.
2. Reservoir (source).
 Humans (clients, visitors, health care personnel), Animals (insects, rats), Plants, General
Environment (air, water, food, soil)
3. Portal of Exit from Reservoir
 Respiratory Tract: droplets, sputum.
 Gastrointestinal Tract: vomitus, feces, saliva, drainage tubes.
 Urinary Tract: urine, urethral catheters.
 Reproductive Tract: semen, vaginal discharge
 Blood: open wound, needle puncture site
4. Mode of Transmission
 1. Contact Transmission. This may be direct or indirect contact:
 Direct contact involves immediate and direct transfer from person to person (body surface-to-
body surface). Examples: healthcare personnel to clients during bathing, dressing changes,
insertion of tubes and catheters; direct transfer between two clients, with one acting as the source
and the other as the host.
 Indirect contact occurs when a susceptible host is exposed to a contaminated object such as
dressing, needle, surgical instrument.

Contact transmission of infectious organisms on the hands of caregivers is the most frequent mode of
transmission in health care facilities.

2. Droplet Transmission. This may be considered a type of contact transmission.

 It occurs when mucous membrane of the nose, mouth, or conjunctiva are exposed to secretions
of an infected person who is coughing, sneezing, laughing, or talking, usually within a distance
of 3 feet.
3. Vehicle Transmission. This involves the transfer of microorganisms by way of vehicles or
contaminated items that transmit pathogens. Examples: food, water, milk, blood, eating utensils,
pillows, mattress.

4. Airborne Transmission. This occurs when fine particles are suspended in the air for a long time or
when dust particles contain pathogens. Air current disperses microorganisms, which can be inhaled
or deposited on the skin of a susceptible host.
5. Vectorborne Transmission. Vectors can be biologic or mechanical.
 Biologic vectors are animals, like rats, snails, mosquitos.
 Mechanical vectors are inanimate objects that are infected with infected body fluids like
contaminated needles and syringes.

5. Portal of Entry
 This permits the organism to gain entrance into the host.
 Pathogens can enter susceptible hosts through body orifices such as the mouth, nose, ears, eyes, vagina,
rectum or urethra. Breaks in the skin or mucous membranes from wounds or abrasions increase chance
for organisms to enter hosts.

6. Susceptible Host
 A host is a person who is at risk for infection; whose own b defense mechanisms, when exposed, are
unable to withstand the invasion of pathogens.
 Examples: malnourished children, the elderly, the client with leukemia are immune- compromised, and
therefore, have propensity to develop numerous types of infection.

For organisms to spread disease, they must grow, reproduce, and move from one source to another.

Factors Influencing the Host's Susceptibility

 Intact skin and mucous membrane are the body's first line of defense.
 The normal ph levels of secretions and of genito-urinary tract help ward off microbial invasion.
 The body's WBC influence resistance to certain pathogens.
 The age, sex and race have been shown to influence susceptibility.
 Immunization. (natural/acquired), acts to resist infection.
 Fatigue, climate, general health status, presence of pre-existing illness, previous/current treatments and
some kinds of medications may play a part in the susceptibility of a potential host.
Types of Immunization

1. Active Immunization. Antibodies are produced by the body in response to infection.

a. Natural. Antibodies are formed in the presence of active infection in the body. It is lifelong.
E.g. recovery from mumps, chicken pox
b. Artificial. Antigens (vaccines or toxoids) are administered to stimulate antibody production.
Requires booster inoculation after many years. E.g. Tetanus toxoid, oral polio vaccine.
2. Passive Immunization. Antibodies are produced by another source, such as animal or human.
a. Natural. Antibodies are transferred from the mother to her newborn through the placenta or
in the colostrums.
b. Artificial. Immune serum (antibody) from an animal or another human is injected to a
person. E.g. Tetanus immunoglobulin human (TIGH).

Principles Underlying Medical and Surgical Asepsis

 The patient is a source of pathogenic microorganisms.
 The patient's microorganisms leave through specific routes.
 There are always microorganisms in the environment which in some individuals and under certain
circumstances can cause illness.
 Microorganisms harmful to man can be transmitted by direct and indirect contact.
 Spread of infection from source to others can be prevented by various methods to stop the spread as
close to the source as possible.
 The effectiveness of medical/surgical asepsis is dependent on the conscientiousness of those carrying
them out.
 In observing medical asepsis, areas are considered contaminated if they bear or are suspected of having
pathogens.
 In observing surgical asepsis, areas are considered contaminated if touched by any object that is not
sterile.

Breaking the Chain of Infection: Aseptic Practices

 Handwashing
 Cleaning, Disinfection, Sterilization
 Use of Barriers
 Isolation Systems
 Surgical Asepsis

1. Handwashing
 Handwashing is the single most important infection control practice. All caregivers, clients and
family members should learn handwashing techniques.
 Microorganisms are transient flora until the hands are washed.
 Soap and water and alcohol-based handrubs are effective preparations for removing transient
microorganisms.
 Wash hands before and after every client care contact.
 Effectiveness of handwashing is greatly influenced by adequate friction and thoroughness of surfaces
cleansed.
 Handwashing for medical asepsis is done by holding hands lower than the elbows. Hands are more
contaminated than lower arms.
 Wash hands using running water, soap and friction for 15 to 30 seconds on each hand. This is to
mechanically loosen and remove dirt and microorganisms on all hand surfaces.
  Clean under fingernails.
 Ideally, turn off faucet with clean paper towel.
 Keep fingernails short and avoid nail polish to prevent harboring microorganisms.
 Always wear gloves during client care when the skin is abraded.

2. Cleaning, Disinfection and Sterilization

 Cleaning. The physical removal of visible dirt and debris by washing dusting or mopping surfaces that
are contaminated. Soap is used for mechanical cleaning.
 Disinfection. The chemical or physical processes used to reduce the number of potential pathogens on
an object's surface. But spores of the pathogens are not necessarily destroyed.
 Sterilization. The complete destruction of all microorganisms, including spores, leaving no viable forms
of organisms.
Any item introduced into sterile tissues or the vascular system, such as surgical instruments, cardiac and urinary
catheters, vaginal speculum, implants, IV fluids, and needles, must be sterile.

Factors to be Considered in the Selection of Sterilization or Disinfection Methods:

1. Nature of organisms present.
 Some may be destroyed easily, others more difficult.
2. Number of organisms present.
 More organisms require longer time to destroy.
 Organism protected by coagulated protein requires longer time to destroy.
 Cleaned articles before disinfection or sterilization are rendered clean/sterile more quickly.
3. Types of equipment.
 Equipment with small lumen, or points are difficult to clean and require special care.
4. Intended use of equipment.
 For medical asepsis: clean technique.
 For surgical asepsis: sterile technique.
5. Available means of sterilization and disinfection.

Methods of Sterilization
1. Steam sterilization
 Autoclaving is sterilization using supersaturated steam under pressure.
 This method is non-toxic, inexpensive, sporicidal, and able to penetrate fabrics rapidly. It is used
to sterilize surgical dressings, surgical linens, parenteral solutions, metals and glass objects.
 Color indicator strips change color, indicating that sterilization has occurred.
 Check packaging for integrity and always check the expiration date to ensure sterility of the
object.
2. Gas sterilization
 Ethylene oxide is a colorless gas that can penetrate plastic, rubber, cotton and other substances.
 This is used to sterilize oxygen or suction gauges, BP apparatus, stethoscopes, catheters.
 Articles must be left to release the gas through aeration before they are used.
 This type of sterilization is expensive and requires 2 to 5 hours to be accomplished.
 Ethylene oxide is toxic to humans.
3. Radiation
 Ionizing radiation penetrates deeply into objects.
 This is used in sterilizing drugs, foods, and other heat-sensitive items.
4. Chemicals
 These are effective disinfectants.
  They attack all types of microorganisms, act rapidly, work with water, are inexpensive, are stable
in light and heat, are not harmful to body tissues, do not destroy articles.
 These are used for instruments and equipment such as glass thermometer.
 Chlorine is used for disinfecting water.
5. Boiling water
 This is least expensive for use in home.
 Items like glass baby bottles should be boiled for at least 15 minutes.

Types of Disinfection

Concurrent Disinfection
Ongoing practices that are observed in the care of the client, his supplies, his immediate environment, to
limit/control the spread of microorganisms.

Terminal Disinfection
Practices to remove pathogens from the client's belongings and his immediate environment after his illness is no
longer communicable.

Medical Aseptic Practices to be Implemented During Client Care

 Wash hands frequently, especially:

1. before handling foods
2. before and after using the toilet
3. before and after performing nursing procedures
4. before and after each patient contact
 Keep soiled items/equipment from touching the clothings. E.g. soiled linens.
 Instruct client to cover mouth and nose when coughing and sneezing.
 Avoid raising dust, do not shake linens.
 Clean least contaminated areas first then move to more contaminated areas.
 Practice segregation of wastes.
 Sterilize objects suspected of containing pathogens.
 Use practices of good personal hygiene to help prevent spread of microorganisms.

3. Use of Barriers
 Techniques that prevent the transfer of pathogens from one person to another are referred to as
"barriers."
 The most commonly used barriers are as follows:
Masks
Caps and shoe coverings
Gloves
Private rooms
Waterproof disposable bags for linen and trash
Labeling and bagging of contaminated equipment and specimens
Control of airflow into the sterile areas and out of contaminated areas
Goggles or face shields

 Masks
 Masks should fit tightly to the face, covering the nose and the mouth.
  Masks lose their effectiveness if they are wet, worn for long periods, and when they are not
changed after caring for each client.
 Disposable particulate respirators look like masks but fit the face more tightly and are able to
filter out particles or organisms as small as 1 micromillimeter. These are indicated whenever a
caregiver is working with a client who has, or is suspected of having contagious, airborne
diseases such as tuberculosis.
 Gowns
 Gowns should be worn when caregiver's clothing is likely to be soiled by infected material. Use
gowns only once and discard them.
 Change gown when it becomes wet.

