CONCEPT

OF HEALTH
 HEALTH-ILLNESS MODELS

MODEL

A model is a theoretical way of understanding a concept or idea. Models represent

different ways of approaching complex issues. Since Health and Illness is a vital matter, Nurses

developed various health models to provide effective health care. The nursing models allow the

nurses to understand and predict patients’ health behaviour.

MODELS OF HEALTH AND WELLNESS

Because health is such a complex concept, various researchers have developed models

or paradigms to explain health and in some instance its relationship to illness or injury. Models

can be helpful in assisting health professionals to meet the health and wellness needs of

individuals.

Models of health include the agent–host–environment model, Holistic Health Model,

Illness-Wellness Continuum, Dunn’s High level Wellness Model, and Iceberg Model.

1. AGENT-HOST-ENVIRONMENT MODEL

The agent–host–environment model of health and illness, also called the ecologic model,

originated in the community health work ofLeavell and Clark (1965) and has been expanded into
a general theoryof the multiple causes of disease. The model is used primarily inpredicting illness

rather than in promoting wellness, although identification

of risk factors that result from the interactions of agent, host,

and environment are helpful in promoting and maintaining health.The model has three dynamic

interactive elements (Figure 17–3 •):

1. Agent. Any environmental factor or stressor (biologic, chemical,mechanical, physical, or

psychosocial) that by its presence or absence(e.g., lack of essential nutrients) can lead to illness

or disease.

2. Host. Person(s) who may or may not be at risk of acquiring a disease.Family history, age, and

lifestyle habits influence the host’sreaction.

3. Environment. All factors external to the host that may or may notpredispose the person to the

development of disease. Physicalenvironment includes climate, living conditions, sound

(noise)levels, and economic level. Social environment includes interactionswith others and life

events, such as the death of a spouse.

Because each of the agent–host–environment factors constantlyinteracts with the others, health

is an ever-changing state. When thevariables are in balance, health is maintained; when the

variables arenot in balance, disease occurs.

 2. HOLISTIC HEALTH MODEL

Healthcare has begun to

take a more holistic view of

health by considering emotional

and spiritual well-being. The

Holistic Health Model of nursing

attempt to create conditions that

promote optimal health. In this

model, nurses using the nursing process. In the holistic health model patients are involved in their

healing process, thereby assuming some responsibility for health maintenance (Edelman and

Mandle, 2010). Nurses using the holistic nursing model recognize the natural healing abilities of

the body and incorporate complementary and alternative interventions such as music therapy,

reminiscence, relaxation therapy, therapeutic touch, and guided imagery, economical, non-

invasive, non-pharmacological complements to traditional medical care. Nurses use holistic

therapies either alone or in conjunction with conventional medicine. For example, they use

reminiscence in the geriatric population to help relieve anxiety for a patient dealing with memory

loss or for a cancer patient dealing with difficult side effects of chemotherapy. Music therapy in

the operating room creates a soothing environment. Relaxation therapy is frequently useful to

distract a patient during a painful procedure. Breathing exercises are commonly taught to help

patients deal with pain associated with labor and delivery.

3.) ILLNESS – WELLNESS CONTINUUM

The Ilness – Wellness Continuum was proposed by Mr. John W. Travis. He started

developing the Continuum in 1972, got published in the Wellness Inventory in 1975, and later re-

published in collaboration with Regina Ryan. Travis believed that a medical approach that relied

on the presence or absence of symptoms of disease to demonstrate wellness was insufficient.

The Continuum proposes that wellbeing includes mental and emotional health, as well as the

presence or absence of illness.

As shown by the continuum, it illustrates two arrows pointing in opposite directions and joined at

a neutral point. Movement to the right of the neutral point indicates increasing levels of health and

well-being for an individual. This is achieved in three steps: (1) awareness, (2) education, and (3)

growth. In contrast, movement to the left of the neutral point indicates progressively decreasing

levels of health. Travis and Ryan believe it is possible to be physically ill and at the same time

oriented toward wellness, or be physically healthy and at the same time function from an illness

mentality.
4.) DUNN’S HIGH LEVEL WELLNESS MODEL/GRID

Dunn described a health grid in which a health axis and an environmental axis intersect.

The grid demonstrates the interaction of the environment with the illness–wellness continuum.

The X or health axis extends from peak wellness to death, and the Y or environmental axis

extends from very favorable to very unfavorable. The intersection of the two axes forms four

quadrants of health and wellness:

Quadrant 1(Upper Right): High-level wellness in a favorable environment. An example is

a person who implements healthy lifestyle behaviors and has the biopsychosocial, spiritual,

and economic resources to support this lifestyle.

Quadrant 2(Upper Left): Protected poor health in a favorable environment. An example

is an ill person (e.g., one with multiple fractures or severe hypertension) whose needs are

met by the health care system and who has access to appropriate medications, diet, and

health care instruction.

Quadrant 3(Lower Left): Poor health in an unfavorable environment. An example is a

young child who is starving in a drought-stricken country.

Quadrant 4(Lower Right): Emergent high-level wellness in an unfavorable environment.

An example is a woman who has the knowledge to implement healthy lifestyle practices

but does not implement adequate self-care practices because of family responsibilities,

job demands, or other factors.

Family wellness enhances wellness in individuals. In a well family that offers trust, love,

and support, the individual does not have to expend energy to meet basic needs and can move

positively on the wellness continuum. Environmental wellness is related to the premise that
humans must be at peace with and guard the environment. Societal wellness is significant

because the status of the larger, social group affects the status of smaller groups. Dunn believes

that social wellness must be considered on a worldwide basis.

5.) ICEBERG MODEL

Illness and health are only the tip of an iceberg. To understand their causes, you must

look below the surface. Icebergs reveal only about one-tenth of their mass above the water. The

other nine-tenths remains submerged. This is why they are such a nightmare in navigation, and

why they make such an appropriate metaphor in considering your state of wellness.

Your current state of health, be it one of disease or vitality, is just like the tip of the iceberg.

This is the apparent part - what shows. To understand all that creates and supports your current

state of health, you have to look underwater. The first level you encounter is the

lifestyle/behavioral level - what you eat, how you use and exercise your body, how you relax

and let go of stress, and how you safeguard yourself from the hazards around you. To understand

why, we must look still deeper, to the cultural/psychological/motivational level. Here we find

what moves us to lead the lifestyle we've chosen. We learn how powerfully our cultural norms

influence us, sometimes in insidious ways - like convincing us that excessive thinness is attractive.

Exploring below the cultural/psychological/motivational level, we encounter the

spiritual/being/meaning realm. Actually, it is more a realm than a level, because it has no clear

boundaries. It includes the mystical and mysterious, plus everything in the unconscious mind,

as well as concerns such as your reason for being, the real meaning of your life, or your place in

the universe. The way in which you address these questions, and the answers you choose,
underlie and permeate all of the layers above. Ultimately, this realm determines whether the tip

of the iceberg, representing your state of health, is one of disease or wellness.

 LEVELS OF CARE

A health care system is the totality of services offered by all health disciplines. The main

purpose of a health care system before was to provide care to people who were ill or injured, but

due to the growing awareness of health promotion, illness prevention, and levels of wellness,

health care systems are changing, and so are the role of the nurses. The services provided by a

health care system are generally characterized according to type and level.

TYPES OF HEALTH CARE SERVICES

Health services are often described in terms of their correlation with disease prevention levels:

PRIMARY PREVENTION : HEALTH PROMOTION AND ILLNESS PREVENTION

The World Health Organization (WHO) has developed a project called Healthy People

based on the idea of maintaining an optimum level of wellness. The current U.S The Health and

Human Services Department (2010) project, which developed from the original work, is called

Healthy People 2020 and has four overall objectives:

1. Increase quality and years of healthy life

2. Achieve health equity and eliminate health disparities

3. Create healthy environments for everyone

 4. Promote health and quality life across the life span

Until the 1980s, health promotion was slow to develop. Since then, more and more people

have recognized the benefits of maintaining health and preventing disease. Primary prevention

programs cover areas such as adequate and adequate nutrition, weight and exercise control and

stress reduction. Activities to promote health emphasize the important role that clients play in

maintaining their own health and encourage them to maintain the highest possible level of

wellness.

Illness prevention programs can be directed at the client or the community and involve

such practices as providing immunization, identifying risk factors for diseases and helping people

to take measures in order to prevent these diseases. Environmental programs that can reduce

the incidence of disease or disability are also included in illness prevention. Environmental

protective measures are often constituted by governments and lobbied for by citizens groups.

SECONDARY PREVENTION : DIAGNOSIS AND TREATMENT

In the past, the largest segment of health services has been devoted to disease diagnosis

and treatment. Hospitals and doctors ' offices were the major agencies offering these complex

services of secondary prevention. Hospitals continue to focus considerable resources on

customers who need acute emergency, intensive and 24-hour care. Freestanding diagnostic and

treatment facilities have also developed and serve more and more customers. Also included as a

health promotion service is early detection of disease. This is accomplished through routine
screening of the population and focused screening of those at increased risk of developing certain

conditions.

Community-based agencies have become instrumental in providing these services. For

example, clinics in some communities provide mammograms and education regarding the early

detection of cancer of the breast. Voluntary HIV testing and counseling is another example of the

shift in services to community-based agencies.

TERTIARY PREVENTION: REHABILITATION, HEALTH RESTORATION

AND PALLIATIVE CARE

The goal of tertiary prevention is to help people move to their previous level of health (i.e.,

to their previous capabilities) or to the highest level they can give their current health status.

Rehabilitative care emphasizes the importance of assisting clients to function adequately

in the physical, mental, social, economic, and vocational areas of their lives. If the injury is

temporary, rehabilitation can assist in return to former function. If the injury is permanent,

rehabilitation assists the client in adjusting the way activities are performed in order to maximize

the client’s abilities. Rehabilitation can start in the hospital but will eventually lead clients back to

the community for further treatment and follow- up once health is restored. Sometimes, people

cannot be returned to health. A growing field of nursing and tertiary prevention services is that of

palliative care—providing comfort and treatment for symptoms. End-of-life care may be conducted

in many settings, including the home.

NURSING AS
AN ART
 COMMUNICATION PROCESS

COMMUNICATION

As nurses, communication is a lifelong learning process because nurses make the

intimate journey with the clients and their families with the use of communication. Scoping from

the miracle of birth to the depths of death.

Communication is any exchange of findings and information from one person to another

and it elicits a response from the receiver. It can also be a transmission of thoughts, feelings and

body gestures as long as it contains context and message to be perceived by the receiver of the

message.

ELEMENTS OF COMMUNICATION

1. Sender is a person or group who wishes to convey a message to another. He/ She can be
considered as the source-encoder.

Encoding involves the selection of specific signs or symbols (codes) to transmit the
message, such as which language and words to use, how to arrange the words, and what tone
of voice and gestures to use.

2. Message is what is actually said or written, the body language that accompanies the words,
and how the message is transmitted.

Channel is the medium used in conveying the message. It can target any of the receiver's
senses.

3. Receiver is the listener, who must listen, observe, and attend; He/ She is the Decoder who
must perceive what the sender intended (Interpretation).
 Decoding means relating the message perceived to the receiver's storehouse of
knowledge ad experience and to sort out the meaning of the message.

4. Response is the message that the receiver returns to the sender.

Feedback can either be verbal, nonverbal, or both. It allows the sender to correct or
reword a message.

LEVELS OF COMMUNICATION

There are different levels of communication which nurses use in their professional role.

The nurse’s communication skills need to include techniques that reflect competence in each

level. There are five levels of communication:

Intrapersonal Communication

Interpersonal Communication

Transpersonal Communication

Small-Group Communication

Public Communication.

INTRAPERSONAL COMMUNICATION

A powerful form of communication that occurs within the individual.

This is also called as self-talk, self-verbalization and inner thought (Balzer Riley, 2004)

This level of communication is very important and essential because the people’s thoughts

strongly influence how a person think, how a person behaves, how they feel and their self-

concept.
 The nurses and clients use this level of communication to build their self-actualization, to

develop their self-awareness and a positive self-concept that will enhance appropriate

self-expression.

INTRAPERSONAL COMMUNICATION

One-to-one interaction between the nurse and the client or other health professional that

may occur face to face.

This is the level which is mostly used in nursing situations and this serves as the heart of

the nursing practice.

This takes place in a social context and also includes all the cues and symbols used to

give and receive meaning.

Messages may be perceived differently from how the message was intended depending

on the sender and the receiver’s status, values, opinions, experiences and belief systems.

TRANSPERSONAL COMMUNICATION

This is the interaction which occurs within a person’s personal domain.

Nurses who value the importance of human spirituality often use this level of

communication for themselves and also for their clients.

The nurses also have responsibility to assess the client’s spiritual needs, intervene to meet

their needs and respect them to create a competent harmonious relationship with the

patient.
SMALL-GROUP COMMUNICATION

The interaction occurs when a small number of people meet together.

This is usually goal directed and requires an understanding of group dynamics.

Nurses sometimes participate in different activities such as conferences, support groups,

form research teams, and client care small groups which use this level of communication.

Small groups are more effective because of the small number of people involved, the

appropriate setting, and cohesiveness and commitment among group members which

helps create a harmonious environment for communication.

PUBLIC COMMUNICATION

This interaction occurs with an audience.

Nurses are given opportunities to speak in front of groups of consumers about health-

related issues, problems, and updates and also some scholarly work to colleagues at

conferences.

This requires special adaptations in eye contact, voice inflection, facial expressions,

gestures and the use of media materials to communicate messages effectively.

MODES OF COMMUNICATION

Verbal communication uses the spoken or written word. It is largely conscious because people
choose the words they us. The words they used vary among individual

Pace and intonation is the manner of speech, as in the pace of rhythm and intonation, will
modify the feeling and impact of message.
 Simplicity is the use of commonly understood words, brevity, and completeness. Nurses
need to learn to select appropriate, understandable, terms based on the age, knowledge, culture,
and education of the client.

Clarity and Brevity is needed in conveying a message that is direct and simple to be more
effective. Clarity is saying precisely what is meant, while Brevity is using the fewest words
necessary.

Timing and Relevance are needed when communicating with clients. Even though the
message has been conveyed clearly, the timing needs to be appropriate to ensure that words are
heard and that the messages need to relate the person or to the person's interest and concerns.

Adaptability is the adjustment needed in the alteration of spoken messages in accordance

with behavioral cues from the client.

Credibility means worthiness of belief, trustworthiness, and reliability. It may be the most
important criterion of effective communication.

Humor can be a positive and powerful tool in the nurse-client relationship, but it must be
used with care. It can be used to help clients adjust to difficult and painful situations. The physical
act of laughter can be emotional and physical release, reducing tension. " Laughter is the best
medicine."

Nonverbal communication includes gestures or facial expressions,, body movements, use of

touch, and physical appearance. It is also called body language. This is important for nurses in
developing effective communication patterns and relationship with clients.

Personal Appearance is how a person dresses is often an indicator of how the person
feels since clothing and adornments can be sources of information about a person. Although
choice of apparel is highly personal, it may convey social and financial status, culture, religion,
group association, and self-concept.

Posture and Gait are the ways people walk and carry themselves are often reliable
indicators of self-concept, current mood, and health.

Facial Expression conveys emotions such as feelings of surprise, fear, anger, disgust,
happiness, and sadness. Many facial expressions convey a universal meaning (eg. smile
expresses happiness).
 Gestures may emphasize and clarify the spoken word, or they may occur without words
to indicate a particular feeling or to give a sign.

Electronic Communication is the result of the modernization and evolution of technology.