 Caps and Shoe Coverings

 Caps are used to cover the hair, and special covers are available for shoes.
 These shield body parts from accidental exposure to contaminated body secretions.

 Gloves
 Gloves protect the hands for acquiring infective organisms.
 These reduce likelihood of transmission of microbial flora from personnel to clients or from
client to other clients.
 Gloves should be changed and discarded between clients or when they become torn or grossly
soiled.
 Hands are washed and dried before and after removing gloves.
 Gloves should not be washed and reused.

Never touch with bare hands anything that is wet coming from a body surface.

 Private Rooms
 Separation of clients into private rooms decreases the chance of transmission of infection by all
routes.
 If this is impossible, a client with an infection may be placed in the same room as another client
who is infected with the same microorganisms, as long as they are not infected with other
potentially transmissible microorganisms and the likelihood of reinfection with the same
microorganism is minimal.
 If transport to another department is necessary, client's gowns and dressings should be changed
before leaving the room and the client should wear necessary barriers such as mask or gown.

 Equipment and Refuse Handling

 Articles and linens soiled by any body fluid should be placed in impervious (water proof) bags
before they are removed from the client's bedside.
 The outside of the bag should not be contaminated when placing articles inside it; if the outside
of the bag becomes contaminated, placing that bag in another bag (double bagging) is required.
 Waste segregation and disposal should ensure prevention of transfer of microorganisms.
 Categories of institutional wastes are as follows:
a. Infectious Waste
 blood and blood products
 pathology laboratory specimen
 laboratory cultures
 body parts from surgery
 contaminated equipment (suction catheters, urinary catheters, nasogastric tubes)
 food unrinsed infant and adult diapers
b. Injurious Waste
 needles
  scalpel blades
 lancets
 broken glass pipettes
c. Hazardous Waste
 radioactive materials
 chemotherapy solutions and their containers and other caustic chemicals

 Recommendations for waste disposal are as follows: incineration or autoclaving of infectious

wastes before disposal in sanitary landfill; liquid body fluids (blood, urine, aspirated body fluids)
can be flushed down a drain connected to a sewer system; use separate containers, clearly
marked "Biohazard," for infectious waste, such as blood - contaminated items.
 Most healthcare agencies use color code for segregation of waste, e.g. black trashcan for wet,
biodegradable items; yellow trashcan for dry, non-biodegradable/ recyclable items.

4. Isolation Systems
 Isolation refers to techniques used to prevent or to limit the spread of infection.
 Isolation precautions are classified standard precautions, as transmissions-based precautions and
protective isolation.

Standard Precautions
 Synthesize the major features of Universal Precautions and Body substance Isolation.
 These precautions are intended to prevent transmission of bloodborne and moist body substance
pathogens.

2. Wear clean gloves when touching

1. blood, body fluids, secretions and excretions, and items containing these body substances.
2. mucous membrane
3. nonintact skin
3. Perform handwashing immediately
1. When there is direct contact with blood, body fluids, secretions and excretions, or contaminated
items.
2. After removing gloves.
3. Between patient contacts.
4. Wear a mask, eye protection and face shield during procedures and patient care activities that are likely
to generate splashes or sprays of blood, body fluids, secretions, and excretions.
5. Wear a cover gown during procedures and patient care activities that are likely to generate splashes or
sprays of blood, body fluids, secretions or excretions, or cause soiling of clothings.
6. Remove soiled protective items promptly when the potential for contact with reservoirs of pathogens is
no longer present.
7. Clean and reprocess all equipment before reuse by another patient.
8. Discard all single use items promptly in appropriate containers that prevent contact with blood, body
fluids, secretions and excretions, contamination of clothing, or transfer to other patients and the
environment.
9. Prevent injuries with used needles, scalpels, and other sharp devices by:
1. Never removing, recapping, bending or breaking used needles.

NEVER RECAP NEEDLES. Use your NEEDLE DISPOSAL container.

2. Never pointing the needle toward a body part.

 3. Using a one-handed "scoop" method, special syringes with a retractable protective guard or
shield for enclosing a needle, or blunt-point needles.
4. Depositing disposable and reusable syringes and needles in puncture-resistant containers.

10. Use a private room or consult with an infection control professional for the care of patients who
contaminate the environment or who cannot or do not assist with appropriate hygiene or environmental
cleanliness measures.

Transmission-based Precautions

1. Airborne Precautions. These are used for microorganisms transmitted by small particle droplets that
can remain suspended and become widely dispersed by air currents, Examples: TB, varicella, measles.
 The client should be cared for in a private, negative - airflow room, to contain the air within the
client's unit.
 Caregivers are to wear masks; the client should wear mask when transported out of the room.
2. Droplet Precautions. These are used for microorganisms transmitted by larger-particle droplets,
(through coughing, sneezing or talking) which disperse into air currents. Examples: haemophilus
influenzae, diphtheria, rubella, mycoplasma pneumoniae.
 The client should be in a private room.
 The caregivers are to wear masks when working within 3 feet of the client.
 The client should wear mask when outside the room.

3. Contact Precautions. These are used with organisms that can be transmitted by hand or skin-to-skin
contact, such as during client care activities or when touching the client's environmental surfaces or care
items. Examples: clostridium difficile, shigella, impetigo.
 The client is cared for in a private room or has a roommate who is infected with the same organism
(cohabitation).
 Personnel use gloves before entering the room and change gloves when exposed to potentially
infected material during care delivery.
 Remove gloves before leaving the client's room.
 Gowns and other protective barriers are to be used when contamination is likely either from the
client, the environmental surfaces or the client's room.

Protective Isolation
 Implemented to prevent infection for people whose resistance to infection/ body defenses are lowered or
compromised. Examples: clients, with low wbc count (leukopenia); on immunosuppressive medications
like cancer chemotherapy; with extensive burns.
 The client should be placed in a private room.
 Meticulous handwashing is strictly practiced by the client, his family, all caregivers.
 Restrict visitors.
 Persons with signs and symptoms of infection are not allowed to visit the client. Examples: those with
cough and colds, diarrhea, skin infections.
 Only cooked or canned fruits are allowed.
 No fresh fruits or vegetables, raw foods, fresh flowers, potted plants

Surgical Asepsis
 The purpose of sterile technique is to prevent the introduction of microorganisms.
 Surgical asepsis is required in the following situations:
o Surgical procedures. All procedures that invade the bloodstream.
o Procedures that cause a break in skin or mucous membranes (eg, intramuscular injections).
 o Complex dressing changes and wound care.
o Insertion of tubes, catheters or devices into sterile body cavities (eg. urinary bladder). Care for
high risk groups (e.g. transplant recipients, burn clients, clients with cancer).

Principles of Surgical Asepsis

1. Moisture causes contamination.

 Prevent splashing of liquids in the sterile fields. Place wet objects on sterile, water-impermeable
surfaces, such as sterile basin.
 Rationale: Microorganisms travel more easily through moist environment. When sterile surface
becomes moist, microorganisms from the unsterile surface may be transmitted into the sterile surface.

2. Never assume that an object is sterile.

 Ensure that it is labeled as sterile.
 Always check the integrity of the packaging.
 Always verify the expiration date on the package. . Whenever in doubt of the sterility of an object,
consider it unsterile.
 Rationale:
o Commercially prepared products are labeled as sterile on their packaging.
o Special indicators are used to show that objects have completed their sterilization process.
o Packages that are torn, punctured, or moist are considered unsterile.
o An object is considered sterile only for a specified period. Items that have passed the expiration
date are considered unsterile.

3. Always face the sterile field.

 Rationale: Objects that are out of the line of vision may be inadvertently contaminated.

4. Sterile articles may touch only sterile articles or surfaces if they are to maintain their sterility.
 Rationale:
o Anything considered unsterile may transfer microorganisms to the sterile object it touches.
o An object used in cleaning the skin (eg, swabs) must be used once and then discarded because
the skin cannot be sterilized.

5. Sterile equipment or areas must be kept above the waist and on top of the sterile field.
 Drapes hanging over the edge of the table are not considered sterile.
 Rationale: Waist level is the limit of good visual field. Maximum visibility of all sterile objects prevents
inadvertent contamination.

6. Prevent unnecessary traffic and air currents around the sterile area.
 Close doors.
 Unfold drapes or wrappers slowly.
 Do not sneeze, cough, or talk excessively over the sterile field.
 Do not reach across sterile fields.
 Move around a sterile field to reach for an object, if necessary.
 Rationale:
o Microorganisms cannot be completely excluded from the air.
o Overreaching across sterile fields will rerider sterile objects unsterile.

7. Open, unused sterile articles are no longer sterile after the procedure.
 Rationale:
 o Once protective wrapping have been removed, the article is being contaminated by air so, it must
be discarded or resterilized before it is used.
o Liquids opened during the procedure that remain in their original container are also considered
contaminated.

8. A person who is considered sterile who becomes contaminated must reestablish sterility.
 Rationale:
o If a "scrubbed" person punctures the gloves or is contaminated by touching an unsterile object,
he or she must change the contaminated article.
o If a "scrubbed" person leaves the area of the sterile field, he or she must go through the
procedure of rescrubbing, gowning and gloving.

9. Surgical technique is a team effort.

 A collective and individual "sterile conscience" is the best method of enhancing sterile technique.
 Rationale:
o Staff members must rely on one another to maintain sterile technique.
o Periodic review of procedures and infection control surveillance reports enhance everyone's
sterile technique.

Related Nursing Skills: Performing Sterile Procedures

 Surgical Hand Scrub

 Applying and Removing Sterile Gloves
 Donning Sterile Gown and Closed Gloving Donning and Removing Caps, Masks, and Eyewear
 Preparing and Maintaining A Sterile Field
 Opening Sterile Drape
 Adding Sterile Supplies to the Field (Opening sterile packages, opening a sterile item on a Flat
surface)
 Pouring Sterile Solutions
 Care of the Sterile Pick-up Forceps

Surgical Hand Scrubs

Purpose: Remove as many microorganisms from the hands as possible before the sterile procedure.
Equipment:
 Sink with knee or foot controls (ideally)
 Antimicrobial soap
 Surgical scrub brush
 Plastic nail stick or sterile nail cleaner (ideally)
 Sterile towel for drying
Steps:

1. Be sure fingernails are short, clean, and healthy. Nail polish should be removed. Rationale: Long nails
and nail polish increase number of bacteria residing on nails.

2. Remove rings. Apply surgical shoe covers, cap, face mask, and protective eye wear. Rationale: Rings
can harbor microorganisms. Applying attire after handwashing would contaminate hands
 3. Wash and rinse hands for initial wash. Rationale: To remove gross contamination and transient
microorganisms.

4. Open disposable brush impregnated with antimicrobial soap, adjust water temperature to warm using
knee or foot control lever. Rationale: Antimicrobial soap reduces microorganisms. Warm water
decreases drying of hands.

5. Wet hands and arms. Keep hands above elbows. Rationale: Movement of water and dirt will flow from
hands to less clean areas; thus preventing contamination of the hands during scrub.

6. Use nail stick or cleaner to clean under nails of both hands. Rationale: The nails can harbor significant
bacteria and need to be cleaned thoroughly.

7. Wet scrub brush or apply antibacterial soap if not already impregnated in the brush. Rationale:
Antibacterial soap assists in removing transient and resident microorganisms.

8. Anatomic Timed Scrub Starting with fingertips, scrub each anatomic 5 area (nails, fingers each side and
web space, palmar surface, dorsal surface and forearm) for around 5 minutes. Scrub vigorously using
vertical strokes. Repeat with other hand. Rationale: Ensures that all surfaces will be systematically
scrubbed to remove transient and resident microorganisms.

9. Counted Brush Stroke Method. Starting with fingertips, scrub each anatomic area (same as in step no. 8)
for the designated number of strokes according to agency policy. Scrub vigorously using vertical
strokes. Rationale: Same as in step no. 8
10. Rinse hands thoroughly under warm running water, holding hands upward. This is to allow water to
drain towards the flexed elbows. Rationale: Prevents contamination of the hands from dirtier areas.

Do not touch anything before and after rinsing hands. Touching nonsterile objects would mean the surgical
scrub would need to be repeated.

11. Keep hands held upward to allow water to drip from the hands to the elbow. Dry hands with sterile
towel. Rationale: Prevents contamination before gloving.

Applying and Removing Sterile Gloves

Purpose: Prevent transfer of microorganisms from hands to sterile objects or open wounds.
Equipment:
 Packaged sterile gloves in correct size
 Flat working surface
Steps:
a. Applying Gloves

1. Wash hands. Rationale: Clean hands reduce the number of microorganisms that could be transmitted if
gloves accidentally puncture or tear.

2. Peel off outside wrapper as directed by manufacturer (peel sides apart). Rationale: This protects inner
package from inadvertently opening and contaminating the gloves.

3. Lay inner package on clean, flat surface about waist level. Open wrapper from the outside, keeping
gloves on inside surface. Rationale: Objects below waist level are considered contaminated. Inner
surface of wrapper is considered sterile.
 4. Grasp first glove by inside edge of cuff with thumb and first two fingers of the dominant hand. Hold
hands above waist, insert non-dominant hand into glove. Adjust fingers inside glove after both gloves
are on. Rationale: Inner edge of cuff unfolds against skin of hand and is not sterile once applied.
Contamination occurs if ungloved hand contacts gloved hand.

5. Slip gloved hand (four fingers with thumb up) underneath second gloved cuff and pull over dominant
hand. Rationale: Sterile cuff protects fingers of gloved hand from being contaminated.

Put on gloves on the nondominant hand first, then on the dominant hand.

6. Keeping hands above waist, adjust glove fit, touching only sterile areas. Rationale: This prevents
potential contamination while ensuring a smooth fit over fingers.

b. Removing Gloves

7. Wash gloved hands first. Rationale: To reduce the number of microorganisms that could contaminate
the hands.

8. With dominant hand, grasp outer surface of non dominant glove just below thumb Peel off glove inside
out, without touching exposed wrist. Rationale: After use, outer surface of gloves is contaminated and
could transfer microorganisms to the nurse's wrist.

9. Place ungloved hand under thumb side of second cuff and peel off toward the fingers holding first glove
inside second glove. appropriate receptacle. Rationale: Folding contaminated glove surfaces toward the
inside minimize the chance of transfer of microorganisms.

Use "glove-to-glove," "skin-to-skin" technique when removing gloves.

10. Wash hands

Safety alert: Wash hands before and after removing gloves to prevent contamination of hands.

Donning A Sterile Gown and Closed Gloving

Purpose: To apply attire necessary to safely carry out sterile procedures usually in the operating room and
delivery room.
Equipment:
 sterile gown
 sterile gloves
 Mayo stand or flat surface area above waist level
Steps:

4. Wear shoe covers, cap that covers all hair, face mask and protective eye wear (ideally) and perform the
surgical scrub. Rationale: The gown and gloves should be donned last, because it is most important for
them to be sterile.

b. Donning a Sterile Gown

 5. Grasp folded sterile gown at the neckline and step away from the sterile field. Allow gown to gently
unfold, being careful that it does not touch the floor. The inside of the gown is toward the
user. Rationale: Maintains sterility of the gown and positions it for donning.

6. Holding the arms at shoulder level, grasp the sterile gown just below the neckband near the shoulders
and slide arms in the sleeves until the fingers are at the end of the cuffs but not through the
cuffs. Rationale: The fingers remain in the cuffs to protect the sterility of the gown and prepare for
closed gloving.

7. Have someone tie the back of the gown, taking care that only the ties are touched and not the sides or
front of the gown. Rationale: Maintains sterility of the gown. Gowns are considered sterile in the front
from the shoulder to the table level, and sleeves are considered sterile from 2 inches above the elbow to
the wrist.

b. Removing Gloves

8. With fingers still within the cuff of the gown, open the inner sterile glove package and pick up the first
glove by the cuff, using the nondominant hand. Rationale: Maintains sterility of the glove.
9. Position the glove over the cuff of the gown so the fingers are in alignment, and stretch the entire glove
over the cuff of the gown, being careful not to touch its edge. Fingers remain within the cuff of the
gown. Rationale: Maintains sterility of the glove.

10. Work the fingers into the glove and pull the glove up over wrist with the nondominant hand that still
remains within the cuff of the gown. Rationale: Maintains sterility of the glove.

11. Use the sterile gloved hand to pick up the second glove, placing it over the cuff of the gown of the other
hand and repeat the glove application process. Rationale: Maintains sterility of the glove.

12. Adjust gloves for comfort and fit, taking care to keep gloved hands above waist level at all
times. Rationale: If gloved hands fall below waist level, they are no longer sterile.

Donning and Removing Gloves, Masks, Gowns and Eye Wear

 For sterile procedures on a general nursing division, the nurse may wear surgical mask and gloves
without a cap. Eye wear is ideally worn if there is risk of fluid or blood splashing into the nurse's eyes.
 For sterile surgical procedures, the nurse first applies a clean cap that covers all of the hair and then the
surgical mask, eye wear, and shoe cover.
 A mask must fit snugly around the face and nose to prevent contamination.
 To remove protective devices: remove gloves first, then the mask, gown, the eye wear or goggles,
cap and shoe cover. Removing the gloves first prevents contamination of the hair, neck and facial area.

For removing protective wear, do:

Glove > Mask > Gown > other devices sequence.

Preparing and Maintaining A Sterile Field

Purpose: To create an environment that helps ensure the sterility of supplies and equipment and prevent
transfer of microorganisms during sterile procedure.
Equipment:
 Flat work surface
 Sterile drape
  Sterile supplies, eg. sterile gauze, sterile basin, solutions, scissors, forceps
 Packaged sterile gloves
Steps:
A. Special considerations

1. Wash hands. Rationale: Minimizes the number of transient bacteria on the hands.

2. Inspect all sterile packages for package integrity, contamination, or moisture. Rationale: Moisture,
breaks in package integrity, and visible contamination indicate that the contents are no loner sterile and
must be discarded.

3. During the entire procedure, never turn back on the sterile field or lower hands below the level of the
field. Rationale: Ensures sterility of the field.

B. Opening A Sterile Drape

4. Remove the sterile drape from the outer wrapper and place the inner drape in the surface of the work
surface, at or above waist level, with the outer flap facing away from you. Rationale: Maintains sterility
of the package and allows for opening the drape in a manner that will not contaminate the sterile field.
5. Touching the outside of the flap, reach around (rather than over) the sterile field to open the flap away
from you. Rationale: Maintains sterility of the field.

6. Open the side flaps in the same manner, using the right hand for the right flap and the left hand for the
left flap. Rationale: This maintains sterility by avoiding crossing over the field.

7. Open the innermost flap that faces you, being careful that it does not touch your clothing or any object.
Rationale: Maintains sterility of the field.