E-mail is the most common form of electronic communication where an individual can
send a message to another person or group of people through electronic means such as
computers.

Advantages:
It is a fast, efficient way to communicate and it is legible.
It provides a record of the date and time of the message that was sent or received.
This improves communication and continuity of client care.
It promises better access.
Disadvantages:
Risk to client confidentiality whereas an e-mail encryption system is needed to
ensure security.

Socioeconomics because not everyone has a computer nor computer skills.

Other forms of communication will be needed for clients who are Illiterate in
communication.

When not to use E-mail:

When the information is urgent and the client's health could be in jeopardy if he or
she doesn't read it immediately.
When it includes highly confidential information.
Abnormal lab data. If the information is confusing and could prompt many
questions by the client, it is better to either see or telephone the person.

Other Guidelines:
It is important to know, per the agency's guidelines, what can be e-mailed to clients.
There should be a signed consent from the client for the e-mail consent.
A disclaimer must specify that the message is to be read only by the person to
whom it is addressed and that no one else is authorized to read the
message.
A copy of the e-mail needs to be put in the client's chart.
FACTORS INFLUENCING THE COMMUNICATION PROCESS

There are several factors influencing the communication process between the nurse and

the client, which are:

Development

Gender

Values and Perception

Personal Space

Territoriality

Roles and relationship

Environment

Congruence

Attitude

DEVELOPMENT

The knowledge of the client’s developmental stage will allow the nurse to gather

information based on their age, their experiences, and knowledge about their health status.

Language, psychosocial, and also intellectual development of a person may vary and

change throughout the life-span and these may greatly influence the data gathered by the

nurse.

GENDER
 The communication of females and males from an early age may vary differently. Females

use communication to gather information, minimize differences and establish intimacy.

Wherein males use communication to establish independence and negotiate status within

groups.

Information can be also be interpreted differently by the nurse considering if the nurse is

a man or a woman.

VALUES AND PERCEPTIONS

Values are the standards that may influence the behavior.

Perceptions are the personal view of an event.

Each person has their own specific and unique personality, beliefs, values and perceptions,

each will receive and interpret messages differently depending on their experiences.

PERSONAL SPACE

This is the distance between two people who are giving and receiving information. This is

the distance that people prefer when communicating.

Proxemics is the study of the distance between people in their interactions.

Communication alters in accordance with the fours distances, such as:

Intimate: Touching to 1 ½ feet

Personal: 1 ½ to 4 feet

Social: 4 to 12 feet

Public: 12 to 15 feet
TERRITORIALITY

A concept of the space and the things that an individual considers as belonging to the self.

As nurses, it is very important to obtain permission form clients to remove, rearrange or

borrow objects in their hospital area.

ROLES AND RELATIONSHIPS

The roles and relationship between the sender and the receiver may greatly influence the

communication process.

The specific relationship between the communicators are significant. The flow of the

conversation will depend on how open the client is to give information to the nurse and

likewise.

ENVIRONMENT

People communicate effectively when put in a comfortable environment.

Temperature extremes, excessive noise, and a poorly ventilated environment can all

interfere with the communication process.

The lack of privacy may also decrease the comfort level of the client which interferes the

communication.

CONGRUENCE

The verbal and non-verbal aspects of the message must match in order to have a

congruent communication.
 When the nurse’s communication is congruent, the client are more likely and readily to

trust the nurse.

If there is an incongruence, the body language or the non-verbal cues is usually one with

the true meaning.

INTERPERSONAL ATTITUDES

Attitudes are consists of beliefs, thoughts and feelings about people and events.

They are communicated convincingly and rapidly by others.

Attitudes such as respect, caring, warmth, and acceptance facilitate communication.

BARRIERS OF COMUNICATION

Stereotyping offers generalized and oversimplified beliefs about groups of people that are
based on experiences too limited to be valid. These responses categorize clients and negate their
uniqueness as individuals.

Agreeing and Disagreeing is a way to judgemental responses, agreeing and disagreeing

imply that the client is either right or wrong and that the nurse is in a position to judge this. These
responses deter clients from thinking through their position and may cause a client to become
defensive.

Being defensive Attempts to protect a person or health care services from negative
comments. These responses prevent the client from expressing true concerns. The nurse is
saying, “You have no right to complain.” Defensive responses protect the nurse from admitting
weaknesses in the health care services, including personal weaknesses.

Challenging is a response that makes clients prove their statement or point of view. These
responses indicate that the nurse is failing to consider the client’s feelings, making the client feel
it necessary to defend a position.
 Probing is a way of asking for information chiefly out of curiosity rather than with the intent
to assist the client. These responses are considered prying and violate the client’s privacy. Asking
“why” is often probing and places the client in a defensive position.

Testing is a way of asking questions that make the client admit to something. These
responses permit the client only limited answers and often meet the nurse’s need rather than the
client’s.

Rejecting refuses discussing certain topics with the client. These responses often make
clients feel that the nurse is rejecting not only their communication but also the clients themselves.

Changing topics and subjects direct the communication into areas of self-interest rather
than considering the client’s concerns is often a self-protective response to a topic that causes
anxiety. These responses imply that what the nurse considers important will be discussed and
that clients should not discuss certain topics.

Unwarranted reassurance uses cliches or comforting statements of advice as a means to

reassure the client. These responses block the fears, feelings, and other thoughts of the client.

Passing judgement gives opinions and approving or disapproving responses, moralizing

or implying one’s own values. These responses imply that the client must think as the nurse thinks,
fostering client dependence.

Giving common advice tells the client what to do. These responses deny the client’s right
to be an equal partner. Note that giving expert rather than common advice is therapeutic.

THERAPEUTIC COMMUNICATION IN THE HELPING

RELATIONSHIP

Characteristics, Goals, and Phases of Helping Relationship

Two Basic Goals (Egan, 1998):

1. Help clients manage their problems in living more effectively and develop unused and or

underused opportunities more fully.

2. Helps clients become better at helping themselves in their everyday lives.

Keys to Helping Relationship:

1. the development of trust and acceptance between the nurse and the client

2. an underlying belief that the nurse cares about and wants to help the client

Characteristics of a Helping Relationship:

A helping relationship

➢ Is an intellectual and emotional bond between the nurse and the client and is focused on the

client.

➢ Respects the client as an individual, including

-Maximizing the client’s abilities to participate in decision making and treatments.

-Considering ethnic and cultural aspects.

-Considering family relationships and values.

➢ Respects client confidentiality.

➢ Focuses on the client’s well-being.

➢ Is based on mutual trust, respect, and acceptance

Principles the therapeutic relationship

The purpose of therapeutic relationship is to support the patient, to promote healing, and

to support or enhance functioning. A therapeutic relationship differs from a social relationship in

that it is health focused and patient centered with defined boundaries. Peplau (1991) described

the nurse’s focused interest in the patient as “professional closeness.”

Respect

Carl Rogers, in his seminal book published in 1961, defined respect or unconditional

positive regard as the ability to accept another person’s beliefs despite your own personal feelings.

Acceptance does not mean approval or agreement; rather, it is a nonjudgmental attitude about

the patient as a whole person. The nurse’s goal is to respectfully take into account the patient’s

symptoms, feelings, values, and beliefs, and to work with the patient to develop the goals of care.

Nurses demonstrate unconditional positive regard by accepting people without negatively judging

their basic worth.

Genuineness
 The ability to be oneself within the context of a professional role is called genuineness.

Rogers described genuineness as congruence, the willingness to be open and genuine and not

hide behind a professional façade. Genuineness is a welcome part of working in health care

because it allows the incorporation of shared humanity and authenticity into nursing care. One

way of expressing genuineness and care is to acknowledge the patient’s effort, difficulties, and

ideas. Another way is to show interest in the patient during daily nursing care. Nurses may

genuinely express some of their feelings with patients within the therapeutic relationship. For

example, laughing when a patient brings in a joke. Likewise, nurses can express sympathy when

patients or families are grieving lost loved ones. Using one’s own personality when talking with

patients humanizes the experience for patients and brings joy to the nurse’s work.

Empathy

Nursing is often described as providing empathetic or compassionate care to patients.

Empathy is educated compassion or the intellectual understanding of the emotional state of

another person. It can be described as the nurse’s desire to understand what a patient is

experiencing from the patient’s perspective. Empathy allows nurses the ability to actually see the

world from the patient’s point of view without experiencing the emotional content. This intellectual

understanding allows the nurse to understand the patient’s experience, define the patient’s needs,

set goals with the patient, deliver appropriate interventions, and assess patient outcomes.

Trust
 The establishment of trust is the foundation of all interpersonal relationships and is vitally

important to the development of the therapeutic relationship in nursing. Patients need to believe

that nurses are honest, knowl- edgeable, dependable, and accepting of who they are as people.

Erikson (1963) described trust as the reliance on consistency, sameness, and continuity of

experiences provided by familiar and predictable things and people. Trust is a choice that a person

makes, based on the need to trust others.

Confidentiality

Nurses have moral and legal obligations not to share patient information with others,

except in specific circumstances.Patients will be more forthcoming and honest in their revelations

and responses if they feel that their information is confidential.

Nurse–patient confiden tiality can be breached only for the following reasons:

Suspicion of abuse of minors or elders

Commission of a crime

Threat or potential threat of harm to oneself or othe

Phases of the Helping Relationship:

The Preinteraction Phase

 The preinteraction phase is similar to the planning stage before an interview. In most

situations, the nurse has information about the client before the first face-to-face meeting such as

the client’s name, address, age, medical history, and/or social history. The nurse reviews pertinent

data and knowledge, considers potential areas of concern, and develops plan for interaction. He

or she must organized data gathering, recognize limitations and seek assistance as required.

The Introductory Phase

The introductory phase is also referred to as the orientation phase or prehelping phase. It sets

the tone for the rest of the relationship. During this initial encounter, the client and the nurse

closely observe each other and form judgments about each other’s behavior.

Three Stages of Introductory Phase (Brammer, 1998)

Opening the relationship

In opening the relationship, both clients and nurse identify each other by name. When the

nurse initiates the relationship, it is important to explain the nurse’s role to give the client an

idea of what to expect. When the client initiates the relationship, the nurse needs to help the

client express concerns and reason for seeking help. Vague, open-ended questions, such as,

“What’s on your mind today?” are helpful at this stage. Attentive attitude may help the client

to become at ease.

For example:
 Hello, Mrs. James. I am Nancy Rivera from Orange Community College. I am in my

psychiatric rotation, and I will be coming to York Hospital for the next six Thursdays. I

would like to spend time with you each Thursday if you are still here. I’m here to be a

support person for you as you work on your treatment goals.

Clarifying the problem

Some clients may not initially see the problem clearly. Therefore, the nurse’s role is to help

clarify the problem through attentive listening, paraphrasing, clarifying, and other effective

communication techniques.

Structuring and formulating the contract

The nurse and the client develop a degree of trust and verbally agree about:

Location, frequency, and length of meetings

Overall purpose of the relationship

How confidential information will be handled

Tasks to be accomplished

Duration and indication for termination of relationship

For example:

Mrs. James, we will meet at 10 AM each Thursday in the consultation room at the clinic

for 45 minutes, from September 15th to October 27th. We can use that time for further

discussion of your feelings of loneliness and anger you mentioned and explore some

things you could do to make the situation better for yourself.

Mrs. James, I will be sharing some of what we discuss with my nursing instructor, and at

times I may discuss certain concerns with my peers in conference or with the staff.
 However, I will not be sharing this information with your husband or any other members

of your family or anyone outside the hospital without your permission.

During initial parts of the introductory phase, the client may display some resistive

behaviors. Resistive behaviors are those that inhibit involvement, cooperation, or change due to

difficulty in acknowledging the need for help and thus a dependent role, fear of exposing and

facing feelings, anxiety about the discomfort. These can be overcome by conveying a caring

attitude, genuine interest in the client, and competence to foster the development of trust.

Working Phase

The nurse and the client in this phase begin to view each other as unique individuals and

appreciate this uniqueness and care about each other. In this phase, nurse and the client

accomplished the tasks outlined in the introductory phase, enhance trust and rapport, and develop

caring.

Two Major Stages

Exploring and Understanding Thoughts and Feelings

The nurse assists the client to explore thoughst and feelings and acquires an

understanding of the client. On the other hand, the client explores thoughts and feeling

associated with problesm, develops the skill of listening, and gains insight into

personal behavior through the following skills:

Emphatetic listening and responding

 The nurse must listen attentively and communicate in ways that indicate that

they have listened to what was said and understand how the client feels.

Empathy is the ability to identify and understand another person’s situation or

feelings. According to Boyd (2008), empathy is the “ability to experience, in the

present, a situation as another did at some time in the past.” This

understanding should then be communicated by forming empathetic response.

Respect

The nurse must show respect for the client’s willingness to be available, desire

to work with the client, and a manner that conveys the idea of taking the client’s

point of view serously.

Genuineness

Components of genuineness that a nurse can uphold according to Egan

(1998):

The genuine helper does not take refuge in or overemphasize the role of a counselor.

The genuine person is spontaneous.

The genuine person is nondefensive.

The genuine person displays few discrepancies- that is, the person is consistent and does

not think or feel one thing but say another.

The genuine person is capable of deep self-disclosure (self-sharing) when it is appropriate.

Concreteness

The nurse must assit the client to be concrete and specific rather than to speak

in generalities through narrowing topic to the specific by pointing it out.

Confrontation
 The nurse points out discrepancies between thoughts, feelings, and actions

that inhibit the client ‘s self-understanding or exploration of specific areas.

2. Facilitating Taking Action

The client must make decisions and take action to become more effcetive. The

responsibility for action belongs to the client. The nurse, however, collaborate in these decisions,

provides support, and may offer opinions or information.

Termination Phase

In this phase, summarizing and reviewing the process can produce a sense of

accomplishment by sharing reminiscences of how things were at the beginning of the relationship

and comparing to how they are now. Discussing termination allows time for the client to adjust to

independence. Nurse and client in this phase accept feelings of loss. The nurse summarizes skills.

Whereas, the client accepts the end of the relationship without feelings of anxiety or dependence.

He or she has the ability to handle problems indepedently.

Developing Helping Relationship

Listen actively.

Help to identify what the person is feeling.

Put yourself in other person’s shoes.

Be honest.

Be genuine and credible.

 Use your ingenuity.

Be aware of cultural differences that may affect meaning and understanding.

Maintain client confidentiality.

Know your role and your limitations.

DEVELOPING THERAPEUTIC COMMUNICATION SKILLS

Therapeutic communication is a fundamental skill expected from the nurses. This

establishes relationship between the nurses and the clients/patients. Thus, the nurses must

master the different techniques in order to have a good therapeutic relationship with the patients.

Techniques to Develop Therapeutic Communication Skills

Attentive Listening

Attentive listening is probably the most important and the most basic technique among

other techniques.
 This involves using all senses since it is defined as listening actively, and opposing the

passive way which is listening through ears only.

An active process that requires energy and concentration.

Paying attention to the client’s verbal and non-verbal message.

Must have an interaction with the client.

Physical Attending

Egan (1998) defined physical attending as “the manner of being present to another or

being with another.”

Egan outlined five specific ways to express physical attending, which he called “the five

actions of physical attending,” which communicate a “posture of involvement.”

Actions of Physical Attending by Egan (1998)

Face the other person squarely. This position says, “I am available to you.” Moving to the

side lessens the degree of involvement.