C. Adding Sterile Supplies to the Field

8. Open unsealed edge of prepackaged sterile supplies, taking care not to touch the supplies with the
hands. Rationale: Maintains sterility of the supplies.

9. Hold supplies 10 to 12 inches above the field and allow them to fall to the middle of the sterile field.
Rationale: Ensures that sterile supplies are placed within the sterile field.

10. Wrapped sterile supplies are added by holding the sterile object with one hand and unwrapping the flaps
with the other hand. Carefully drop the object onto the sterile field. Rationale: Maintains sterility of the
object and the field.

D. Pouring Solutions to a Sterile Field

11. Check the label and expiration date of the solution. Note any signs of contamination. Rationale: Ensures
that the correct solution is used and that it is sterile.

12. Remove cap and place it with the inside facing up on a flat surface. Do not touch inside of cap or rim of
bottle. Rationale: Maintains sterility of the solution and the field.

13. Pour a small amount of solution into a sink or waste container to rinse the rim of the container. (This is
done when pouring weak solutions like sterile normal saline solution, distilled water). Rationale: This
ensures sterility of the solution.
 14. Hold bottle 6 inches above receptacle on the sterile field and pour slowly to avoid spills. Rationale:
Spilling fluid on the sterile field results in contamination because a wet surface allows microorganisms
to transfer from the flat surface which is not sterile.

15. Recap the solution bottle, place it outside the sterile field and label it with date and time of opening if
the solution is to be reused. Rationale: Keeps solution in the bottle sterile and avoids use of solution that
has passed expiration date.

16. Add any additional supplies and don sterile gloves before starting the procedure. Rationale: Donning
sterile gloves just prior to beginning the procedure helps to ensure sterility.

Care of the Sterile Pick-up Forceps

Purpose: To transfer sterile articles and maintain sterility of these articles and the sterile field.
Equipment: Sterile forceps in a sterile bottle with germicidal/ disinfectant solution
Steps:

1. The prongs of the sterile forceps should be fully immersed in disinfectant solution. Rationale: This
maintains sterility of the part of the forceps that will keep in touch with sterile objects.

2. Sterile forceps are always held above and in front of the waist, within the vision of the nurse. Rationale:
To prevent inadvertent contamination out of nurse's range of vision.

3. The tips of the forceps are always considered sterile and need to be held down. Rationale: This prevents
the fluid from flowing from the sterile tips to the unsterile handles, becoming contaminated, and then
flowing back by gravity to the tips when they are held down again.

4. The handles of the forceps are considered contaminated except when handled by sterile
gloves. Rationale: Handles of the sterile forceps when held by the bare hands are considered nonsterile.

5. Use the thumb and middle fingers when lifting the forceps from the container. The tip should not touch
the rim or any part of the container not directly in contact with the disinfectant. Rationale: The rim and
any part of the container not immersed in disinfectant are considered nonsterile. Sterile object should
touch only sterile objects or surface.

6. Tap the handle of the forceps with the index finger to remove excess solution from the tip, outside the
sterile field. Rationale: To prevent the solution from flowing to the handles, then back to the tips of the
forceps. This will prevent contamination of the sterile tips of the forceps.

7. When removing sterile items from a container, the tips of the forceps and/or the item should be kept
away from the edges of the container or disposable wrapper. Rationale: The edges are exposed to air
and are considered contaminated.

8. Return the forceps to the container, without touching the tips to the rim or part of the container not
immersed in disinfectant. Rationale: This maintains sterility of the forceps.
 Block 3. Health and Illness
3.3. Stress, Adaptation, Homeostasis
3.3.1. Physiologic Responses to Stress and Illness

Introduction

In this contemporary world, stress has become a household word, Parents refer to the stress of raising
children; working people to the stress of their jobs; students to the stress of studying adolescents to the stress of
changing body image.

The concept of stress is important because it provides a way of understanding the person as a unified
being who responds in totality-mind and body, to a variety of changes that may take place in daily life. Stress is
a universal phenomenon. All people experience stress. As Hans Selye avers, "Stress is always a part of the
fabric of daily life."

Stressors are found in the internal environment and in the external environment. Stressors can also be
both physiologic and psychologic Therefore, a person who is experiencing an increased state of stress brought
on by any stressor exhibits both physiologic and psychologic signs and symptoms.

Moreover, stress accompanies every disease and illness. It is therefore important that we, nurses be able
not only to recognize stress but that we would be able to assist people to adapt to stress.

All stressors to the body evoke common adaptive responses regardless of whether they arise from within
or without the body, whether they are pleasant or unpleasant, whether they are real or imagined.

As the person encounters any stress, various systems of the body are brought into play in order to adapt
and maintain homeostasis---the dynamic state of equilibrium.

People adapt on a number of levels-physiologically, mentally and emotionally. This Block (3.3.1)
focuses on the physiologic responses to stress and illness. Block 3.3.2 focuses on the psychosocial and spiritual
responses to stress and illness.

It is the goal of this Block to help you, to assist clients to adapt to stress and maintain homeostasis in any
health care setting and prevent crisis.

Stress

Modern Stress Theory (Hans Selye)

Stress is the nonspecific response of the body to any demand made upon it.

Statements on Stress

1. Stress is not a nervous energy.

Stress is a psycho- physiologic response. Examples of psychologic responses to stress: anxiety, fear, use
of ego defense mechanisms.Examples of physiologic responses to stress: fever, inflammation, antigen-
antibody response, immune response.

2. Man, whenever he encounters stress, he tends to adapt to it.

Man possesses different adaptive mechanisms such physiologic, psychologic, social, technologic
adaptations. Examples: A physiologic adaptation to constant carrying of heavy objects is increase in the size
of muscles in the arms and chest (hypertrophy).
 A psychologic adaptation to stress is use of ego defense mechanisms like rationalization, sublimation,
etc.
A student rationalizes that he failed in the course because the professors are not teaching well. A woman
who is lonely because her husband is working overseas had put up a store so that she will be busy and her
loneliness will be relieved.

3. Stress is not always something to be avoided.

There are stresses that a person should inevitably face or accept. Example: a student should not avoid the
stress of taking examinations so that he will fulfill the requirements of the course; a woman with cancer of
the breast should not avoid undergoing surgery so that the cancer will be controlled; a Type 1 diabetic
should not avoid daily insulin injections because his life depends on the medication.

4. Stress does not always lead to distress.

Stress may be pleasant or unpleasant. A distress is an unpleasant stress. Examples of stresses that will
not always lead to distress are as follows: diarrhea is the body's protective mechanism to rid itself of toxins;
fever is a warning signal to the presence of infection; pain enables the body to protect itself from injury.

5. A single stress does not cause a disease.

A disease is multicausal. A person develops ulcer because of irregular meals for quite a long time,
practices excessive smoking, alcohol abuse, and many other factors.

6. Stress may lead to another stress.

Examples: the stress of diarrhea may lead to dehydration; the stress of fever may lead to convulsions;
the stress of pain may lead to neurogenic shock."

7. A stress, whenever prolonged or intense may lead to exhaustion.

Exhaustion means that adaptive mechanisms of the body can no longer persist, so illness or death may
occur.

8. Stress is always a part of the fabric of daily life.

Stress has always been part of human experience. It is essential, although at times problematic.
As long as a person is alive, he will be experiencing stress because he is in constant contact with various
factors in the environment which most often are antagonistic. Even in sleep, man encounters stress because
his vital functions continue.

Adaptation
The adjustments that a person make in different situations.

Types of Adaptation

A. General Adaptation Syndrome (GAS)

 Man, whenever he responds to stress, the entire body is involved.
 There are many similar manifestations that characterize different disease conditions; and there are very
few specific manifestations that characterize a particular disease. Fever, weakness fatigue, headache,
anorexia, pain are examples of manifestations that characterize various disease conditions.

Stages of GAS

1. Stage of Alarm (SA)

 The person becomes aware of the presence of threat or danger.
 Levels of resistance are decreased.
  Adaptive mechanisms are mobilized (fight-or-flight reaction).
 If the stress is intense enough, even at the stage of alarm, death may ensue. Example: profuse
bleeding in amputated limb due to vehicular accident.

2. Stage of Resistance (SR)

 Characterized by adaptation.
 Levels of resistance are increased.
 The person moves back to homeostasis.

3. Stage of Exhaustion
 Results from prolonged exposure to stress and adaptive bris otsib mechanisms can no longer
persist.
 Unless other adaptive mechanisms will be mobilized, death ensue.

B. Local Adaptation Syndrome (LAS)

 Man may respond to stress through a particular body part or body organ. Eg, inflammation, backache,
headache, diarrhea.

Characteristics of Adaptive Responses

1. Attempts to maintain homeostasis.
2. Whole body/total organism responses.
3. Have limits.
4. Require time.
5. Vary from person to person.
6. Inadequate or excessive.
7. Egocenteric, tiring.
- Requires body energy and tax physical and psychological resources.

Modes of Adaptation

1. Physiologic/Biologic Adaptive Mode

 e.g. enlargement of arm and chest muscles among men whose jobs include heavy lifting people who live
in countries with very hot/warm climate develop dark skin. This is due to overproduction of melanin to
protect inner layers of the skin.

2. Psychologic Adaptive Mode

 e.g. use of ego defense mechanism like denial, rationalization.

3. Sociocultural Adaptive Mode

 eg. talking, acting, dressing like the people in a particular place

4. Technologic Adaptive Mode

 eg. nurses learn how to use electronic devices and computers.

Homeostasis
 A state of dynamic equilibrium; stability; balance; constancy; uniformity. It is now more commonly
referred to as "homeodynamics," because it is characterized by constant change.
 It is regulated by negative feedback mechanism.
Local Physiologic Responses To Stress
Inflammation involves mobilization of specific and nonspecific defense mechanism in response to tissue
injury or infection.
Purposes of Inflammation
1. To localize tissue injury
2. To protect tissue from injury
3. To prepare tissue for repair

Cellular Response
 Neutrophils. First to be launched at the site of tissue injury.
 Monocytes. Perform phagocytosis in chronic tissue injury.
 Lymphocytes. Responsible for immune response.

Processes Involved:
 Marginal/pavementation. Phagocytes line up at the peripheral walls of the blood vessels.
 Emigration/diapedesis. Phagocytes shift out of the blood vessels
 Chemotaxis. Injured tissues release substances which exert magnet like force to the phagocytes to bring
them to the area of injury.
 Phagocytosis. Phagocytes ingest or engulf the antigens.

Healing Process (Reparative Phase)

 Regeneration. Involves replacement of damaged tissue cells by new cells which are identical in
structure or function.
 Scar Formation. Involves replacement of damaged tissue cells by fibrous tissue formation. In the early
stage, granulation tissue (pink or red, fragile gelatinous tissue) forms; later in the process, a cicatrix or
scar forms because the tissue shrinks and the collagen fibers contract.
 Healing may also be classified as follows:
o First Intention: Occurs in clean-cut wound (e.g. surgical wound). The wound edges are
approximated, there is minimal or no scar tissue formation (also primary intention healing or
primary union)
o Second Intention: Occurs when the wound is extensive and there is a great amount of tissue loss
(e.g. decubitus ulcer). The repair time is longer; the scarring is greater (also, secondary intention
healing).
o Third Intention: Occurs when there is delayed surgical closure of infected wound (also, tertiary
intention healing)

The Systemic Manifestations of Inflammation

 Fever
 Leukocytosis (elevated WBC)
 Elevated ESR (erythrocyte sedimentation rate)
 Lymphadenopathy
 Anorexia
 Headache
 Bofy Weakness/ Fatigue
 Body Malaise

Other Responses to Tissue Injury:

1. Necrosis. Is death of tissues.
2. Hypertrophy. Is an increase in cell size.
3. Hyperplasia. Is an increase in cell number:

4. Metaplasia. Is a replacement of one mature cell type with another mature cell type. The new cell type is not
one normally seen in the area.

Nursing Interventions for Clients with Inflammation

1. Promote rest. To enhance recovery.
2. Reduce swelling
 Position: Elevate the affected body part to promote venous return.
 Heat and Cold Application: Cold application during the first 72 hours; heat application after 72 hours.
3. Relieve pain
4. Increase excretion of microorganism by adequate hydration.
5. Provide adequate nutrition: high caloric, high protein with Vitamins A and C rich foods.
6. Pharmacotherapy
 Analgesic/Antipyretic: e.g. Aspirin, Acetaminophen, Paracetamol, Mefenamic Acid, etc.
 Anti-inflammatory: Non-steroidal anti-inflammatory drugs (NSAIDs), Steroids
 Antimicrobials: to control infection
7. Surgery
 Incision and Drainage: To remove inflammatory exudates to promote healing process.
 Debridement: To remove necrotic tissues.
- Surgical and mechanical debridement.
- Mechanical debridement is performed using the wet-to-dry dressing method.
 Block 3. Health and Illness
3.3. Stress, Adaptation and Homeostasis
3.3.2. Psychosocial and Spiritual Responses to Stress and Illness

Introduction

The presence of illness can be stressful. Both of which, stress and illness serve as stimuli. Man, being an
open system responds to these stimuli. Since man is composed of different parts, he can have a wide range of
responses biological, psychological, emotional, social and spiritual responses to stress and illness. A common
psychobehavioral response is anxiety. However any of the following behaviors may also be experienced:
aggression, depression, withdrawal, suspiciousness and somatic complaints. Past experiences, his resources,
culture and religion to which he belongs could influence his perception of stress and illness and consequently
affect his responses.

When a person cannot escape or solve the stress with his usual problem-solving process, it could lead to
psychological disequilibrium, and he is said to be in crisis. A person who is experiencing stress, more so, one
who is in crisis, needs help and intervention from the nurse. The nurse can help by using the self therapeutically,
by establishing a therapeutic nurse-client/helping relationship and implementing her skills in therapeutic
communication.

This Block will help you, to understand various dimensions of responses to stress, illness, specifically
psychosocial responses. It will also help you gain knowledge about stress management interventions/techniques
and the helping relationship.

Therapeutic Relationship
A therapeutic relationship is directed towards helping a patient heal, both physically and emotionally.
Unlike a social relationship, which is based on friendship and mutual interest, a therapeutic relationship is:
 A professional relationship between a nurse, physician or therapist and a client.
 Focused on helping the patient solve problems and achieve certain well-defined, mutually agreed upon,
health-related goals.
 A means for more smoothly implementing the five steps of the nursing process: assessing, making a
nursing diagnosis, planning implementing the plan and evaluating the client's progress.
 Maintained only as long as the client requires professional help meet important health-related goals

The foundation of a therapeutic relationship is therapeutic communication.Therapeutic communication

is goal-oriented and essentially considers culture of clients. The goal of transcultural therapeutic communication
is to help patients from different culture:
 Explore their life experiences, value and belief systems and reactions to illness and treatment.
 Establish realistic, culturally acceptable, health related goals.
 Take actions that will benefit their physical and mental health, yet still are in keeping with their personal
and culture values.

Phases of Therapeutic Nurse - Patient Relationship

 Preinteraction Phase
 Orientation Phase
 Working Phase
 Termination Phase

1. Preinteraction Phase. During this phase of relationship, you will need to learn as much as possible
about your client, including reasons for seeking care.
 To begin your assessment:
 review the client's medical record and nursing notes
 note the client's history of previous hospitalizations, as well as any procedures that he had
undergone in the past
 note the symptoms that brought the client to the clinic or hospital
 speak with other health care providers who may have cared for the client; inquire about the
client's cultural background and emotional state, and the client's ability to comprehend his
disorder and its treatment.

In relation to learning about your client, you also need to think about your own culturally-based
beliefs and values. Honestly examine yourself for any feelings of bias, prejudice, ambivalence or
hostility that you may harbor toward a client of a different race or culture. Of course, uncovering these
feelings is only the first step in building transcultural relationship. In addition to facing your feelings of
prejudice, you must also be able to put these feelings aside when providing care.

2. Orientation Phase. During the orientation phase, you need to continue gathering information about
your client's history and current problems. This is also the time to: (a) perform a physical, psychosocial
and cultural assessment; (b) formulate patient outcomes; (c) plan interventions Throughout the
orientation phase, it is important to show the client respect and to establish trust and rapport.

3. Working Phase. As soon as you and the client have established a therapeutic relationship, the working
phase begins. Now you can begin to:
1. Assess the person's concerns, strengths and weaknesses.
2. Establish a contract with the client regarding expectations and responsibilities.
3. Decide on mutually agreed upon goals.
4. Establish a plan of action that satisfies you and the client.
5. Set limits.
6. Discuss the time frame for your relationship. During this phase, continue to establish rapport and
build
trust. In doing so, encourage the client to speak openly about feelings, fears and regrets.

Nursing diagnosis, plans of action and evaluations may change as a result of your assessment of
the patient.

4. Termination Phase. A therapeutic relationship may be terminated for a variety of reasons: the client
may be discharged, the nurse or nursing student may change services, or the client's goal may be met.
Regardless of the reason for termination, it should not come as a surprise to the client. Remember that
one of the tasks of the orientation phase is to set a time-framed relationship, and to make certain that the
client understands that the relationship will eventually end.

During the termination phase, the major tasks are to:

 Outline the client's strengths and discuss the progress the person has made while in your care.
 Review areas in need of improvement.
 Discuss the client's goals, and develop a plan of self-care following discharge.
 Discuss any feelings (positive or negative) that the client might have regarding the termination of
your relationship.

Ingredients of Therapeutic Communication

 Empathy
 Positive Regard
  Comfortable Sense of Self

1. Empathy. Is the ability to enter into another person's experience to perceive it accurately and to understand
how situation is viewed from the client's perspective. Empathy includes the ability to respond receptively to
the other person's experience while maintaining objectivity and ability to communicate to the person that he
or she is understood. This is done through the process of reflective or active listening.

Empathy is a complex process. The nurse must:

 Have enough knowledge and experience to perceive the client's perspective accurately.
 Feel secure enough not to be intimidated if the client experiences a situation differently.
 Feel comfortable enough to be able to imagine what a situation might be like someone else, while
remaining outside that situation to maintain objectivity.
 Convey to the client that the nurse perceives the client's feelings, thoughts and experiences accurately.
 Empathy is a strong component in therapeutic relationships. However, constant exposure to client care
can emotionally drain the nurse. It is not necessarily appropriate to use the entire emphatic process in
every clinical situation. Simple action such as touch, kindness, attentiveness and information sharing
also signify empathy.

2. Positive Regard. Refers to warmth, caring, interest and respect for the person, seeing the person
unconditionally or non-judgmentally. Respect for the person does not depend on his or her behavior;
instead, the person is regarded as worthwhile simply for being human.

Positive regard does not mean that the nurse accepts all aspects of a person's behavior. The nurse does
not condone or encourage behavior that is socially inappropriate or abusive. However, the nurse must
separate that behavior from the person. The underlying assumption is that the person is worthwhile and has
value and dignity.