Adopt an open posture. The nondefensive position is one in which neither arms nor legs

are crossed. It conveys that the person wishes to encourage the passage of

communication, as the open door of a home or an office does

Lean toward the person. People move naturally toward one another when they want to

say or hear something—by moving to the front of a class, by moving a chair nearer a friend,

or by leaning across a table with arms propped in front. The nurse conveys involvement

by leaning forward, closer to the client.

 Maintain good eye contact. Mutual eye contact, preferably at the same level, recognizes

the other person and denotes willingness to maintain communication. Eye contact neither

glares at nor stares down another but is natural.

Try to be relatively relaxed. Total relaxation is not feasible when the nurse is listening with

intensity, but the nurse can show relaxation by taking time in responding, allowing pauses

as needed, balancing periods of tension with relaxation, and using gestures that are

natural.

Therapeutic Communication Techniques

Using Silence

Accepting silences and pauses without interjecting verbal responses.

Providing General Leads

Using statements and questions that encourages the patients and put thoughts into

verbalization.

Being Specific and Tentative

Giving precise and absolute statements.

Using open-ended questions

Asking broad questions that lead or invite the client to explore (elaborate, clarify, describe,

compare, or illustrate) thoughts or feelings.

Using touch

Providing appropriate forms of touch to reinforce caring feeling.

Restating or paraphrasing
 Actively listen to the client’s basic message and the repeat the exact same ting the client

have said. This will show that you are attentive towards the client.

Seeking clarifications

Making the client’s meaning of the message to be more understandable. The nurse clarify

the message though paraphrasing the statement or by confessing his/her confusion. The

nurses can also clarify their own statements.

Perception checking or seeking consensual validation

A method similar to clarifying that verifies the meaning of specific words rather than the

overall meaning of a message.

Offering self

Suggesting one’s presence, interest, or wish to understand the client without making any

demands or attaching conditions that the client must comply with to receive the nurse’s

attention.

Giving information

Providing the precise and factual information needed by the client, either requested or not.

Acknowledging

Giving recognition on client’s change of behavior, effort, and participation in

communication.

Clarifying time or sequence

Helping the client clarify an event, situation, or happening in relationship to time.

Presenting reality

Helping the client to differentiate the real from the unreal.

Focusing
 Helping the client expand on and develop a topic of importance. It is important for the

nurse to wait until the client finishes stating the main concerns before attempting to focus.

Reflecting

Directing ideas, feelings, questions, or content back to clients to enable them to explore

their own ideas and feelings about a situation.

Summarizing and Planning

Stating and clarifying the main points of a discussion. This is useful at the end of an

interview or to review health teaching session. Acts as an introduction to future planning.

NURSING AS
A SCIENCE
NURSING PROCESS
INTRODUCTION TO NURSING PROCESS

The nursing process is defined as,

“a systematic, rational method of planning and providing individualized nursing care.” It is
described as systematic for the phases are approached in a fixed and organized manner. Each
phase in the nursing process has a process on its own, and every process within the phases is
done with scientific methods, and has a rationale behind it.

The term nursing process originated from the nurse theorist, Lydia Hall in 1955, and other
nurse theorists namely, Johnson (1959), Orlando (1961) and Wiedenbach (1963), were the first
ones to make use of the term to refer to a series of phases describing the nursing practice.

In 1973, the use of nursing process gained additional legitimacy when it was included in
the American Nurses Association (ANA).

The purpose of the nursing process is it clearly defines the client’s health status, address
their actual or potential problem, and have an establishment of plans, deliver specific nursing
interventions, provides consistency of care and quality patient care through deliberate actions.

Components

The nursing process is composing of 5 phases, and each phase interrelates with all the others.

The phases are described as interrelated for it is connected in a way to the succeeding phases
which are also dependent to the phases that precedes them. The assessment for example being
the initial phase can still be utilized in the implementing and evaluating phases. Being closely
interrelated to each other, if during the assessment phase, inadequate data were acquired, the
succeeding phases will be affected.

Benefits

Promotes critical thinking skills, decision-making

skills

Promotes quality of health care provision

Provision of continuity of care

Prevention of any legal complications by

minimizing errors or inconsistencies

Promotes professional growth

Promotes accountability

The deliberate and systematic nursing process allows the structured flow of information
which benefits the nurses by the promotion of their critical thinking skills and decision-making
skills since they often encounter complicated cases, and with that they must know how to
distinguish significant information. If all of the nursing processes are done with accuracy, the
nurse should be able to implement appropriate nursing care actions, at the same time, avoiding
legal complications as the nurse is responsible enough to do what is only needed by the client.
This kind of actions promotes professional growth among nurses, and it’s another advantage from
following the nursing process. Finally, it promotes accountability as well for every nurse are
required to document every actions to be given to the client, they are encouraged to do what they
had planned and take accountability for the outcomes.

Accountability

According to the American Nurses’ Association Code of Ethics, accountability is,

“to be answerable to oneself and others for one’s own actions”

Aside from being an important component of the nursing practice, it is also important for
the safety of the clients. We are accountable to meet the legal requirements and standards of the
nursing profession. For every actions or behaviors that we manifest, we are accountable for it,
but it is important to know that we are not accountable for the decisions made by other nurses or
healthcare professionals.

Professional Accountability includes:

Declining from activities wherein you’re not competent in or skilled in

Being well-informed or seeking help/assistance

Learning the rationale of your actions

-----Follows the Principle of Res ipsa loquitur ("the thing speaks for itself,") a principle that the
occurrence of an accident implies negligence.

Knowing your own limits and refraining from doing things in which you’re not competent in
will do no harm and will put you away from further complications. If there are certain things that
you’re not aware of, it’s your responsibility to learn and be knowledgeable, more importantly, since
you’re dealing with health-related things. Seeking assistance from other nurses/healthcare
assistance when needed is also a must, so you can prevent yourself from putting your client in
danger. And with every actions that you’ll do, there should be a reason why or a purpose.

ASSESSMENT
 Assessment is a systematic and continuous process of collecting, organizing, validating,
and documenting the client’s data to establish a database—all the information about a client—to
know the client’s response to health concerns or illness and the ability to manage health care
needs. This first phase of the nursing process is a very vital stage where you will need all
throughout the process that is why the health professional during this process has to have an
accurate and complete collection of data. This data-gathering stage will be the phase where you
will obtain information from different sources like the client’s history or physical exams, lab or test
results, client records, the client’s support system or his or her family members. Depending upon
the situation, there are different types of assessments namely: initial nursing assessment,
problem-focused assessment, emergency assessment, and time-lapsed reassessment.

Assessment includes not only physiological data, but also psychological, sociocultural,
spiritual, economic, and life-style factors as well. For example, a nurse’s assessment of a
hospitalized patient in pain includes not only the physical causes and manifestations of pain, but
the patient’s response—an inability to get out of bed, refusal to eat, and withdrawal from family
members, anger directed at hospital staff, fear, or request for more pain medication.

Types of Assessment:

Initial Assessment
It is the kind of assessment that is formed within specified time after admission to a health care
agency.
Problem-focused Assessment
It is the kind of assessment that done in an ongoing process integrated with nursing care.
Emergency Assessment
It is the kind of assessment done during any physiological or psychological crisis of a client.
Time-lapsed Assessment
It is the kind of assessment done several months after the initial assessment of a client.

Framework for Data Collection

Functional health patterns are defined as sequences of health behavior across time. Within
nursing, alternate systems of health assessment are being developed around the organizing
framework of functional health patterns (Gordon, 1987 and 1993). According to (Kozier, 2014):

Health Perception – Health Management Patterns

Aware/understands medical diagnosis
Gives thorough history of illnesses and surgeries
Complies with Synthroid regimen
Relates progression of illness in detail
Expects to have antibiotic therapy and “go home in a day or two”
Nutritional – Metabolic Pattern
158 cm (5 ft, 2 in.) tall; weighs 56 kg (125 lb)
Usual eating pattern “three meals a day”
“No appetite” since having “cold”
Has not eaten today; last fluids at noon
Nauseated
Oral temperature 39.4°C (103°F)
Decreased skin turgor

Elimination Process
Usually no problem
Decreased urinary frequency and amount × 2 days
Last bowel movement yesterday, formed, states was “normal”
Activity – Exercise Pattern
No musculoskeletal impairment
Difficulty sleeping because of cough
“Can’t breathe lying down”
States “I feel weak”
Short of breath on exertion
Exercises daily
Sleep – Rest Pattern
Usual Sleep Pattern
Sleep/Bedtime Pattern
Sleep Environment. Sleep Position
Psychophysiological influences
Sleep-pattern disturbance symptoms
Cognitive – Perceptual Pattern
No sensory deficits
Pupils 3 mm, equal, brisk reaction
Oriented to time, place, and person
Responsive, but fatigued
Responds appropriately to verbal and physical stimuli
Recent and remote memory intact
States “short of breath” on exertion
Reports “pain in lungs,” especially when coughing
Experiencing chills
Reports nausea
Self-Perception – Self Concept Pattern
Expresses “concern” and “worry” over leaving her children with their grandparents until
husband returns
Anxiety related to missing her nursing classes, missing her medical–surgical clinical day, and
inability to study
Well-groomed; says, “Too tired to put on makeup”
Role – Relationship Pattern
Lives with husband, 13-year-old daughter, and 5-year-old son
Husband out of town; will be back tomorrow afternoon
Children are with their grandparents until husband returns
States “good” relationships with friends and coworkers
Nursing student and part-time home health aid
Sexuality – Reproductive Pattern
Sex Roles and Gender identification
Knowledge about sexuality and reproductions
Concerns about sexual performance and satisfaction
Coping – Stress Tolerance Pattern
 Anxious: “I can’t breathe”
Facial muscles tense; trembling
Expresses concerns about work: “I’ll never get caught up”
Value – Belief Pattern
Catholic
No special practices desired except anointing of the sick
Middle-class, professional orientation
No wish to see chaplain or priest at present

Patient History

Eliciting a full patient history through open-ended questioning and active listening will
ultimately save time while offering critical clues to the diagnosis. In one classic study, researchers
evaluated the relative importance of the medical history, the physical exam, and diagnostic
studies. Health professionals were asked to predict their diagnosis after taking just the history,
and then again after performing the history with the physical exam. In studies, an accurate
diagnosis was predicted based solely on the medical history. It is now estimated that between 70
to 90 percent of medical diagnoses can be determined by the history alone; in addition to being
one of the oldest diagnostic tools, a comprehensive history is one of the most reliable.

Patient history is obtained through collecting from subjective data—verbal from clients. This
provides the opportunity to convey interest, support, and understanding to the patient and to
establish rapport. This patient history includes the client’s biographic data, chief complaint, history
of present illness, past history, family history, and the psychosocial data.

BIOGRAPHICAL DATA

The biographical data is obtained through interviewing the patient at the beginning during the
client’s first visit or admission. These are the list commonly used, and sometimes critical,
biographical information.

Full Name:
Address:
Age:
Sex:
Race:
Marital Status:
Occupation:
Religious Orientation:
Health Care Financing:

CHIEF COMPLAINT

This part of the patient history is recorded in the client’s own words and is in quotation marks
indicating the client’s purpose or concern why he or she came sought for medical assistance in
the hospital. The health professional may ask questions to the patient like. “What is troubling you?”
or “May we know the reason you came to the hospital today?”. In this portion, you have to list the
client’s priorities as he or she stated.
PRESENT HEALTH HISTORY

This section describes the information relevant to the client’s reason for seeking care. The
interviewing of this phase is quite difficult especially for beginning practitioners because this
process requires both interviewing skills and clinical knowledge.

When the symptoms started?

How often the problem occurs
Exact location of the distress
Character of the complaint (e.g., intensity of pain or quality of sputum, emesis, or discharge)
Type of activity of client when problem occurred?
Phenomena or symptoms associated with the chief complaint
Factors that aggravate or alleviate the problem
Was help or consultations sought?
What were the medications taken?
How has the problem interfere with your daily life?

PAST HEALTH HISTORY

The purpose of this section is to identify all the client’s major past health problems. Past
illnesses may have an effect on the client’s current health needs and problems. Information about
the past care provided provides some indicator of client’s possible response to current and future
health issues.

Childhood Diseases
Immunizations
Allergies
Accidents and injuries
Hospitalizations
Medications taken
Operations

FAMILY HEALTH HISTORY

The purpose of this section is to learn about the general health of the client’s blood relatives,
spouse, and children, and to identify any illnesses of a genetic, familial, or environmental nature
that may affected the client’s current or future health problems. This also includes the health and
ages of parents, siblings, children, or ages of deaths and its cause.

PSYCHOSOCIAL DATA
Major stressors experienced and the client’s perception of them
Usual coping pattern for a serious problem or a high level of stress
Communication style: ability to verbalize appropriate emotion; nonverbal communication—
such as eye movements, gestures, use of touch, and posture; interactions with support
persons; and the congruence of nonverbal behavior and verbal expression

PHYSICAL EXAMINATION
 According to Berman, A., Snynder, S. & Frandsen, G., “the physical examination or physical
assessment is a systematic data collection method that uses observation (i.e., the senses of sight,
hearing, smell, and touch) to detect health problems. To conduct the examination, the nurse uses
techniques of inspection, auscultation, palpation, and percussion. The physical examination is
carried out systematically. It may be organized according to the examiner’s preference, in a head-
to-toe approach or a body systems approach. Usually, the nurse first records a general impression
about the client’s overall appearance and health status: for example, age, body size, mental and
nutritional status, speech, and behavior. Then the nurse takes such measurements as vital signs,
height, and weight. The cephalocaudal or head-to-toe approach begins the examination at the
head; progresses to the neck, thorax, abdomen, and extremities; and ends at the toes. The nurse
using a body systems approach investigates each system individually, that is, the respiratory
system, the circulatory system, the nervous system, and so on. During the physical examination,
the nurse assesses all body parts and compares findings on each side of the body (e.g., lungs).
Instead of giving a complete examination, the nurse may focus on a specific problem area noted
from the nursing assessment, such as the inability to urinate. On occasion, the nurse may find it
necessary to resolve a client complaint or problem (e.g., shortness of breath) before completing
the examination. Alternatively, the nurse may perform a screening examination. A screening
examination, also called a review of systems, is a brief review of essential functioning of various
body parts or systems. An example of a screening examination is the nursing admission
assessment. Data obtained from this examination are measured against norms or standards,
such as ideal height and weight standards or norms for body temperature or blood pressure levels.”

LABORATORY AND DIAGNOSTIC STUDIES

Collaboration with other clinicians in the care planning is vital. The nurse should include
modalities to help patients cope with the actual diagnostic procedure and test outcomes, as well
as accommodate patients with special needs, such as hearing or sight impairment, ostomy care,
or diabetic care. The comatose, the confused, the child, and the frail, elderly patient also require
special consideration. Nurses and other health care clinicians treat collaborative patient problems
simultaneously. During diagnostic tests, the nurse identifies both nursing diagnoses and
collaborative problems that require appropriate and independent nursing interventions.