Positive regard also means that the professional avoids unnecessary labeling of clients. The focus of
healthcare professionals on disease tends to label the client as an object (e.g., a diabetic, an amputee
alcoholic). As a result, viewing a client as his or her disease rather than as someone who has that disease can
interfere with seeing the an person behind the label. This viewpoint tends to come through in the
communication process. Ignoring the response makes it more difficult to know and understand his/her
response to health and illness and to use the client's strengths and potential.

3. Comfortable Sense of Self. Before a nurse can communicate therapeutically, a comfortable sense of self,
such as being aware of one's own personality, values, cultural background and style of communication, is
necessary. A person's sense of self comprises a collection of characteristics. For example, the nurse may be
a professional, a parent, and may be overweight, tall or athletic.
 The nurse with comfortable sense of self can evaluate his/her strength and weaknesses. For example,
one nurse may say, "I work well with postoperative clients, but I have less aptitude for working with
rehabilitation clients because I like things to happen more quickly," another nurse might enjoy working
with psychiatric clients because he/she finds working on interpersonal goals rewarding.
 Self evaluation also means taking responsibility for one's actions as a professional. For example, a nurse
might think, "I could have said something more supportive," or, "I should have included the family in
the planning phase." Through this process, the nurse grows in professional competency.
 A person with a comfortable sense of self is open to experiences and is aware of his/her feelings and
attitudes. This allows the person to take a more flexible view of life. For example, the nurse may notice
that not all clients respond the same way to surgical procedure and that not all people in a given culture
fit the stereotypes of that culture. The differences between the nurse and the client can be seen as
interesting or challenging, rather than threatening or bad.
  The professional with comfortable sense of self feels separate from others, an important aspect of being
therapeutic. Because it is easy for a nurse to over identify with clients, clear interpersonal boundaries
need to be maintained. A nurse who becomes too involved in the suffering of clients soon becomes
emotionally and physically exhausted, lacking the objectivity it takes to be therapeutic. Also, the ability
to separate prevents the nurse from seeking gratification through excessive client dependence. The nurse
gives appropriate support and care but has confidence in client's abilities to make choices in their health
and lives.
 To maintain professional enthusiasm and job satisfaction, nurses must attend to their own needs as
people. Rest, exercise and To maintain professional enthusiasm and job satisfaction, nurses interesting
activities, and time for relaxation and enjoyment are balanced diet are important physical needs.
Supportive relationships, important emotional needs. Being therapeutic with one's self is necessary
before one can be therapeutic with others.

Stress, Crisis and Coping

 As stress is an essential aspect of existence and has always been part of human experience, it is
something that each person has to cope.

 Coping is a process that a person uses to manage events that he/she encounters, perceives, and interprets
as stressful. Successful coping requires adjusting or adapting to circumstances, environmental demands
and challenges. The ability to cope is a crucial element that influences well-being. Failure to cope may
lead to crisis.

 A crisis suggests a situation in which usual coping strategies are ineffective, and the person is
disorganized or unable to solve problems appropriately. Examples of situations that may precipitate
crisis are as follows: acute health problems, illness, loss, or trauma.

Behavioral Responses to Stress/Crisis

 Anxiety
 Aggressiveness
 Depression
 Withdrawal
 Suspiciousness
 Somatic behavior

Anxiety
 with physiologic/psychologic component
 a feeling of dread or uneasiness from unrecognized cause.
 fear is a feeling of dread to a recognized cause.
 results when one perceives threat to the self; may be physiologic or psychologic threat.

Levels of Anxiety and Manifestations

1. Mild
 Increased alertness.
 Quick eye movements.
 Increased hearing acuity.
 Increased awareness of the environment details.
2. Moderate
 Decreased awareness of environment details.
 Focus is on selected aspects of self/illness.
3. Severe
 Characterized by disturbances in thought patterns.
 Incongruence of thoughts, feelings and actions.
 Perceptual field is greatly decreased.
4. Panic
 Distorted perceptions of the environment.
 Inability to see/understand situations.
 Unpredictable responses.
 Random motor activity.

Signs and Symptoms of Anxiety

1. Physiologic Signs and Symptoms
 SAMR (Sympatho-adreno-medullary-responses)
 Motor
o Restlessness
o frequent hand movements (moderate)
o immobility (severe)
2. Behavioral Signs and Symptoms
 Decreased attention span.
 Decreased ability to follow directions.
 Increased acting out (experiences exaggerated responses to situation) Increased somatization (perception
of physiologic problems like headache, fatigue, difficulty of breathing).
3. Interactional Signs and Symptoms
 Increase in number of questions.
 Constant seeking of reassurance.
 Frequent shifting of topics of conservation.
 Avoidance of focusing on feelings.
 Focus on equipment or procedure.

Nursing Interventions for Clients with Anxiety

 Reduce stimuli, e.g. calm, quiet, nonstimulating environment.
 Calm approach.
 Provide structure/explanations for treatments, procedures.
 Explain situation.
 Help to use coping mechanisms to bring the anxiety level down to a controllable level.
 Promote, explore feelings.
 Focusing on the client's feelings prove to be therapeutic in most situations.
 Avoid asking client to make choices.

Therapeutic Communication for Clients with Anxiety

1. Validate perception.
"You look anxious/uncomfortable."
2. "How are you feeling?"
3. Pause. To give the client time to think and give response.
4. "It must be awful to feel anxious."
5. "How does it feel to be anxious?"
6. "What do you think is making you anxious?"
7. "How did you deal with your anxiety before?"
8. "What would alleviate your anxiety right now?"
9. "In what ways can I help you?"
10. "I'll stay with you until you settle down."

Aggressiveness
 Self-concept is threatened.
 A way to feel less helpless and more powerful. Acting in a hostile manner or launching an attack.
 A way of handling anxiety.
 Angry due to loss of health status and question what is happening to them.
 Irritable, uncooperative, project anger to others.
 Allow expression of anger in socially acceptable manner, to prevent anger from being turned inwards
thereby prevent depression.

Nursing Interventions for Clients with an Aggressive Behavior

 Provide opportunities to express feelings and reason for the feelings.
 Accept expressions of hostility without retaliation or making the person feel guilty.
 Anticipate demands.
 Maintain eye contact with patient.
 Approach in calm, direct manner. Decrease environmental stimuli.
 Set limits.
 Provide outlets (e.g. Increase psychomotor activity).
 Chemical/Physical restraints (done judiciously require physician's order.

Depression
 Sadness/Unhappiness.

Signs and Symptoms of Depression

1. Decreased interactions with others.
2. Lack of interest in activities and environment.
3. Voices concern about illness/lack of care.
4. Expresses wish for or concepts of dying.
5. Dependent behavior.
6. Decreased activity.
7. Complains of fatigue.
8. Crying spells.
9. Change in appetite.
10. Change in sleep pattern.

Nursing Interventions for Clients with Depressed Behavior

 Approach in a serious mood.
 Convey by action and communicate an understanding of feeling.
 Help to express feelings and concerns.
 Convey acceptance of the right to feel sad.
 Listen to the person (to turn feelings such as anger outward and prevent depression)

Withdrawal
 Labeled as "good patients".
 Demand little, and are oftentimes overlooked.
 Feelings of low self-worth and low self-esteem.

Nursing Interventions for Clients who are Withdrawan

  Spend time with the client to increase self-worth and self-esteem.
 Gentle encouragement to talk, express feelings, and relate to others.
 Express acceptance of the client.

Suspiciousness

Signs and Symptoms of Suspiciousness

 Powerlessness.
 Lack of control.
 Difficulty with trust.
 Suspiciousness:
o medical staff
o health care
o routine medications
o procedures

Nursing Interventions for Clients with Suspiciousness

 Encourage to talk about concerns.
 Provide trust, keep promises made.
 Avoid overzealous approach.
 Provide explanations to help the client understand what to expect.
 Avoid whispering or talking softly within person's hearing.

Somatic behavior

Signs and Symptoms of Somatic Behavior

 Express anxiety through physical symptoms, e.g. headache, backache, fatigue, palpitations.
 Preoccupied with body functions and feelings of pain.
 Seeks attention.

Nursing Interventions in Somatic Behavior

 Accept all symptoms and report them to the physician.
 Spend time with the person and listen to physical complaints with some limit setting.

Stress Management

General Intervention Strategies:

1. Supporting protective mechanisms
 Rest
 Comfort measures, massage.
 Relief of pain.
 Decrease stimuli from environment, eg., calm, quiet, nonstimulating environment.
2. Providing structure or explanations.
3. Exploration of feelings.
4. Facilitating problem solving.
5. Regular pattern of exercise.
6. Relaxation techniques.
 4 Basic Components of Relaxation Techniques
o Quiet environment
 o Comfortable position
o Passive attitude
o Mental device
o Focus on sound, word, phrase, object or breathing pattern
 Approaches of Relaxation Techniques
 Progressive Relaxation
 Systematically tensing-relaxing of muscle groups from head to toe. (It usually takes 15 to 30
minutes).
- Face, jaw, mouth (squint eyes, wrinkle brow)
- Neck (pull chin to neck) Right hand (make a fist)
- Right arm (bend elbow in tightly)
- Left hand (make a fist) Left arm (bend elbow in tightly)
- Back shoulders, chest (shrug shoulders up tightly)
- Abdomen (pull stomach in and bear down on chair)
- Right upper leg (push leg down)
- Right lower leg and foot (point toes toward body)
- Left upper leg (push leg down)
- Left lower leg and foot (point toes toward body)
(Tense each muscle group for 5 to 7 seconds then relax quickly)

 Benson's Relaxation
 Omits muscle tensing
- Relax body muscles ("let go").
- Concentrate on breathing; repeat a word or sound such as "one" or "uhmm" after each
exhalation.
- Continue for about 20 minutes
 Other Advanced Stress Management and Relaxation Techniques
 Autogenic training. Teaching the body and mind to respond to verbal commands (self-suggestion or
self-hypnosis) to achieve deep state of relaxation.
 Visualization and imagery. Using a conscious suggestion or a mental picture of the desired change.
 Affirmation. Using strong positive, feeling about a desired change. For example, a person with
strong sense of time urgency may use this affirmation: "I am relaxed and rich statements focused. I
have plenty of time for everything"
 Meditation. Using quiet place, comfortable position, an object to dwell on such as word or symbol,
and a passive attitude.
 Biofeedback. Exerting control over physiologic processes such as autonomic functions. Information
such as heart rate, musde tension and finger temperature, is translated into an auditory or visual
signal that the person senses.
 Therapeutic touch. Using touch to reduce anxiety and stress, relieve pain, and provide comfort.
 Massage. Manipulating soft tissues with the hands to promote relaxation and reduce stress and
anxiety.
 Yoga. Exercising (combined with meditation) to foster relaxation, mental alacrity, and good health.

7. Music therapy. Consider the client's preference for music.

8. Anti-anxiety medications as ordered by the physician, e.g. alprazolam (Xanax), clorazepate (tranxene),
diazepam (valium), lorazepam (ativan).

How Filipinos Respond to Stress or Getting III

1. Denial. Initial response to discomfort "pagwawalang bahala".
 Withdraws from engaging in the crisis or illness, from "facing the facts.
2. Fatalistic Resignation, "bahala na."
  Believes that disease is caused by forces beyond his control.
 Accepts the complaint as God's will.
 Life is either "swerte or malas" (swerte is good luck, malas is bad luck).
 Fears are greatly allayed by religious ritual or turning to supernatural.

Management for Behavior of Fatalistic Resignation

 Do not interfere but do not encourage them.
 Discourage the extreme attitude of leaving everything to God at the expense of developing self-reliance.

Other Responses to Stress or Getting III

1. Shock
 Initial response.
 Frozen to inaction or panic.
 Incapable of thinking clearly or acting rationally
2. Fear and Anxiety
 Adults. Additional expenses, effects of illness to their familles, jobs, friends and future. Primigravida.
Fear of giving birth to deformed child, miscarriage, and premature delivery
 Surgical Patients. Fear of pain, discomfort, anesthesia and death.
 Orthopedic Patients. Loss of function and loss of job.
 ICU/CCU patients. Fear of dying

Management of clients with Fear and Anxiety

 Empathy, explanation of procedures, proper orientation.

3. Shame and Guilt

 Believes that illness is a punishment for sin or wrongdoing.
 Stigma is attached to certain illness eg. TB, Hansen's (leprosy), Mental Illness, Venereal Diseases and
Alcoholism
 "Hiya" (shame) is social sanction that regulates social behavior.
 Patient won't complain because of "hiya".
 Hesitates to approach the nurse.
 Hesitates in exposure of body parts for examination.

Spiritual Responses to Stress/Crisis

1. Spiritual Pain. Alteration in one's relationship with God; a lack of peace.
2. Spiritual Alienation. Biologic relationship with God or whatever one determines to be of greatest value is
broken.
3. Spiritual Anxiety. Expression of fear that God will not be supportive and might be punitive.
4. Spiritual Guilt. Feeling of not having lived up to God's expectations.
5. Spiritual Anger. Frustration towards God;feeling that what has happened to him is unfair.
6. Spiritual Loss. Threatened loss of God's love; feeling of emptiness
7. Spiritual Despair. Expression of hopelessness regarding relationship God or receiving God's care.

Factors Affecting Spiritual Needs

1. Crisis
Spiritual Crisis occurs when relationship with God is broken
 Doubts that life has any meaning.
 Doubts that prayers are heard.
  Doubts that God exists.
 Often coincides with physical crisis.

2. Support system
 A network of people who are able to provide support or strength in times of need.
 May include family, friends, significant others, spiritual leader, worker.

3. Religion
 One's religious beliefs provide strength, an inner quietness and faith with which to work with life's
problems.
 Includes rituals, prayers, spiritual exercises, etc.

4. Hospitalization During Religious Holidays

 Upsetting for many people especially those who have made their faith as a part of their everyday life.

Areas of Concern in Assessing Spiritual Needs

1. Person's source of strength and hope.
2. Person's concept of God.
3. Significance of religious practices and rituals to the person.
4. Person's perceived relationship, spiritual belief, and state of health.

Nursing Interventions in Meeting Spiritual Needs

1. Have adequate religious and cultural knowledge.

 Must recognize struggle in working through practices especially when patient has beliefs contrary to the
nurse's knowledge.
 Explore the result of healing the body while injuring the spirit.
 Discuss with chaplain the conflict.
2. Use tact when opening oneself in the course of meeting spiritual needs.
3. Accept patients as they are with their strengths and limitations.
4. Listen intently and encourage patient to show both negative and positive feelings.
5. Offer to pray with the patient in times of crisis.
6. Help clients with the use of scripture or religious writings.
7. Recognize the role played by spiritual leaders and seek their assistance.

Communication Techniques
Therapeutic Techniques
1. Using silence.
2 Accepting.
 Yes.
 Uhmm.
 Nodding.
 I follow what you said.
 Yes...that must have been difficult for you.
3. Giving Recognition.
 Good Morning, Mrs. Smith. I noticed that you've combed your hair.
4. Offering Self.
 I'll sit with you for a while.
 I'll stay here with you.
 I'm interested in your comfort.
  I'll walk with you.
5. Giving broad openings.
 Is there something you'd like to talk about?
 What are you thinking about?

6. Offering General Leads

 Where would you like to begin?
 Go on...
 And then?
 Tell me about it.
 You were saying...
7. Making observations
 You appear tense.
 I notice that you're biting your lips.
 It makes me uncomfortable when you.
8. Encouraging Description of Perception
 Tell me when you feel anxious.
 What is happening?
 What does the voice seem to be saying?
 How do you feel when you take the medications?
9. Encouraging Comparison.
 Was this something like....?
 Have you had similar experiences?
10. Restating.
 Patient: I can't sleep. I stay awake all night.
 Nurse: You have difficulty sleeping.
11. Focusing.
 This point is worth looking at more closely.
12. Reflecting
 Patient: Do you think I should tell the doctor?
 Nurse: Do you think you should?
 Patient: My brother spends all my money and then has the nerve to ask for more.
 Nurse: This causes you to feel angry.
13. Exploring
 Would you describe it more fully.
 Tell me more about that.
 What kind of work?
14. Giving information.
 My name is....
 Visiting hours are...
 My purpose of being here is...
 I'm taking you to the...
15. Seeking Clarification.
 I'm not sure that I follow.
 What would you say is the main point of what you said?
 I'm puzzled....
 Please give me more information.
16. Presenting reality.
 I see no one else in the room.
  That sound was a car backfiring
 Your mother is not here, I'm a nurse.
 This is a hospital, not a hotel.
17. Asking Direct Questions
 How does your wife feel about your hospitalization?
18. Summarizing.
 During the past hour, we talked about your plans for the future and they include...
19. Voicing Doubt.
 Isn't that unusual?
 Really?
 That's hard to believe.
20. Seeking Consensual Validation.
 Tell me whether my understanding of it agrees with yours.
 Are you using this word to convey the idea?
 You sound annoyed with me, is that correct?
 I'd like to see if what I'm hearing is accurate.
21. Verbalizing the Implied.
 Patient: I won’t be bothering you anymore soon.
 Nurse: Are you thinking of killing yourself?
22. Encouraging evaluation.
 What do you think led the court to commit you here?
 Can you tell me the reasons you don’t want to be discharged?
23. Attempting to translate words into feelings.
 Patient: My sister is lazy!
 Nurse: You sound upset with your sister for not helping the family, that must have been discouraging.
24. Suggesting collaboration.
 Perhaps you can discuss this with your children so they will know how you feel and what you want.
25. Encouraging formulation of a plan of action.
 If you decide to leave home when your husband beat you again what will you do next?
Non-therapeutic Techniques
1. Reassuring
2. Giving advice
3. Rejecting
4. Disapproving
5. Agreeing
6. Disagreeing
7. Advising
8. Probing
9. Challenging
10. Testing
11. Defending
12. Requesting an Explanation
13. Indicating the Existence of an External Source
14. Belittling Feeling Expressed
15. Making Stereotyped Comments
16. Giving Literal Responses
17. Using Denial
18. Interpreting
19. Introducing an Unrelated Topic
Mental Defense Mechanisms (Adaptive Coping Processes)

Mental mechanisms are acquired during the development of the personality as an attempt to defend
itself, establish compromises between conflicting impulses and allay inner tensions. A conflict can be thought
of as the struggle between two parts of the personality. An example would be a girl who does not want to go to
school one day in order to go to a movie and yet knows that she should go to school.

Conflict produces anxiety.

Adaptive defense mechanisms are generally employed by a person unconsciously.

1. Repression

Is one of the commonest mental mechanisms used to deal with conflicts. By repression, desires,
impulses, thoughts and strivings that conflict with the image we have of ourselves or are disturbing to us, are
put out of consciousness. They cannot be recalled or recognized and thus we are protected from anxiety.
Experiences that involve guilt, shame or lowering of self esteem are most important to be repressed.

As an example, a young man was engaged to be married. His fiancée terminated the engagement; the
man found this to be embarrassing and repressed the fact that his fiancée had broken the engagement and
instead believed he had terminated the relationship himself. Another example is that of a patient who could not
control her urine postoperatively. The patient urinated in her bed and felt ashamed and embarrassed. As a result,
she completely repressed the incident so that she did not remember it upon leaving the hospital.