EXAMPLES OF NURSE-DIRECTED TESTING

TEST NURING RESPONSSIBILITY
Blood draws for testing (arterial, venous, Monitor blood glucose levels, cardiac
or capillary) enzymes, electrolytes, drug presence (licit or
illicit), cell counts (red and white blood cells),
alcohol intake, oxygenation levels, acid-base
status, presence of bacterial pathogens,
hormone levels, tumor markers, antibodies,
etc.
 Guaiac stool testing Check for fecal blood, color, consistency, and
presence of pathogenic organisms
Tuberculin skin testing Interpret results; obtain blood and/or sputum
for TB testing
HIV/AIDS testing Obtain blood or saliva and obtain informed
consent
Rectal exams Obtain stool for occult blood, positive guaiac
smears as possible sign of rectal or colon
cancer
Finger- or heelsticks Screen newborns and infants for genetic
disorders
Pap smears Perform vaginal swab for diagnosis of pre-
cancers and cancers of genital tract; check for
the presence of microorganisms
Throat swabs Swab throat for the diagnosis of Streptococcus
infections
Urine dipsticks Determine blood glucose level, alcohol levels,
and the presence of bladder infection
Lung function testing Use spirometer for peak airflow assessment in
asthma
Breath alcohol testing Use specialized devices to detect above-
normal levels of alcohol
Audiometric examination Follow guidelines for hearing deficits
Vision testing Conduct simple to complex vision tests; follow
guidelines for retinal and macular
degeneration disorders
Pulse oximetry Apply special device to monitor arterial
oxygenation levels (during rest, walking,
exercise)
ECG Apply leads to identify normal cardiac rhythms,
arrhythmias, and myocardial ischemia;
evaluate pacemaker function
IV Draw blood and collect specimens from
invasive lines for evaluation

B. Organizing Information Elements

Data Collection
The gathering of data about the client’s health status. It is systematic and continuous to avoid
the omission of important information.

Database- contains all the information about the client

Types of Data
 Subjective data- also known as symptoms or covert data, are information that can be
described or verified only by that person.
Objective data- also known as signs or overt data, are information that can be observed
or can be measured or tested against an accepted standard.

Sources of Data
Primary Source- statements made by the client but also include those objective data that
can be directly obtained by the nurse from the client such as gender. The best source of
data is usually the client, unless the client is too ill, young, or confused to communicate
clearly.
Secondary Source- family members or other support persons, other health professionals,
records and reports, laboratory and diagnostic analyses, and relevant literature are
secondary or indirect sources.

Information supplied by family members, significant others, or other health professionals

is considered subjective if it is not based on fact.
Client records- include all information documented by various health care professionals.

Types of Client Record

Medical Records
Records of Therapies
Laboratory Records

Data Collection Method

Observing- a conscious, deliberate skill that is developed through effort and with an
organized approach.
Has 2 aspects:
a. noticing the data
b. selecting, organizing, and interpreting the data.

2. Interviewing- a planned communication or a conversation with a purpose.

Two approaches:

Directive Approach- a highly structured and elicits specific information.

Nondirective Interview- rapport-building interview where the nurse allows the client to
control the purpose, subject matter, and pacing

Types of interview question

Close-ended Questions- used in the directive interview, are restrictive and generally
require only “yes” or “no” or short factual answers giving specific information.
Open-ended question- used in nondirective interview, invite clients to discover and explore,
elaborate, clarify, or illustrate their thoughts or feelings.
 Neutral question- a question the client can answer without direction or pressure from the
nurse, is open ended, and is used in nondirective interviews.
Leading question- usually closed and used in a directive interview, and thus directs the
client’s answer.

Planning the interview and the setting

Time
Place
Seating Arrangement
Distance
Language

Stages of an interview
Opening- can be the most important part of the interview. The purposes of the opening
are to establish rapport and orient the interviewee.
Body- the client communicates what he or she thinks, feels, knows, and perceives in
response to questions from the nurse.
Closing- the nurse terminates the interview when the needed information has been
obtained

The following techniques are commonly used to close an interview:

Offer to answer questions

Conclude by saying “Well, that’s all I need to know for now” or “Well, those are all the
questions I have for now.”
Thank the client
Express concern
Plan for the next meeting
Provide a summary
EXAMINING

Physical Examination/Physical Assessment- a systematic data collection method that uses

observation to detect health problems.

Cephalocaudal- head-to-toe approach that begins the examination at the head; progresses to
the neck, thorax, abdomen, and extremities; and ends at the toes.

Screening Examination/Review of Systems- a brief review of essential functioning of various

body parts or systems.

DATA VALIDATION

The act of “double-checking” or verifying data to confirm that it is accurate and factual.

Helps the nurse complete these tasks:

Ensure that assessment information is complete.

Ensure that objective and related subjective data agree.
 Obtain additional information that may have been overlooked.
Differentiate between cues and inferences.
Cues- subjective or objective data that can be directly observed by the nurse.
Inferences- the nurse’s interpretation or conclusions made based on the cues.
Avoid jumping to conclusions and focusing in the wrong direction to identify problems.

As a rule, the nurse validates data when there are discrepancies between data obtained in
the nursing interview and the physical examinatio, or when the client’s statements differ at
different times in the assessment.

DATA CLUSTERING

Data clustering or grouping of cues is a process of determining the relatedness of facts

and determining whether any patterns are present, whether the data represent isolated
incidents, and whether the data are significant.

The nurse may cluster data inductively by combining data from different assessment areas
to form a pattern; or the nurse may begin with a framework.

DATA DOCUMENTATION

It is the recording of the client’s data as a completion of the assessment phase. Data
should be recorded in a factual manner and not interpreted by the nurse. To increase accuracy,
the nurse records subjective data in the client’s own words, using quotation mark

DIAGNOSIS
Following the assessment phase, the second in the nursing process is the diagnosis.
During this phase, the critical thinking skills of the nurse would be necessary, for diagnosis is
considered as a ‘pivotal’ step in the nursing process. It is because prior to diagnosis are the
activities included in the assessment phase, which will serve as an important basis for formulating
the diagnosis. The gathered data from the assessment must be accurate and comprehensive
enough to make an appropriate and error-free diagnosis, since it will be used to determine the
health care needs of the client, then the nursing planning activities will be based from it.

Brief History:

The North American Nursing Diagnosis Association (NANDA) is an organization group

with participating and contributing nurses, was initiated by Kristine Gebbie and Mary Ann Lavin in
1973. The first held national conference aimed to identify and develop nursing diagnoses, and it
was sponsored by Saint Louis University School of Nursing and Allied Health Professions,
followed by conferences in 1975 and in 1980, and every two years thereafter.

In 1977 was the First Canadian Conference in Toronto and in May 1987 in Calgary, Alberta,
Canada. The conference group accepted the name North American Nursing Diagnosis
Association, acknowledging the participation of nurses in United States and Canada, and then in
2002, it was changed to NANDA International to engage with the worldwide interests in nursing
diagnoses.

The purpose of NANDA:

To define, refine and promote taxonomy of nursing diagnostic terminology of general use
to professional nurses.

TAXONOMY: is a classification system or set of categories arranged based on a single principle

or set of principles.

Currently, there are more than 200 approved nursing diagnosis labels for clinical use and
testing.

NANDA NURSING DIAGNOSES

A nurse must be knowledgeable of the definitions of terms, as well as the components of nursing
diagnoses in order to utilize the concepts of nursing diagnoses effectively in formulating and
completing a nursing care plan.

DEFINITIONS:

Diagnosing refers to the reasoning process, whereas diagnosis is the statement or conclusion
regarding the nature of a phenomenon.

Diagnostic labels refer to the standardized NANDA names for the diagnoses, and the nursing
diagnosis refers to the client’s problem statement composing of the diagnostic label plus the
etiology (related factor and risk factor)

According to NANDA,

Nursing Diagnosis is “…a clinical judgment concerning a human response to health

conditions/life processes, or a vulnerability for that response, by an individual, family, group or
community”

“A nursing diagnosis provides the basis for selection of nursing interventions to achieve
outcomes for which the nurse has accountability” This definition is consistent with the following:

Professional nurses are responsible for making nursing diagnoses, even though other nursing
personnel may contribute date to the process of diagnosing and may implement specified nursing
care.
The domain of nursing diagnosis includes only those health states that nurses are educated and
licensed to treat.
A nursing diagnosis is a judgment made only after thorough, systemic data collection.
Nursing diagnoses describe a continuum of health states: deviations from health, presence of risk
factors and areas of enhanced personal growth.

DIAGNOSTIC ANALYSIS

This process a nurse must go through before formulating a diagnosis requires clinical thinking.

Analysis and interpretation of data

Steps for analyzing in the diagnostic process:
Compare data against standards (identify significant cues)
Cluster the cues (generate tentative hypotheses)
Identify gaps and inconsistencies.
COMPARING DATA WITH STANDARDS

After the nurse has thoroughly gathered the client’s data, it is then followed by comparing it to a
wide range of standards or norm (laboratory values, normal vital signs, development patterns) to
identify significant and relevant cues.

Cues can be considered significant,

If it indicates a positive or negative change in a client’s health status or pattern.

If it deviates from norms of client population
If it indicates a developmental delay

CLUSTERING CUES

Data clustering or grouping of client data or cues is a process wherein the presence of pattern,
relatedness and significance of data are distinguished.

The nurse may cluster data by:

Inductive Approach: Combining of data from different assessment areas to form a pattern
Deductive Approach: Starting with a framework (such as Gordon’s functional health patterns,
and organize the subjective and objective data into the appropriate categories

Involved in this process is the interpretation of the possible meaning of the cues, and labeling of
the cues with tentative diagnostic hypotheses.

IDENTIFYING GAPS AND INCONSISTENCIES IN DATA

The minimizing of gaps and inconsistencies in data are accomplished during the assessment
phase, however to ensure the accuracy and appropriacy of data, it is recommended to do a final
checking.

If there are inconsistencies, it means that there is presence of errors in assessment,

interpretations, reports, and in other sources, also incomplete or incorrect recordings and this will
result to a misleading data. Thus to prevent inconsistencies, obtained data should be clarified to
establish a valid pattern.

IDENTIFYING HEALTH PROBLEM, RISKS, AND STRENGTHS

This process includes:

Determining the client’s problem

Determining if the client’s problem is a nursing diagnosis, medical diagnosis, or collaborative
diagnosis
Determining the client’s strength

The nurse identifies problems that can be treated solely with nursing intervention (nursing
diagnosis) or problems wherein a nurse could not prescribe a treatment/take independent action
(medical diagnosis), or if it’s a problem that requires both medical and nursing orders
(collaborative problem).

The establishment of strengths on the other hand can serve as the client’s assistance during the
recovery process, because it contributes to the positive thinking of the client’s self-concept and
self-image, increasing their ability to cope with their problem. Example of client strengths: absence
of allergies, smoking habits, alcoholism, etc. These kinds of strengths are obtainable from the
nursing assessment record, health examinations, and records.

B. Nursing Diagnostic Analysis

Types of nursing diagnoses according to status:

“Status of the nursing diagnosis refers to the actuality or potentiality of the problem/syndrome or
the categorization of the diagnosis as a health promotion diagnosis” (Herdman & Kamitsuru, 2014,
p. 100). The kinds of nursing diagnoses according to status are actual, health promotion, risk, and
syndrome.

1. An actual diagnosis is a type of diagnosis wherein the problem must be present at the time
during nursing assessment. In order to yield this diagnosis, it should be based on the presence
of associated signs and symptoms. Examples are Ineffective Breathing Pattern and Anxiety.

2. A health promotion diagnosis relates to clients’ preparedness to implement behaviors to

improve their health condition. It concerns on motivation and desire to increase well-being and to
achieve the person’s own optimum health potential. These diagnoses use terms related to a
patient's readiness for specific health behaviors. These diagnosis labels begin with the phrase
Readiness for Enhanced, as in Readiness for Enhanced Nutrition.

3. A risk nursing diagnosis is a diagnosis where the problem does not exist, but the presence
of risk factors indicates that a problem is likely to develop unless nurses intervene. It examines
the client’s susceptibility for developing an undesirable human response to health conditions/life
processes. For example, all people admitted to a hospital have some possibility of acquiring a
nosocomial infection; however, a client with diabetes or a weak immune system is at higher risk
than others. Therefore, the nurse would appropriately use the label Risk for Infection to describe
the client’s health status.

4. A syndrome diagnosis is concern about a specific cluster of nursing diagnoses that occur
together in a pattern and are therefore best addressed together and through similar interventions.
For example, a person that has a chronic pain experiences recurrent or persistent pain that has
lasted at least 3 months and that significantly affects daily functionings or well-being. It has
significant impact on other human responses and thus includes other diagnoses, such as
disturbed sleep pattern, fatigue, impaired physical mobility, or social isolation.

Components of a NANDA Nursing Diagnosis

Problem (Diagnostic Label) and Definition

The problem statement, or diagnostic label, defines the client’s health problem or reaction for
which a nursing treatment would be given. It describes the client’s health status clearly and
concisely. The diagnostic label directs the formation of client goals and desired outcomes and
may also suggest some nursing interventions.

Diagnostic labels need to be specific; when the word Specify follows a NANDA label, the nurse
states the area in which the problem occurs, for example, Deficient Knowledge (Medications) or
Deficient Knowledge (Dietary Adjustments).

Qualifiers are words that have been added to some NANDA labels to give additional meaning
to the diagnostic statement; for example:

■ Deficient (inadequate in amount, quality, or degree; not sufficient; incomplete)

■ Impaired (made worse, weakened, damaged, reduced, deteriorated)

■ Decreased (lesser in size, amount, or degree)

 ■ Ineffective (not producing the desired effect)

■ Compromised (to make vulnerable to threat).

Etiology (Related Factors and Risk Factors)

The etiology identifies the related factors (causes or the contributing factors) and the risk factor
which is the determinant (increase risk). It gives direction to the required nursing intervention, and
enables the nurse to individualize the client’s care. A review of client history often helps to identify
related factors. Whenever possible, nursing interventions should be aimed at these etiological
factors in order to remove the underlying cause of the nursing diagnosis.

Defining Characteristics

Defining characteristics are the observable cluster of signs and symptoms that indicate the
presence of a particular diagnostic label. For actual nursing diagnoses, the defining
characteristics are the client’s signs and symptoms. For risk nursing diagnoses, no subjective and
objective signs are present. Thus, the factors that cause the client to be more vulnerable to the
problem form the etiology of a risk nursing diagnosis.

Formulating Diagnostic Statements

Most nursing diagnoses are written as two-part or three-part statements, but there are variations
of these.

Basic Two-Part Statements

1. Problem (P): statement of the client’s response

(NANDA label)

2. Etiology (E): factors contributing to or probable

causes of the responses.

The two parts are linked by the term related to (RT)

Basic Three-Part Statements

The basic three-part nursing diagnosis statement is called the

PES format and includes the following:

1. Problem (P): statement of the client’s response

(NANDA label)

2. Etiology (E): factors contributing to or probable causes of

the response

3. Signs and symptoms (S): defining characteristics manifested

by the client.

Actual nursing diagnoses can be documented by using the three-part statement because the
signs and symptoms have been identified. This format cannot be used for risk diagnoses because
the client does not have signs and symptoms of the diagnosis. The PES format is especially
recommended for beginning diagnosticians because the signs and symptoms validate why the
diagnosis was chosen and make the problem statement more descriptive.
One-Part Statements

Some diagnostic statements, such as wellness diagnoses and syndrome nursing diagnoses,
consist of a NANDA label only. As the diagnostic labels are refined, they tend to become more
specific, so that nursing interventions can be derived from the label itself. Therefore, an etiology
may not be needed.

NANDA has specified that any new wellness diagnoses will be developed as one-part statements
beginning with the words Readiness for Enhanced followed by the desired higher level of

wellness (for example, Readiness for Enhanced Parenting). Currently the NANDA list includes
several wellness diagnoses. Some of these are Spiritual Well-Being, Childbearing Process, and
Comfort.

Variations of Basic Formats

Variations of the basic one-, two-, and three-part statements include the following:

1. Writing unknown etiology when the defining characteristics are present but the nurse does
not know the cause or contributing factors. One example is Noncompliance (Medication Regimen)
related to unknown etiology.