2. Identification

Identification is an important mental mechanism in the growth of an individual. A young boy will take
the attitudes and behavior patterns of both parents, especially his father. It will also adapt the behavior and
attitudes of other people who are significant to him. In identification, a person admires the qualities of
significant people and aspires to be like them. In the development context, successive identifications finally
evolve into adult individuation, that is, a firm personal identity.

An example of identification is a teenage patient who changes her hairstyle so that it is like the style of a
nurse whom she admires. In another example, a young boy swears just as his father swears.

3. Reaction Formation

Is the behavior of a person that is the exact opposite of what the feels would tend to show. For example,
a person shows great concern for a person about whom she is actually hostile, or an aggressive person demands
his rights continually who is really defending himself against feelings of insecurity.

4. Compensation
 Is a substitute phenomenon. Physiologically the body frequently compensates for pathologic conditions;
for example, a person with a heart valve stricture will often have a hypertrophied heart muscle. In this case, the
heart tries to overcome the blockage and pump blood through the valve by increasing the size of muscle.

Compensating behavior can also be highly commendable socially. For example, a boy who cannot
participate in athletics compensates by studying hard and attaining high grades. Another example is that of a
blind person and the highly acute hearing she develops to compensate for the loss of sight.

5. Rationalization

Is one of the commonest mechanisms; it is designed to maintain the self- respect of a person and prevent
feelings of guilt. This mechanism provides rational, intellectual reasons for behavior that really has been
prompted by unrecognized motives. Allied to rationalization is the sour grapes mechanism In this defense,
persons disparage some goal, which in reality they would like to attain. For example, the student who really
wanted to be class president states that she wouldn't take the job if it were offered because it is a lot of work and
no fun. Another example of rationalization is the patient who comes to the hospital for an operation and states
that he is really pleased to come in order to obtain good rest.

6. Substitution

Is a mechanism used to reduce one's tension if frustrated. In one chooses alternate goals, which are
attainable and which have comparable gratification. When one is unable to attain a goal, such as being a
substitution, one has three choices: (a) to continue to strive for and overcome obstacles to the goal, (b) to avoid
the goal or flee from it, or (c) to choose a substitute goal.

Substitution in the case of the student who wishes to be a physician might be to choose dentistry, or
nursing which is an attainable goal for the student.

7. Displacement

Is an anxiety-reducing device. In this mechanism, an emotional feeling is transferred from the actual
object to a substitute. Feelings such as love and hate are apt to be displaced. For example, hostility toward a
parent by a child is redirected to a teacher because it is too threatening and socially unacceptable to hate a
parent. Thus the child verbalizes hostility toward this teacher, who does not produce as much anxiety. Another
example of displacement is the adolescent who kicks the dog and bangs the door, after he was reprimanded by
his parents.

8. Restitution

Is a mechanism by which one relieves one's mind of guilt by restitutive acts. For example, a boy breaks
his sister's toy, then feels guilty and offers to give the sister his prize frog to make up for the broken toy.

9. Projection

Is a mechanism by which one attributes to others characteristics that one does not want to admit are
one's own. That is, persons criticize others for traits that in effect the persons themselves possess. This is
frequently seen in daily life, as for example, a man who criticizes his neighbor for being terrible gossip when in
fact it is the man himself who gossips but is not aware of it.

10. Symbolization
 Is the use of objects to represent ideas or emotions that are too painful to express. To the conscious mind
of the person, the symbol is not a symbol but is real in itself. Examples might be a woman whose cat is an
unconscious symbol of her child who died at birth, or a teenage who wears clothes his mother dislikes, the
clothes symbolizing rebellion against his mother.

11. Regression

By regression, an individual adopts behavior that was comforting earlier six-year-old child who starts
bedwetting after his mother returns home with a new baby. In this example, the child unconsciously in life. One
example is returns to an earlier behavior pattern in order to obtain his mother's attention,

12. Denial

Denial is a mechanism by which consciously intolerable though wishes, facts and deeds are disowned by
unconscious denial of existence. An example is a patient with cancer; he finds this to be an intolerable fact and
denies it unconsciously as if he had never been told.

13. Sublimation

Is a mechanism by energy inherent in unacceptable impulses is redirected into socially useful goals. In
sublimation the energy is frequently transformed to channels such as a vocation, art, music or other endeavors
that provide richer life for the person and often the social group. Examples might be the physician who devotes
all her energies to her practice, when at home the has a husband who is an alcoholic, or a man who devotes most
of his time to charitable endeavors, rather than recognize his loneliness in his home.

14. Suppression

It can be considered as the opposite of repression in that one willfully and consciously puts a thought or
feeling out of one's mind. An example is the man who forgets and misses an appointment to the dentist. He feels
threatened by the event, and by refusing to think about it, he relieves his anxiety.

15. Introjection

Is the opposite of projection, but it is also an unconscious mechanism. The character traits of another
person are taken into oneself. These traits that are made part of oneself may be desirable or undesirable.
Children develop a healthy conscience in this manner by taking in the advice and warnings of parents. On the
other hand, feelings of hatred about a person that are turned inward can create depression and suicide.

16. Conversion

Is the mechanism of transforming a mental conflict into a physical symptom. Shameful feelings or
painful emotions are first repressed and then converted into physical symptoms such as numbness or pain. The
resulting physical discomfort is often accepted by the person without much distress. Thus, in reality, one is
punishing oneself.

17. Fantasy

Is likened to make-believe and daydreams. Wishes and desires are as fulfilled. Imagination makes life
more acceptable and is helpful when used to determine constructive action and thought Past experiences can
imagined be relived, everyday problems solved and plans for the future made. However, the person who uses
fantasy to excess and who retreats from reality is using this mechanism in an unhealthy way.
Crisis

Crisis is a sudden event in one's life that disturbs a person's homeostasis. If the event is such that the
normal coping mechanisms of a person cannot resolve the problem and the disequilibrium continues from a few
hours to a few days, the disruption is called a crisis. Persons who have a crisis in their lives experience three
main signs and symptoms:
1. Heightened feeling of stress.
2. Inability to function in the usual organized manner.
3. Signs that indicate unpleasant emotional feelings.

When people have crises in their lives, there can be three outcomes. First, previously developed coping
mechanisms may be sufficient to return the person to the same level of emotional homeostasis as before.
Second, the person's coping mechanisms may be insufficient, which results in less emotional stability than
previously. Third, the person's coping mechanisms may be such that as a result of the crisis the person gains
strength and stability.

A crisis has been described as having four phases:

1. The person experiences feelings of stress and uneasiness. The person therefore tries emergency problem-
solving methods to solve the crisis. These are found to be ineffective.
2. The person then experiences increased tension and disorganization due to the continual impact of the crisis
and ineffective coping.
3. By the third phase, the person is experiencing even more tension and is mobilizing both internal and
external resources.
4. In the fourth phase, the person experiences major disorganization and thus true emotional homeostatic
imbalance.

Before the fourth phase or the crisis phase, the problem may be resolved in one of the following ways:
1. The person uses emergency problem-solving methods.
2. The person changes from unattainable goals to attainable goals.
3. The problem itself is removed or dissipated.
4. The problem is defined in another manner.

Characteristics of Crisis are as follows:

1. The crisis state tends to be temporary, self-limiting, acute, lasting one to six weeks.
2. Triggering event (death loss etc): usual coping mechanisms are not serving the purpose.
3. Situation is not dangerous to the person he might harm himself or others
4. Individual will return to a state that is better, worse or the same a before the crisis therefore, intervention by
the therapist is important.
5. Person is totally involved-hurts all over.
6. At this time, he is most open for intervention; therefore, major changes can take place and the crisis can be
the turning point of the person.

Types of Crises

1. Internal (Developmental) Crises

 Developmental crises occur at critical points in the development of the person. Erik Erikson formulated
four stages in the development of person. These are infancy, childhood, adolescence and adulthood. He
further identified eight developmental crises, which must be resolved. These are in order, basic trust
versus mistrust, autonomy versus shame and doubt, initiative versus guilt, industry versus inferiority,
Identity versus role confusion, intimacy versus isolation, generativity versus stagnation and ego integrity
versus despair. These developmental crises are anticipated in the life of a person, and therefore the
 person has the opportunity to prepare for them before they occur. A person who does not cope
successfully with one or more of these developmental crises is described as having fixation.

2. External (Coincidental) Crises

 External crises occur at any time in a person's life. They include stress such as may be due to loss of a
job, loss of an income or an accidental death of a loved one. Nurses may see crises of people as a result
of the occurrence of illness, the admission of a child to a hospital, or death of a member of a family, for
example.

Crisis Intervention

A basis of crisis intervention is the problem-solving method or the nursing process. This involves four
steps: assessing the problem, planning the intervention, intervening and evaluating the results. When a person's
crisis is in the first phase, environmental manipulation can be an effective method of intervening. At this stage,
the problem for patients may be removed, for example, by changing the environment or by providing persons
with detailed information about the medications they are receiving.

At the second stage, general support is effective. The nurse listens, expresses warmth and empathy and
is non-judgmental.

At the third level, the intervention involves dealing with those areas in which there is enough knowledge
needed to help the patient resolve the pre-crisis situation. An example might be helping a patient who has been
told he must have heart surgery, with information about what to expect.

At the fourth level, the nurse applies intervention to the person by learning the person's particular needs
and problem. The patient often needs to be assisted to understand the why of the situation and given a choice of
options as to how to solve the problem.

Crisis intervention is oriented to help clients solve problems that they have not been able to solve
themselves. Through it, persons can learn skills, such as establishing options, which can assist them throughout
life.