2. Using the phrase complex factors when there are too many etiologic factors or when they are
too complex to state in a brief phrase. The actual causes of chronic low self-esteem, for instance,
may be long term and complex, as in the following nursing diagnosis: Chronic Low Self-Esteem
related to complex factors.

3. Using the word possible to describe either the problem or the etiology. When the nurse
believes more data are needed about the client’s problem or the etiology, the word possible is
inserted. Examples are Possible Low Self-Esteem related to loss of job and rejection by family;
Altered Thought Processes possibly related to unfamiliar surroundings.

4. Using secondary to to divide the etiology into two parts, thereby making the statement more
descriptive and useful. The part following secondary to is often a pathophysiologic or disease
process or a medical diagnosis, as in Risk for Impaired Skin Integrity related to decreased
peripheral circulation secondary to diabetes.

5. Adding a second part to the general response or NANDA label to make it more precise. For
example, the diagnosis Impaired Skin Integrity does not indicate the location of the problem. To
make this label more specific, the nurse can add a descriptor as follows: Impaired Skin Integrity
(Left Lateral Ankle) related to decreased peripheral circulation.

Avoiding Errors in Diagnostic Reasoning

It is important for nurses to make nursing diagnoses with a high level of accuracy.

Verify.

Hypothesize possible explanations of the data, but realize that all diagnoses are only tentative
until they are verified. Begin and end the diagnostic process by talking with the client and family.
When collecting data, ask them what their health problems are and what they believe the causes
to be. At the end of the process, ask them to confirm the accuracy and relevance of your
diagnoses.

Build a good knowledge base and acquire clinical experience.

Nurses must apply knowledge from many different areas to recognize significant cues and
patterns and generate hypotheses about the data. To name only a few, principles from chemistry,
anatomy, and pharmacology each help the nurse understand client data in a different way.

Have a working knowledge of what is normal.

Nurses need to know the population norms for vital signs, laboratory tests, speech development,
breath sounds, and so on. In addition, nurses must determine what is usual for a particular person,
taking into account age, physical makeup, lifestyle, culture, and the person’s own perception of
what his or her normal status is. For example, normal blood pressure for adults is in the range of
110/60 to 140/80 mmHg. However, a nurse might obtain a reading of 90/50 mmHg that is perfectly
normal for a particular client. The nurse should compare actual findings to the client’s baseline
when possible.

Consult resources.
 Both novices and experienced nurses should consult appropriate resources whenever in doubt
about a diagnosis. Professional literature, nursing colleagues, and other professionals are all
appropriate resources. The nurse should use a nursing diagnosis handbook to determine whether
the client’s signs and symptoms truly fit the NANDA label chosen.

Base diagnoses on patterns—that is, on behavior over time—rather than on an isolated

incident.

For example, even though Margaret O’Brien is concerned today about needing to leave her
children with her in-laws, it is likely that this concern will be resolved without intervention by the
next day. Therefore, the admitting nurse should not diagnose Interrupted Family Processes but,
rather, Risk for Interrupted Family Processes.

Improve critical thinking skills.

These skills help the nurse to be aware of and avoid errors in thinking, such as overgeneralizing,
stereotyping, and making unwarranted assumptions.

Differentiating Nursing Diagnoses from Medical Diagnoses

Nursing Medical Diagnoses Collaborative Problem/Diagnosis

Diagnoses
Clinical Clinical judgment Manages by a nurse using
judgment by physician that both independent and
by a identifies or physician-prescribed
professiona determines interventions
l nurse that specific disease or Independent nursing
identifies condition. interventions for a
the client’s Refers to a collaborative problem focus
actual, risk, condition only a mainly on monitoring the
wellness, or physician can client’s condition and
syndrome treat. preventing development of
responses It refers to disease the potential complication
to a health processes in Definitive treatment of the
state or which specific condition requires both
problem. pathophysiologic medical and nursing
Describes responses are interventions.
the client’s fairly uniform from
 response, one client to
physical, another.
sociocultur
al,
psychologic
al, and
spiritual
responses
to an
illness.
More
individualiz
ed to a
specific
client
Emphasize
s human
responses
to which the
nurse can
independen
tly take
action.

Nursing diagnosis relates to independent functions in which the areas of health care that are
unique to nursing and separate and distinct from medical management. With regard to medical
diagnoses, nurses are obligated to carry out physician-prescribed therapies and treatments, that
is, dependent functions.

PLANNING
The third (3rd) phase of nursing process after identifying the nursing diagnoses and strengths of
the client. It involves decision-making, problem solving, and focuses on the goals and outcomes
of the nursing. In planning, the nurse refer to the client’s assessment data and diagnostic
statements for direction in formulating client goals and designing the nursing interventions
required to prevent, reduce, or eliminate the client’s health problems.
There are three types of Planning. (1) Initial Planning, the nurse who performs the admission
assessment usually develops the initial comprehensive plan of care; (2) Ongoing Planning, is
done by all nurses who work with the client. As the nurse obtain new information and evaluate
the client’s response to care, they can individualize the initial care plan further; and (3) Discharge
Planning, the process of anticipating and planning for needs after discharge, is a crucial part of
comprehensive health care and should be addressed in each client’s care plan.

Setting Priorities
Priority setting is the process of establishing a preference sequence for addressing nursing
diagnoses and interventions. The nurse and client begin planning by deciding which nursing
diagnoses requires attention first, which second, and so on. Instead of rank-ordering
diagnoses, nurses can group them as having high, medium, or low priority. In other words, as
you care for a client or a group of clients, there are certain aspects of care that you need to
deal with before others.

Priorities can change as the client’s responses, problems, and therapies change. The nurse
must consider a variety of factors when assigning priorities, including the following:
Client’s health values and beliefs
Client’s priorities
Resources available to nurse and client:
Urgency of the health problem
Medical Treatment

Establishing Goals
A goal is a broad statement that describe a desired change in a patient’s condition
or behavior. It has three types (1) Expected outcomes, a measurable criterion to
evaluate goal achievement. Once an outcome is met, you then know that a goal
has been at least partially achieved. Sometimes several expected outcomes must
be met for a single goal; (2) Short-term goal, an objective behavior or response
that you expect to patient to achieve in a short time, usually less than a week. In
an acute care setting, you often set goals for over a course of just few hours; and
(3) Long-term goal, an objective behavior or response that you expect a patient
to achieve over a longer period, usually over several days, weeks, or months.

Identifying expected desired outcomes

An expected outcome is a specific measureable change in a patient’s status that
you expect to occur or response to nursing care. In addition, expected outcome
direct nursing care because they are the desired physiological, psychological,
social, developmental, or spiritual responses that indicate resolution of a patient’s
health problems.

Purpose:
To provide direction for planning nursing interventions.
Serve as criteria for evaluating client progress
Enable the client and nurse to determine when the problem has been
resolved.
 Help motivate the client and nurse by providing a sense of achievement.

Planning appropriate nursing intervention

Nursing intervention are identify and written during the planning step of nursing process;
however, they are actually perform during the implementing phase. Nursing intervention
includes two caring process: (1) Direct care, an intervention performed through interaction
with the client; and (2) Indirect care, an intervention performed away from but on behalf
of the client such interdisciplinary collaboration or management of the care of the
environment. In addition, there are three categories of nursing intervention: (1) nurse-
initiated, (2) physician-initiated and (3) collaborative interventions. The nurses must base
his/her selection of interventions on the client needs. Some clients requires all three
categories, whereas other clients need only nurse- and physician-initiated interventions.

Independent nursing intervention (Nurse-initiated intervention)

Are those activities that nurses are licensed to initiate based on their knowledge and skills.
These do not require direction or an order from another health care professional. As a
nurse, you act independently on a client’s behalf. In addition, it is an autonomous actions
based on scientific rationale. Example are instructing client in side effects of medications
or directing a client to splint an incision during coughing.

Dependent nursing intervention (Physician-initiated intervention)

Are activities carried out under the physician’s orders or supervision, or according to
specified routines. As the nurse, you intervene by carrying out the independent provider’s
written and/or verbally orders. Examples are administering a medication, implementing an
invasive procedure, changing a dressing and preparing a client for diagnostic tests.

Collaborative nursing intervention (Interdependent nursing intervention)

Are actions the nurse carries out in collaboration with other health team members, such a
physical therapists, social workers, dietitians and physicians. Typically, as a nurse when
you plan care for a client, you will review the necessary interventions and determine if the
collaboration of other health care disciplines is necessary. A client care conference with
an interdisciplinary health care team results in selection of interdependent nursing
intervention.

Selection of nursing intervention

Nursing interventions are the actions that a nurse perform to achieve client goal. As a
nurse, you need to learn to not select interventions randomly. When choosing
interventions, you consider the six important factors: (1) characteristic of the nursing
diagnosis, (2) goals and expected outcomes, (3) evidence base (research or proven
practice guidelines) for the intervention, (4) feasibility of the intervention, (5) acceptability
to the client, and (6) your own competency. As the nurse select interventions, he/she must
review their client’s needs, priorities, and previous experiences to select intervention that
have the best potential for achieving the expected or desired outcomes.
 Choosing Nursing Interventions

1. Characteristic of the Nursing Diagnosis 4. Feasibility

- A specific intervention has the potential for
- Interventions should alter the etiological interacting with other interventions;
(related to) factor or signs of symptoms
associated with the diagnostic label; - Be knowledgeable about the total plan of care

- When an etiological factor cannot change, - Consider cost

direct the interventions toward treating the
signs and symptoms; - Consider time

- For potential or high-risk diagnoses, direct

interventions at altering or eliminating risk
factors for the diagnosis.
2. Expected Outcomes
- Because nurses state outcomes in terms
used to evaluate the effect of an
intervention, this language assists in
selecting the intervention;
- Nursing Intervention Classification (INC) is
designed to show the link to Nursing
Outcomes Classification (NOC).
3. Research Base
- Research evidence in support of a nursing
intervention will indicate the effectiveness of
using the intervention with certain types of
clients;
- When research is not available, use
scientific principles or consult a clinical
expert about your client population. (eg.
Infectious control)
5. Acceptability to the Client
- A treatment plan needs to be acceptable to the
client and family and match the client’s goals,
health care values and culture;
- Promote informed choice; help a client know
how to participate in and anticipate the effect of
interventions.
6. Capability of the Nurse
- Be prepared to carry out the intervention
- Know the scientific rationale for the
intervention
- Have the necessary psychosocial and
psychomotor skills to complete the intervention.
- Be able to function within the specific setting
and effectively and efficiently use health care
resources.

Developing nursing care plan

In any health care setting, a nurse is responsible for providing a written plan of care for all
client. Generally, a written nursing care plan includes nursing diagnoses, goals and/or
expected outcomes and specific nursing intervention so that any nurse is able to quickly
identify a client’s clinical needs and situations. Moreover, the end product of planning has two
phase: (1) Informal nursing care plan, a strategy for action that exists the nurse’s mind (2)
Formal nursing care plan, a written or computerized guide that organizes information about
 the client’s care. Under the formal nursing care plan there are two other care plan mentioned,
they are (1) Standardized care plan, a formal plan that specifies the nursing care for a group
of clients with common needs; and (2) Individualized care plan, is tailored to meet the unique
needs of specific client needs that are not addressed by the standardized plan.

During planning phase, the nurse must (1) decide which of the client’s problems need
individualized plans and which problems can be addressed by standardized plans and routine
care; and (2) write individualized desired outcomes and nursing interventions for client
problems that require nursing attention beyond preplanned, routine care. Technically, the
complete plan of care for a client is made up of several different documents, they are:
Described the routine care needed to meet the basic need;
Address the client’s nursing diagnoses and collaborative problems; and
Specify nursing responsibilities in carrying out the medical plan of care.

IMPLEMENTING

In performing the nursing process, implementing is the action phase in which the nurse
performs his or her nursing interventions. With the use of Nursing Interventions Classification’s
meaning, the process implementing consists of doing and documenting the activities that are the
specific nursing actions needed to carry out the interventions. During this stage, the nurse
performs and prepares thoroughly the nursing activities for the interventions that were developed
in the planning step and then concludes the implementing step by recording nursing activities and
the resulting client responses. It is also throughout this course of action the nurse organize the
coordination of care, health teaching and health promotion, and consultation.

A. Relationship of Implementing to Other Nursing Process Phases

The process of nursing and its phases are interrelated to one another. The first three
nursing process phases namely, assessing, diagnosing, and planning provide the basis for the
nursing actions performed during the implementing step. In return, the implementing phase then
provides the actual nursing activities and client responses that are examined in the final phase,
which is the evaluating phase. Using the data acquired during assessment, the nurse can create
their own plan of care. They can now modify and alter the interventions to fit a specific client rather
than applying them consistently to group of clients. While implementing nursing care, the nurse
continues to reassess the client at every contact, gathering data about the client’s responses to
the nursing activities and about any new problems that may develop.

B. Implementing Skills
 Necessary skills are required when providing an excellent execution of the intervention or
implementation. In order to implement the care plan successfully, the nurses should be able to
possess cognitive, interpersonal and technical skills. Nevertheless, they can use them in a range
of different combinations depending on the weight of the activity.

Cognitive skills can also be called the intellectual skills. It includes problem solving, decision
making, critical thinking, and creativity. These skills are exceptionally crucial in giving an intelligent
nursing care.

Interpersonal skills are all of the activities, verbal and nonverbal, people use when interacting
directly with one another.The effectiveness of a nursing action often depends largely on the
nurse’s ability to communicate with others. The nurse uses therapeutic communication to
understand the client and in turn be understood. Nurse also needs to work effectively with others
as a member of the health care team.

These skills are necessary for all nursing activities such as caring, comforting, advocating,
referring, counseling, and supporting. It also consists of conveying knowledge, attitudes, feelings,
interest, and appreciation of the client’s cultural values and lifestyle. Before a nurse can be highly
skilled in interpersonal skills, he or she must have self-awareness and is sensitive to others.

Technical skills are hands-on skills such as manipulating equipment, giving injections,
bandaging, and moving, lifting, and repositioning clients. These skills are also called tasks,
procedures, or psychomotor skills which refer to the physical actions that are controlled by the
mind, not by reflexes.

It requires knowledge and manual dexterity. Due to the presence of technology, number of
technical skills are expected of a nurse has greatly increased in recent years.

C. Process of Implementing

The process of implementing normally includes the following:

■ Reassessing the client

 ■ Determining the nurse’s need for assistance

■ Implementing the nursing interventions

■ Supervising the delegated care

■ Documenting nursing activities.

Reassessing the Client

Before implementing an intervention, the nurse must reassess the client to make sure the
intervention is still needed.
Even though an order is written on the care plan, the client’s condition may have changed.
New data may indicate a need to change the priorities of care or the nursing activities.

Determining the Nurse’s Need for Assistance

When implementing some nursing interventions, the nurse may require assistance and it may
include the following:

■ Nurse is unable to implement the nursing activity safely or efficiently alone

■ Assistance would reduce stress on the client

■ Nurse lacks the knowledge or skills to implement a particular nursing activity

Implementing the Nursing Interventions

It is important to explain to the patients what nursing interventions will be done to him or
her. You may need to tell them what sensations, they are expected to do and most essential is
the expected outcome based on the intervention. Nurses should also be able to ensure the client’s
privacy. It also involves scheduling the patient’s contacts to other hospital departments and it
serves a connection among the other members of the health care team.

When implementing interventions, nurses should follow these guidelines:

Base nursing interventions on scientific knowledge, nursing research, and professional standards
of care when these exist.
Clearly understand the interventions to be implemented and question any that are not understood.
The nurse is responsible for intelligent implementation of medical and nursing plans of care.
Adapt activities to the individual client.
Implement safe care.
Provide teaching, support, and comfort.
Be holistic
Respect the dignity of the client and enhance the client’s self esteem.
Encourage clients to participate actively in implementing the nursing interventions.

Supervising Delegated Care

If the care has been assigned to other health care professionals, then nurse is responsible
for the client’s overall care. They also must ensure that the activities have been implemented
according to the nursing care plan. Several other healthcare providers may be required to
communicate their activities to the nurse by documenting them one by one. The nurse validates
and responds to any undesirable findings.

Documenting Nursing Activities

After carrying out the nursing activities, the nurse then completes the implementing phase
by recording the interventions and client responses in the nursing progress notes. These will
become a part of the agency’s permanent record for the client. The nursing care must not be
recorded in advance because the nurse may determine on reassessment of the client that the
intervention should not or cannot be implemented.

The nurse may record routine or recurring activities in the client record at the end of a shift.
In the meantime, the nurse maintains a personal record of these interventions on a worksheet. In
some instances, it is important to record a nursing intervention immediately after it is implemented.
This is particularly true of the administration of medications and treatments because recorded
data about a client must be up to date, accurate, and available to other nurses and health care
professionals. Immediate recording helps safeguard the client.
 Nursing activities are communicated verbally as well as in writing. When a client’s health
is changing rapidly, the charge nurse and/or the primary care provider may want to be kept up to
date with verbal reports. Nurses also report client status at a change of shift and on a client’s
discharge to another unit or health agency in person, via a voice recording, or in writing.

EVALUATING

Evaluating is the fifth phase of the nursing process. It is a planned, ongoing, purposeful
activity in which clients and health care professionals determine (a) the client’s progress toward
achievement of goals/outcomes and (b) the effectiveness of the nursing care plan.

Evaluation is an important aspect of the nursing process because conclusions drawn from the
evaluation determine whether the nursing interventions should be terminated, continued, or
changed. The evaluation is continuous and should not stop there. It is done while or immediately
after implementing a nursing order enables the nurse to make modifications in an intervention.
Evaluation performed at specified intervals shows the extent of progress toward achievement of
goals and enables the nurse to correct any deficiencies and modify the care plan as needed.

Evaluation continues until the client achieves the health goals or is discharged from nursing care.
Evaluation at discharge includes the status of goal achievement and the client’s self-care abilities
with regard to follow-up care. Through evaluating, nurses demonstrate responsibility and
accountability for their actions, indicate interest in the results of the nursing activities, and
demonstrate a desire not to perpetuate ineffective actions but to adopt more effective ones.

Similarly, the effectiveness of interventions and achievement identified outcomes is continuously

evaluated as the client status is assessed. Evaluation should ultimately occur at each step in the
nursing process, as well as once the plan of care has been implemented.

1 .Evaluation of goal achievement

Before evaluation, the nurse identifies the desired outcomes that will be used to measure
client goal achievement. Desired outcomes serve two purposes: They establish the kind of
evaluative data that need to be collected and provide a standard against which the data are judged.

Collecting data related to the desired outcomes

Comparing the data with desired outcomes
Relating nursing activities to outcomes
Drawing conclusions about problem status
Continuing, modifying, or terminating the nursing care plan.

Collecting Data

Using the clearly stated, precise, and measurable desired outcomes as a guide, the nurse
collects data so that conclusions can be drawn about whether goals have been met. It is usually
necessary to collect both objective and subjective data.

When interpreting subjective data, the nurse must rely on either

(a) the client’s statements

(b) objective indicators

Data must be recorded concisely and accurately to facilitate the next part of the evaluating
process.

Comparing Data with Desired Outcomes

Both the nurse and client play an active role in comparing the client’s actual responses
with the desired outcomes.

When determining whether a goal has been achieved, the nurse can draw one of three
possible conclusions:

1. The goal was met; that is, the client response is the same as the desired outcome.

2. The goal was partially met; that is, either a short-term outcome was achieved but the long-term
goal was not, or the desired goal was incompletely attained.

3. The goal was not met.

 2. Formulating the Quality of nursing care

After determining whether or not a goal has been met, the nurse writes an evaluation
statement

An evaluation statement consists of two parts: a conclusion and supporting data. The
conclusion is a statement that the goal/desired outcome was met, partially met, or not met. The
supporting data are the list of client responses that support the conclusion.

Relating Nursing Activities to Outcomes

The third phase of the evaluating process is determining whether the nursing activities
had any relation to the outcomes. It should never be assumed that a nursing activity was the
cause of or the only factor in meeting, partially meeting, or not meeting a goal.

Drawing Conclusions About Problem Status

The nurse uses the judgments about goal achievement to determine whether the care
plan was effective in resolving, reducing, or preventing client problems. When goals have been
met, the nurse can draw one of the following conclusions about the status of the client’s problem:

■ The actual problem stated in the nursing diagnosis has been resolved, or the potential problem
is being prevented and the risk factors no longer exist. In these instances, the nurse documents
that the goals have been met and discontinues the care for the problem.

■ The potential problem stated in the nursing diagnosis is being prevented, but the risk factors
are still present. In this case, the nurse keeps the problem on the care plan.

■ The actual problem still exists even though some goals are being met.
■ The care plan may need to be revised, since the problem is only partially resolved. The revisions
may need to occur during the assessing, diagnosing, or planning phases, as well as implementing.
OR

■ The care plan does not need revision, because the client merely needs more time to achieve
the previously established goal. To make this decision, the nurse must assess why the goals are
being only partially achieved, including whether the evaluation was conducted too soon.

3. Care Plan Revision

Continuing, Modifying, or Terminating the Nursing Care Plan

After drawing conclusions about the status of the client’s problems, the nurse modifies the
care plan as indicated. Depending on the agency, modifications may be made by drawing a line
through portions of the care plan, marking portions using a highlighting pen, or indicating revisions
as appropriate for electronic charting systems. Whether or not goals were met, a number of
decisions need to be made about continuing, modifying, or terminating nursing care for each
problem.

Before making modifications, the nurse must determine the effectiveness of the plan as a
whole. This requires a review of the entire care plan and a critique of each step of the nursing
process involved in its development.

ASSESSING

An incomplete or incorrect database influences all subsequent steps of the nursing

process and care plan. If data are incomplete, the nurse needs to reassess the client and record
the new data. In some instances, new data may indicate the need for new nursing diagnoses,
new goals/outcomes, and new nursing interventions.
 DIAGNOSING

If the database was incomplete, new diagnostic statements may be required. If the
database was complete, the nurse needs to analyze whether the problems were identified
correctly and whether the nursing diagnoses were relevant to that database. After making
judgments about problem status, the nurse revises or adds new diagnoses as needed to reflect
the most recent client data.

PLANNING: DESIRED OUTCOMES

If a nursing diagnosis was inaccurate, obviously the goal/outcome statement will need
revision. If the nursing diagnosis was appropriate, the nurse then checks if the goals were realistic
and attainable. Unrealistic goals require correction. The nurse should also determine whether
priorities have changed and whether the client still agrees with the priorities. Goals and outcomes
must also be written for any new nursing diagnoses.

PLANNING: NURSING INTERVENTIONS

The nurse investigates whether the nursing interventions were related to goal
achievement and whether the best nursing interventions were selected. Even when diagnoses
and goals/outcomes were appropriate, the nursing interventions selected may not have been the
best ones to achieve the goal. New nursing interventions may reflect changes in the amount of
nursing care the client needs, scheduling changes, or rearrangement of nursing activities to group
similar activities or to permit longer rest or activity periods for the client.

IMPLEMENTING

Even if all sections of the care plan appear to be reasonable, the manner in which the plan
was implemented may have interfered with goal achievement. Before selecting new interventions,
the nurse should check whether they were carried out. Other personnel may not have carried
them out, either because the interventions were unclear or because they were unreasonable in
terms of external constraints such as money, staff, time, and equipment. After making the
necessary modifications to the care plan, the nurse implements the modified plan and begins the
nursing process cycle again.

4. Evaluating the Quality of Nursing Care

In addition to evaluating goal achievement for individual clients, nurses are also involved
in evaluating and modifying the overall quality of care given to groups of clients. This is an
essential part of professional accountability of the nurse. Nurses and all other health care
providers work together as an interdisciplinary team focused on improving client care. The
activities both use and contribute to evidence-based practice.

Quality Assurance

A quality assurance program is an ongoing, systematic process designed to evaluate

and promote excellence in the health care provided to clients. Quality assurance frequently refers
to evaluation of the level of care provided in a health care agency, but it may be limited to the
evaluation of the performance of one nurse or more broadly involve the evaluation of the quality
of the care in an agency, or even in a country.

Quality assurance requires evaluation of three components of care: structure, process,

and outcome.

Structure evaluation It focuses on the setting in which care is given. It answers this
question: What effect does the setting have on the quality of care? Structural standards describe
desirable environmental and organizational characteristics that influence care, such as equipment
and staffing.

Process evaluation focuses on how the care was given. It answers questions such as
these: Is the care relevant to the client’s needs? Is the care appropriate, complete, and timely?
Process standards focus on the manner in which the nurse uses the nursing process.
 Outcome evaluation focuses on demonstrable changes in the client’s health status as a
result of nursing care. Outcome criteria are written in terms of client responses or health status,
just as they are for evaluation within the nursing process.

Quality Improvement

Serious national efforts are currently under way to evaluate and improve the quality of
health care based on internal assessment by health care providers and increasing awareness by
the public that medical errors are not uncommon and can be lethal.

Center for Quality Improvement and Patient Safety

Conducts and supports user-driven research on client safety and health care quality
measurement, reporting, and improvement.

Develops and disseminates reports and information on health care quality measurement,
reporting, and improvement.

Collaborates with stakeholders across the health care system to implement evidence-based
practices, accelerating amplifying improvements in quality and safety for clients.

Assesses our own practices to ensure continuous learning and improvement for the Center and
its members.”

A sentinel event is an unexpected occurrence involving death or serious physical or

psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function.
The phrase “or the risk thereof” includes any process variation for which a recurrence would carry
a significant chance of a serious adverse outcome.

Root cause analysis is a process for identifying the factors that bring about deviations in
practices that lead to the event. It focuses primarily on systems and processes, not individual
performance. It begins with examination of the single event but with the purpose of determining
which organizational improvements needed to decrease the likelihood of such events occurring
again

Nursing Audit
 An audit refers to the examination or review of records. A retrospective audit is the
evaluation of a client’s record after discharge from an agency. Retrospective means “relating to
past events.” A concurrent audit is the evaluation of a client’s health care while the client is still
receiving care from the agency. These evaluations use interviewing, direct observation of nursing
care, and review of clinical records to determine whether specific evaluative criteria have been
met.
 PROCEDURES BASIC TO NURSING CARE

ASEPSIS AND INFENCTION CONTROL

CHAIN OF INFECTION

There are many different germs and infections inside and outside of the healthcare setting.
Despite the variety of viruses and bacteria, germs spread from person to person through a
common series of events. This infectious disease process is called the chain of infection which
can only occur when all six links in the chain are intact. Therefore, to prevent the spread of
infection, we must break the chain of infection at any of the links. The six links include: the
infectious agent, reservoir, portal of exit, mode of transmission, portal of entry, and susceptible
host.
.INFECTIOUS AGENT/ ETIOLOGIC AGENT

Infectious agents or pathogens are the microorganisms

or “germs”—bacteria, viruses, fungi, and protozoa—that can cause disease or illness in its host.

Some microorganisms, such as the smallpox virus, have the ability to infect almost all
susceptible people after exposure. By contrast, microorganisms such as the tuberculosis bacillus
infect a relatively small number of the population who are susceptible and exposed, usually people
who are poorly nourished, who are living in crowded conditions, or whose immune systems are
less competent (such as older adults or those with HIV or cancer).

Breaking the Link:

✓ Rapid and accurate identification of organism

✓ Early recognition of signs of Infection
✓ Diagnosis and Treatment
✓ Antimicrobial Stewardship

RESERVOIR
 The reservoir (source) is a host which allows the pathogen to live, and possibly grow, and
multiply. Humans, animals and the environment can all be reservoirs for microorganisms. General
rule: If an area stays wet, it is probably a reservoir.

● Human Reservoir-Diseases that are transmitted from person to person without

intermediaries include the sexually transmitted diseases, measles, mumps, streptococcal
infection, and many respiratory pathogens.
o Symptomatic-persons who are aware of their illness. They may be less likely to
transmit infection because they are either too sick to be out and about, take
precautions to reduce transmission, or receive treatment that limits the disease.
o Carrier - a person with no apparent infection who is capable of transmitting the
pathogen to others.
▪ Asymptomatic Carriers - those who never experience symptoms despite
being infected.
▪ Incubatory carriers - those who can transmit the agent during the
incubation period before clinical illness begins.

▪ Convalescent carriers -those who have recovered from their illness but
remain capable of transmitting to others.
▪ Chronic carriers - those who continue to harbor a pathogensuch as
hepatitis B virus or Salmonella Typhi, the causative agent of typhoid fever,
for months or even years after their initial infection.

*Carriers commonly transmit disease because they do not realize they are infected, and
consequently take no special precautions to prevent transmission.

● Animal Reservoir -Humans are also subject to diseases that have animal reservoirs.
Many of these diseases are transmitted from animal to animal, with humans as incidental
hosts.
Zoonosis - refers to an infectious disease that is transmissible under natural conditions
from vertebrate animals to humans.

o Direct Zoonoses
▪ Direct Zoonoses - The lower vertebrates - domestic and wild animal- are
the reservoir hosts for many infectious zoonotic pathogens and these
reservoirs transmit infections to the human beings by accidental exposures
or direct contact with infected population or contaminated materials.

Examples: Rabies

▪ Direct-zooanthroponoses- Zoonotic diseases transmitted from human

beings to the lower vertebrate animals by direct contact with infected
person or contaminated materials.

Examples: Diphtheria, Tuberculosis

▪ Direct-amphixenoses- Zoonotic diseases maintained in nature either in

animal population or in human population are transmitted in both directions
by direct contact with infected population or contaminated materials.

Examples: Streptococcosis, Staphylococcosis

o Cyclozoonoses - the disease which requires more than one vertebrate host to
complete the life cycle, but invertebrate host is not involved. Depending upon the
involvement of human being it may be obligatory cyclozoonoses or non-obligatory
cyclozoonoses.
▪ Obligatory cyclozoonoses– In obligatory cyclozoonoses, agents require
essentially a human being for completion of their life cycle.

Examples: Taeniosis (Taeniasaginata and T.solium) – measly beef and

measly pork
 ▪ Non-obligatory cyclozoonoses- In non-obligatory cyclozoonoses, agents
require man's involvement as accidental or not essential for completion of
their life cycle.

Example: Hydatidosis (Echinococcusgranulosus). (Venkatesan, 2016)

● Environmental Reservoir - Plants, soil, and water in the environment are also reservoirs
for some infectious agents. Many fungal agents, such as those that cause histoplasmosis,
live and multiply in the soil. Outbreaks of Legionnaires disease are often traced to water
supplies in cooling towers and evaporative condensers, reservoirs for the causative
organism Legionella pneumophila.

Examples: food, water, soil, air

Breaking the Link:

✓ Cleaning, disinfection, sterilization

✓ Infection prevention policies
✓ Pest control
✓ Employee Health Awareness

PORTAL OF EXIT

This refers to the route by which the infectious microorganisms escape or leave the
reservoir. The portal of exit usually corresponds to the site where the pathogen is localized.
PORTAL OF EXIT BREAKING THE LINK
Respiratory Tract. Microorganisms leave the • Wear a mask
body of the infected person by means of
droplets exhaled as a spray when coughing, • Do not talk directly into patient’s face

sneezing, talking, singing or just breathing.

• Stay home if you are sick
Microorganisms also escape through nose and
throat secretions. •Practice good cough etiquette (cover your
coughs and sneezes)
Example: Influenza viruses and
Mycobacterium tuberculosis • Perform good hand hygiene
Gastrointestinal Tract. Microorganisms that • Handle and dispose of body secretions
leave the body of the infected person by means
of body secretions (e.g. stool and vomit). properly

Example: Hepatitis A and cholera vibrios • Use personal protective equipment

• Perform good housekeeping

• Perform good hand hygiene

Skin. Microorganisms that leave the body of the • Dispose of wound dressings properly
infected person by wound drainage or through
skin lesions. • Use personal protective equipment (PPE)

Example:Sarcoptesscabiei • Perform good hand hygiene

Blood. Infection may occur when someone’s • Safe handling of sharps

blood gets into another person’s system.
• Use gloves for procedures where there is risk
Example: Malaria
of exposure to blood

• Use care in obtaining, transporting and

 processing specimens

• Perform good hand hygiene

MODE OF TRANSMISSION

• Mode of Transmission - way the infectious agent can be passed on. It is the journey of the
agent in the external environment (Association for Professionals in Infection Control and
Epidemiology).

● Vertical Transmission

Vertical transmission occurs when a trait or a disease is passed down through

several generations, directly from an affected individual to affected descendants in
successive generations.

● Horizontal Transmission

Horizontal Transmission meaning that direct host-to-host transmission occurs.

Viruses with horizontal transmission rely upon a high rate of infection to sustain the virus
population (Science Direct)

Three Mechanisms:
1. Direct transmission

Direct transmission involves immediate and direct transfer of microorganisms from person to
person through touching, biting, kissing, or sexual intercourse. Droplet spread is also a form of
direct transmission but can occur only if the source and the host are within 1 m (3 ft) of each other.
Sneezing, coughing, spitting, singing, or talking can project droplet spray into the conjunctiva or
onto the mucous membranes of the eye, nose, or mouth of another person.

2. Indirect transmission

Indirect transmission may be either vehicle borne or vector borne:

Vehicle-borne transmission
- A vehicle is any substance that serves as an intermediate means to transport and
introduce an infectious agent into a susceptible host through a suitable portal of
entry. Fomites (inanimate materials or objects), such as handkerchiefs, toys, soiled
clothes, cooking or eating utensils, and surgical instruments or dressings, can act
as vehicles. Water, food, blood, serum, and plasma are other vehicles.
Ex: Food or water may become contaminated by a food handler who carries the
hepatitis A virus. The food is then ingested by a susceptible host.
Vector-borne transmission
- A vector is an animal or flying or crawling insect that serves as an intermediate
means of transporting the infectious agent. Transmission may occur by injecting
salivary fluid during biting or by depositing feces or other materials on the skin
through the bite wound or a traumatized skin area.

3. Airborne transmission

Airborne transmission may involve droplets or dust.

Droplet nuclei, the residue of evaporated droplets emitted by an infected host such as someone
with tuberculosis, can remain in the air for long periods. Dust particles containing the infectious
agent (e.g., C. difficile, spores from the soil) can also become airborne. The material is transmitted
by air currents to a suitable portal of entry, usually the respiratory tract, of another person.
PORTAL OF ENTRY

The portal of entry refers to the manner in which a pathogen enters a susceptible host.
Before a person can become infected, microorganisms must enter the body. The skin is a barrier
to infectious agents; however, any break in the skin can readily serve as a portal of entry. Often,
microorganisms enter the body of the host by the same route they used to leave the source.

SUSCEPTIBLE HOST

- can be any person (the most vulnerable of whom are receiving healthcare, are
immunocompromised/ compromised host, or have invasive medical devices including lines,
devices, and airways

The risk of an individual acquiring an infection is influenced by their susceptibility or

vulnerability. The term host is used to describe a welcoming destination to harbor the organism.
There are certain factors or characteristics which affect an individual’s natural ability to fight
against infection and these include:

Factors that affect the body’s natural ability to fight infection include:

● Physical and Psychological well-being or presence of underlying disease – diabetes

mellitus, vascular disease, or malignancy may increase vulnerability by impairing the
natural cellular or body defenses.
● Immune Status – this will vary between individuals , especially those who are immune
suppressed. Immune compromised status – due to HIV, chemotherapy treatment, steroid
therapy may also cause weakness in the body’s defenses
● Nutritional Status – if malnourished, this may impair the immune functioning
● Age – susceptibility is greater in the extremes of age - very young and the very old
● Medical Interventions or Invasive Techniques: drug therapies such as antibiotics or
steroids or procedures such as surgery, intravenous cannula, or indwelling urinary
catheters all breach the body’s natural defenses and can be the source of susceptibility.
COURSE OF INFECTION

The five periods of disease include the incubation, prodromal, illness, decline, and
convalescence periods.

1. The incubation period occurs in an acute disease after the initial entry of the pathogen
into the host (patient). It is during this time the pathogen begins multiplying in the host.
However, there are insufficient numbers of pathogen particles (cells or viruses) present
to cause signs and symptoms of disease. Incubation periods can vary from a day or two
in acute disease to months or years in chronic disease, depending upon the pathogen.
Factors involved in determining the length of the incubation period are diverse, and can
include strength of the pathogen, strength of the host immune defenses, site of infection,
type of infection, and the size infectious dose received. During this incubation period, the
patient is unaware that a disease is beginning to develop.

2. The prodromal period occurs after the incubation period. During this phase, the
pathogen continues to multiply and the host begins to experience general signs and
symptoms of illness, which typically result from activation of the immune system, such as
fever, pain, soreness, swelling, or inflammation. Usually, such signs and symptoms are
too general to indicate a particular disease.

3. Following the prodromal period is the period of illness, during which the signs and
symptoms of disease are most obvious and severe.

4. The period of illness is followed by the period of decline, during which the number of
pathogen particles begins to decrease, and the signs and symptoms of illness begin to
decline. However, during the decline period, patients may become susceptible to
developing secondary infections because their immune systems have been weakened by
the primary infection.
5. The final period is known as the period of convalescence. During this stage, the
patient generally returns to normal functions, although some diseases may inflict
permanent damage that the body cannot fully repair.

Infectious diseases can be contagious during all five of the periods of disease.
Which periods of disease are more likely to associated with transmissibility of an infection
depends upon the disease, the pathogen, and the mechanisms by which the disease
develops and progresses.

NURSE’S ROLE IN INFECTION CONTROL

• The nurse primarily protect the clients, caregivers, and the general community
(the nurse is not exempted from this) from the transmission of disease.
o This is important especially for client who are immunocompromised, who
have infectious diseases or has any invasive access devices.

• The nurse's main course of action is health teaching

o Examples of health teaching is by teaching the clients or better yet, the
general community itself about effective handwashing, proper usage and
wearing of gloves, proper handling of linens, proper disposal of waste, and
also the practice of infection control (standard precautions)
▪ Example of Standard Precautions in Infection Control
• 5 Moments in Hand Hygiene
• Proper wearing of sterile gloves
• Alcohol hand rubbing
• Usage of PPE
SAFETY, SECURITY, AND EMERGENCY PREPAREDNESS

PHYSICAL AND BIOLOGICAL DIMENSIONS

Environment

• Nursing is an act of utilizing an environment of the patient to assist him in

his recovery.
• Three Types of Environment:
❖ Physical Environment
- Physical Environment consists of physical elements where the
patient is being treated.
- It affects all other aspects of the environment. Cleanliness of
environment relates directly to disease prevention and patient
mortality.
- Aspects of the physical environment influence the social and
psychological environments of the person.
❖ Psychological Environment
- Psychological environment can be affected by a negative
physical environment which then causes stress.
- It requires various activities to keep the mind active.
❖ Social Environment
- It includes components of physical environment ─ clean air, clean
water, proper drainage.
- It consists of a person’s home or hospital room, as well as the
total community.

Environmental Safety
 • This includes all of the many physical and psychosocial factors that
influence or affect the life and survival of the client.
• Safety in health care settings reduces the incidence of illness and injury,
prevents extended length of treatment and/or hospitalizations, improves
or maintains a client’s functional status, and increases the client’s sense
of well-being.
• A safe environment gives protection to staff as well, allowing to work or
function at an optimal level.
• A safe environment is one where the threat of attack from biological ,
chemical, or nuclear weapons is prevented or minimized.

Physical Hazards

• These place clients at risk for accidental injury and death.

• According to Centers for Disease Control and Prevention (CDC),
unintentional injuries are the fifth leading cause of death for Americans
of all ages.
- Motor vehicle accidents are the leading cause, followed by
poisonings and falls.
- Among older adults 65 years and above, falls are the leading cause
of unintentional death.
- Falls are the most common cause of hospital admissions for trauma
for older clients.
- Fractures are the most serious health consequence of falls.
• You can minimize many physical hazards, especially those contributing
to falls, through adequate lighting, reduction of obstacles, control of
bathroom hazards, and security measures.

Adequate Space
 • Patient Movement : Spaces shall be wide enough for free movement of
patients, whether they are on beds, stretchers, or wheelchairs. Circulation
routes for transferring patients from one area to another shall be available and
free at all times.
5.1 Corridors for access by patient and equipment shall have a minimum
width of 2.44 meters.
5.2 Corridors in areas not commonly used for bed, stretcher and
equipment transport may be reduced in width to 1.83 meters.
5.3 A ramp or elevator shall be provided for ancillary, clinical and nursing
areas located on the upper floor.
5.4 A ramp shall be provided as access to the entrance of the hospital
not on the same level of the site.
• Space : Adequate area shall be provided for the people, activity, furniture,
equipment and utility.

2. Lighting

• Adequate lighting reduces physical hazards by illuminating areas in which a

person moves and works.
• A brightly lit room is usually stimulating, but a darkened room is best for sleep
and rest.
• Outside the home, there needs to be adequate lighting on all walkways.
• Outdoor lighting also helps protect the home and its inhabitants from crime.
• Well-lighted garages, walkways, and doorways discourage intruders from
entering homes or hiding in shadows.
• Inside the house, halls, staircases, and individual rooms need to be adequately
lighted so that residents are able to safely carry out activities of daily living.
• Night-lights in dark halls, bathrooms, and the rooms of children and older adults
help maintain safety by reducing the risk of falls.
• A night-light in a guest room will help orient an overnight guest who needs to
get up in the middle of the night.
• Make sure artificial lighting is soft and nonglaring, because glare is a major
problem for older adults.
• There are several different types of artificial light sources. Some of these
sources are incandescent bulbs, halogen lamps, metal halide, fluorescent tube,
compact florescent light, and LEDs. All lights emit energy in the form of photons.
• According to Nightiangle:
- She viewed that direct sunlight was what patients wanted.
- Although acknowledging a lack of scientific rationale for it, she noted that
light has “quite real and tangible effects upon the human body.”
o Formation of Vitamin D:

• Vitamin D is a vital ingredient for the development of bones. So

how vitamin D gets generated inside the human body? It’s not
produced by the synthesis of food particles by enzymes, but totally
in a different way:

• Vitamin D8 (aka chole-calciferol) is formed when ultraviolet

radiation of sun is absorbed by 7-dehydrocholestrerol.

• Vitamin D2 on the other hand is produced by the consumption of

milk and other foods in which ergosterol; a natural plant sterol is
converted to vitamin D2 on the exposure of ultraviolet radiation
coming from direct sunrays.

o Effects of Natural Lights:

The effects of light on mammalian tissue can be digressed as direct

or indirect, depends on the immediate cause like photo chemical
reaction within the tissue or a neurological signal generation by
photoreceptor cell present in the skin. When the effect is direct, the
molecule may or may not be one that absorbs the photon. For
example, certain molecules can act as “photosensitizers”: when the
molecules are raised to higher state of energy, it catalyzeS the
 oxidization of other compounds before coming to the ground state.
Photosensitizers in human body include constituents of food, drugs
and toxins produced in excess by some disease.

It has to be taken into consideration that visible light has been able
to penetrate mammalian tissue to a considerable depth. Study
shows than light has been detected reaching the brain of living sheep.

o Artificial Light

It is tacit that the role of light is majorly for the purpose of illumination
for working and reading purpose. It’s also observed that the artificial
light available in the office (~100 foot candles) at eye level is only
around 10 percent of the light available in the shade of a tree on a
sunny day. The decision of using 100 foot candles artificial light is
more of a technology decision rather than understanding the real
biological needs of human beings. In comparison, the amount of light
we are exposed for 16 hours in office is equivalent to 1 hour of
expose to a sunny day. So if in the future we come up with a study
which states the need of higher amount of exposure of light for better
bone mineralization, then the society will have a hard time making a
decision on it!

o Melatonin

Melatonin is a hormone secreted from pineal gland; when human

body is under dark environmental condition such as our bedroom at
night. It gives the signal to the brain and hence to whole of the body
that it’s time to rest.

Humidity and Temperature

 • Usual comfort range is between 18.3 ͦ and 23.9 ͦ C (65 ͦ and 75 ͦ F)
• In foreign countries, exposure to severe cold for prolonged periods causes
frostbite and accidental hypothermia. Frostbite occurs when a surface area of
the skin freezes as a result of exposure to extremely cold temperatures.
• Hypothermia occurs when the core body temperature is 35 ͦ C (95 ͦ F) or below.
• Older adults, the young, clients with cardiovascular conditions, clients who
have ingested drugs or alcohol in excess, and the homeless are at high risk for
hypothermia.
• Exposure to extreme heat raises the core body temperature, resulting in
heatstroke or heat exhaustion.
• Chronically ill clients, older adults, and infants are at great risk for uinjury from
extreme heat. These clients need to avoid extremely hot, humid environments.
• Relative humidity is the amount of water vapor in the air compared with the
maximum amount of water vapor that the air could contain at the same
temperature. The comfort zone varies from person to person, but most people
are comfortable when the humidity is between 60% and 70%
• Increasing the environmental humidity by using a home humidifier has
therapeutic benefits for clients with upper respiratory tract infectious because
humidity helps to liquefy pulmonary secretions and improve breathing.

4. Ventilation and Warming

• Nurses were “to keep the air he breathes as pure as the external air, without
chilling.”
• Nightiangle was very concerned about “noxious air” or “effluvia” or foul odors
that came from excrement.
• Nightiangle stressed the importance of room temperature. The patient should
not be too warm or too cold.
• Depending on the client’s age and physical condition, maintain the room
temperature between 20 ͦ and 23 ͦ C (68 ͦ AND 74 ͦ F).
• Infants, older adults, and the acutely ill often need a warmer room.
 • However, certain ill clients benefit from cooler room temperatures to lower the
body’s metabolic demands.
• A good ventilation system keeps stale air and odors from lingering in the room.
• Use lightweight blanket
• Good ventilation also reduces lingering odors caused by draining wounds,
vomitus, bowel movements, and unemptied urinals.
• Always empty and rinse commodes, bedpans, and urinals promptly.
• Room deodorizers help remove many unpleasant odors, but use them with
discretion in consideration of the client’s possible embarrassment. (Assure the
client is not allergic to room deodorizer)

NOTES ON NURSING BY FLORENCE NIGHTIANGLE

Ventilation and Warming

First rule of nursing, to keep the air within as pure as the air without.]

The very first canon of nursing, the first and the last thing upon which a nurse's attention
must be fixed, the first essential to a patient, without which all the rest you can do for him
is as nothing, with which is this: TO KEEP THE AIR HE BREATHES AS PURE AS THE
EXTERNAL AIR, WITHOUT CHILLING HIM.

[Sidenote: Without chill.]

With a proper supply of windows, and a proper supply of fuel in open fire places, fresh air
is comparatively easy to secure when your patient or patients are in bed. Never be afraid
of open windows then. People don't catch cold in bed. This is a popular fallacy. With
proper bed-clothes and hot bottles, if necessary, you can always keep a patient warm in
bed, and well ventilate him at the same time.
But a careless nurse, be her rank and education what it may, will stop up every cranny
and keep a hot-house heat when her patient is in bed, and, if he is able to get up, leave
him comparatively unprotected. The time when people take cold (and there are many
ways of taking cold, besides a cold in the nose,) is when they first get up after the two-
fold exhaustion of dressing and of having had the skin relaxed by many hours, perhaps
days, in bed, and thereby rendered more incapable of re-action. Then the same
temperature which refreshes the patient in bed may destroy the patient just risen. And
common sense will point out, that, while purity of air is essential, a temperature must be
secured which shall not chill the patient. Otherwise the best that can be expected will be
a feverish re-action.

To have the air within as pure as the air without, it is not necessary, as often appears to
be thought, to make it as cold.

In the afternoon again, without care, the patient whose vital powers have then risen often
finds the room as close and oppressive as he found it cold in the morning. Yet the nurse
will be terrified, if a window is opened.

[Sidenote: Open windows.]

I know an intelligent humane house surgeon who makes a practice of keeping the ward
windows open. The physicians and surgeons invariably close them while going their
rounds; and the house surgeon very properly as invariably opens them whenever the
doctors have turned their backs. In a little book on nursing, published a short time ago,
we are told, that, "with proper care it is very seldom that the windows cannot be opened
for a few minutes twice in the day to admit fresh air from without." I should think not; nor
twice in the hour either. It only shows how little the subject has been considered.

[Sidenote: What kind of warmth desirable.]

Of all methods of keeping patients warm the very worst certainly is to depend for heat on
the breath and bodies of the sick. I have known a medical officer keep his ward windows
hermetically closed. Thus exposing the sick to all the dangers of an infected atmosphere,
because he was afraid that, by admitting fresh air, the temperature of the ward would be
too much lowered. This is a destructive fallacy.

To attempt to keep a ward warm at the expense of making the sick repeatedly breathe
their own hot, humid, putrescing atmosphere is a certain way to delay recovery or to
destroy life.

[Sidenote: Bedrooms almost universally foul.]

Do you ever go into the bed-rooms of any persons of any class, whether they contain one,
two, or twenty people, whether they hold sick or well, at night, or before the windows are
opened in the morning, and ever find the air anything but unwholesomely close and foul?
And why should it be so? And of how much importance it is that it should not be so?
During sleep, the human body, even when in health, is far more injured by the influence
of foul air than when awake. Why can't you keep the air all night, then, as pure as the air
without in the rooms you sleep in? But for this, you must have sufficient outlet for the
impure air you make yourselves to go out; sufficient inlet for the pure air from without to
come in. You must have open chimneys, open windows, or ventilators; no close curtains
round your beds; no shutters or curtains to your windows, none of the contrivances by
which you undermine your own health or destroy the chances of recovery of your sick.[3]

[Sidenote: When warmth must be most carefully looked to.]

A careful nurse will keep a constant watch over her sick, especially weak, protracted, and
collapsed cases, to guard against the effects of the loss of vital heat by the patient himself.
In certain diseased states much less heat is produced than in health; and there is a
constant tendency to the decline and ultimate extinction of the vital powers by the call
made upon them to sustain the heat of the body. Cases where this occurs should be
watched with the greatest care from hour to hour, I had almost said from minute to minute.
The feet and legs should be examined by the hand from time to time, and whenever a
tendency to chilling is discovered, hot bottles, hot bricks, or warm flannels, with some
warm drink, should be made use of until the temperature is restored. The fire should be,
if necessary, replenished. Patients are frequently lost in the latter stages of disease from
want of attention to such simple precautions. The nurse may be trusting to the patient's
diet, or to his medicine, or to the occasional dose of stimulant which she is directed to
give him, while the patient is all the while sinking from want of a little external warmth.
Such cases happen at all times, even during the height of summer. This fatal chill is most
apt to occur towards early morning at the period of the lowest temperature of the twenty-
four hours, and at the time when the effect of the preceding day's diets is exhausted.

Generally speaking, you may expect that weak patients will suffer cold much more in the
morning than in the evening. The vital powers are much lower. If they are feverish at night,
with burning hands and feet, they are almost sure to be chilly and shivering in the morning.
But nurses are very fond of heating the foot-warmer at night, and of neglecting it in the
morning, when they are busy. I should reverse the matter. All these things require
common sense and care. Yet perhaps in no one single thing is so little common sense
shown, in all ranks, as in nursing.

All these things require common sense and care. Yet perhaps in no one single thing is so
little common sense shown, in all ranks, as in nursing.

[Sidenote: Cold air not ventilation, nor fresh air a method of chill.]

The extraordinary confusion between cold and ventilation, even in the minds of well
educated people, illustrates this. To make a room cold is by no means necessarily to
ventilate it. Nor is it at all necessary, in order to ventilate a room, to chill it. Yet, if a nurse
finds a room close, she will let out the fire, thereby making it closer, or she will open the
door into a cold room, without a fire, or an open window in it, by way of improving the
ventilation. The safest atmosphere of all for a patient is a good fire and an open window,
excepting in extremes of temperature. (Yet no nurse can ever be made to understand
this.) To ventilate a small room without draughts of course requires more care than to
ventilate a large one.

[Sidenote: Night air.]

Another extraordinary fallacy is the dread of night air. What air can we breathe at night
but night air? The choice is between pure night air from without and foul night air from
within. Most people prefer the latter. An unaccountable choice. What will they say if it is
proved to be true that fully one-half of all the disease we suffer from is occasioned by
people sleeping with their windows shut? An open window most nights in the year can
never hurt any one. This is not to say that light is not necessary for recovery. In great
cities, night air is often the best and purest air to be had in the twenty-four hours. I could
better understand in towns shutting the windows during the day than during the night, for
the sake of the sick. The absence of smoke, the quiet, all tend to making night the best
time for airing the patients. One of our highest medical authorities on Consumption and
Climate has told me that the air in London is never so good as after ten o'clock at night.

[Sidenote: Air from the outside. Open your windows, shut your doors.]

Always air your room, then, from the outside air, if possible. Windows are made to open;
doors are made to shut--a truth which seems extremely difficult of apprehension. I have
seen a careful nurse airing her patient's room through the door, near to which were two
gaslights, (each of which consumes as much air as eleven men,) a kitchen, a corridor,
the composition of the atmosphere in which consisted of gas, paint, foul air, never
changed, full of effluvia, including a current of sewer air from an ill-placed sink, ascending
in a continual stream by a well-staircase, and discharging themselves constantly into the
patient's room. The window of the said room, if opened, was all that was desirable to air
it. Every room must be aired from without--every passage from without. But the fewer
passages there are in a hospital the better.

[Sidenote: Airing damp things in a patient's room.]

In laying down the principle that this first object of the nurse must be to keep the air
breathed by her patient as pure as the air without, it must not be forgotten that everything
in the room which can give off effluvia, besides the patient, evaporates itself into his air.
And it follows that there ought to be nothing in the room, excepting him, which can give
off effluvia or moisture. Out of all damp towels, &c., which become dry in the room, the
damp, of course, goes into the patient's air. Yet this "of course" seems as little thought of,
as if it were an obsolete fiction. How very seldom you see a nurse who acknowledges by
her practice that nothing at all ought to be aired in the patient's room, that nothing at all
ought to be cooked at the patient's fire! Indeed the arrangements often make this rule
impossible to observe.

If the nurse be a very careful one, she will, when the patient leaves his bed, but not his
room, open the sheets wide, and throw the bed-clothes back, in order to air his bed. And
she will spread the wet towels or flannels carefully out upon a horse, in order to dry them.
Now either these bed-clothes and towels are not dried and aired, or they dry and air
themselves into the patient's air. And whether the damp and effluvia do him most harm in
his air or in his bed, I leave to you to determine, for I cannot.

LIGHT

[Sidenote: Light essential to both health and recovery.]

It is the unqualified result of all my experience with the sick, that second only to their need
of fresh air is their need of light; that, after a close room, what hurts them most is a dark
room. And that it is not only light but direct sun-light they want. I had rather have the power
of carrying my patient about after the sun, according to the aspect of the rooms, if
circumstances permit, than let him linger in a room when the sun is off. People think the
effect is upon the spirits only. This is by no means the case. The sun is not only a painter
but a sculptor. You admit that he does the photograph. Without going into any scientific
exposition we must admit that light has quite as real and tangible effects upon the human
body. But this is not all. Who has not observed the purifying effect of light, and especially
of direct sunlight, upon the air of a room? Here is an observation within everybody's
experience. Go into a room where the shutters are always shut (in a sick room or a
bedroom there should never be shutters shut), and though the room be uninhabited,
though the air has never been polluted by the breathing of human beings, you will observe
a close, musty smell of corrupt air, of air i.e. unpurified by the effect of the sun's rays. The
mustiness of dark rooms and corners, indeed, is proverbial. The cheerfulness of a room,
the usefulness of light in treating disease is all-important.

[Sidenote: Aspect, view, and sunlight matters of first importance to the sick.]

A very high authority in hospital construction has said that people do not enough consider
the difference between wards and dormitories in planning their buildings. But I go farther,
and say, that healthy people never remember the difference between bedrooms and
sickrooms in making arrangements for the sick. To a sleeper in health it does not signify
what the view is from his bed. He ought never to be in it excepting when asleep, and at
night. Aspect does not very much signify either (provided the sun reach his bed-room
some time in every day, to purify the air), because he ought never to be in his bed-room
except during the hours when there is no sun. But the case is exactly reversed with the
sick, even should they be as many hours out of their beds as you are in yours, which
probably they are not. Therefore, that they should be able, without raising themselves or
turning in bed, to see out of window from their beds, to see sky and sun-light at least, if
you can show them nothing else, I assert to be, if not of the very first importance for
recovery, at least something very near it.
And you should therefore look to the position of the beds of your sick one of the very first
things. If they can see out of two windows instead of one, so much the better. Again, the
morning sun and the mid-day sun- the hours when they are quite certain not to be up, are
of more importance to them, if a choice must be made, than the afternoon sun. Perhaps
you can take them out of bed in the afternoon and set them by the window, where they
can see the sun. But the best rule is, if possible, to give them direct sunlight from the
moment he rises till the moment he sets.

Another great difference between the bedroom and the sickroom is, that the _sleeper_
has a very large balance of fresh air to begin with, when he begins the night, if his room
has been open all day as it ought to be; the _sick_ man has not, because all day he has
been breathing the air in the same room, and dirtying it by the emanations from himself.
Far more care is therefore necessary to keep up a constant change of air in the sick room.

It is hardly necessary to add that there are acute cases (particularly a few ophthalmic
cases, and diseases where the eye is morbidly sensitive), where a subdued light is
necessary. But a dark north room is inadmissible even for these. You can always
moderate the light by blinds and curtains.

Heavy, thick, dark window or bed curtains should, however, hardly eve be used for any
kind of sick in this country. A light white curtain at the head of the bed is, in general, all
that is necessary, and a green blind to the window, to be drawn down only when
necessary.

[Sidenote: Without sunlight, we degenerate body and mind.]

One of the greatest observers of human things (not physiological), says, in another
language, "Where there is sun there is thought." All physiology goes to confirm this.
Where is the shady side of deep vallies, there is cretinism. Where are cellars and the
unsunned sides of narrow streets, there is the degeneracy and weakliness of the human
race--mind and body equally degenerating. Put the pale withering plant and human being
into the sun, and, if not too far gone, each will recover health and spirit.

[Sidenote: Almost all patients lie with their faces to the light.]

It is a curious thing to observe how almost all patients lie with their faces turned to the
light, exactly as plants always make their way towards the light; a patient will even
complain that it gives him pain "lying on that side." "Then why do you lie on that side?"
He does not know,--but we do. It is because it is the side towards the window. A
fashionable physician has recently published in a government report that he always turns
his patient's faces from the light. Yes, but nature is stronger than fashionable physicians,
and depend upon it she turns the faces back and towards such light as she can get. Walk
through the wards of a hospital, remember the bed sides of private patients you have
seen, and count how many sick you ever saw lying with their faces towards the wall.

• Comfortable Sound Levels

According to the theory, noise can also hurt a patient. If a patient cannot put
up with a conversation of two people at his side, what more if there is a louder
noise available, example from the theory would be the scaffolding of the house
being built. It would especially hurt patients of those who are with concussion or
slight disturbance of the brain. It is said that intermittent noise (noise that is
recurring), is more disturbing than a continuous noise.
 The reason for sound to be in a comfortable level has different objectives.
One would be proper sleep, if a patient is woken up due to noise, they are sure to
be unable to get more sleep.

In summary, the sound itself should be healthy and what the patient must
hear is also healthy. A whispered conversation inside the room holds cruelty to the
patient because attention span would be drawn to the conversation itself and the
patient would want to know more but is unable to.

• Furniture and Clean Surfaces

Just like in the theory and in our times, we would love to clean the dust,
waste, litter away in order to improve the environmental health since it also affects
the patient’s health. In the theory there are different ways to suggested on how to
clean the surface and furniture.
It is said that cleaning here should not be simply flapping off the carpet,
equipment and etc. Cleaning is supposed to be the complete removal of dust from
the room itself. Run a wet towel through the surface itself in order to remove the
dust then a dry towel in order to stop the dust from accumulating.
• Food and Water

According to the Environmental Theory of Florence Nightingale, a person is

sure to suffer when one uses impure water with an epidemic disease ongoing. It is
always best to drink clean water for proper rehydration and proper maintenance of
body such as body temperature, nutrients, blood and etc. Also, according to the
theory of Florence Nightingale taking food and what food is equally as important.
For instance as stated in the book, a weak patient cannot actually eat solid food
and so one must ingest a liquid yet nutritious food, an example in our country would
be eating porridge, soup (crab&corn, mushroom) and etc.

In the same manner, there is a right time to ingest food and water. As much
as possible, drink water whenever one is thirsty or as long as there is fluid loss.
For the food, it should also be at the right time because according to the theory,
 eating food hangs on the life on the last minute because proper nutrition is needed
everyday for the body to function properly.

• Waste Disposal

Proper waste disposal is equivalent to a proper surrounding. According to

the theory, a sewer that does not have a proper waste management is a laboratory
for epidemic diseases and illness is being brought into the house itself. An
untrapped sink can spread fever or other diseases inside the household. An
environment that is dirty is a household for different disease carrier and so it is truly
important to maintain proper waste management and a clean environment.

SAFE ENVIRONMENT
1.Safety Precaution
There are a lot of safety precautions in the hospital. It’s use is the placement of a physical,
mechanical, or chemical barrier between the microorganisms and the individual
Wash hands after contact with blood, body fluids, secretions, excretions, and contaminated
objects whether or not gloves are worn.
Wear clean gloves when touching blood, body fluids, secretions, excretions, and contaminated
items (i.e. soiled gowns).
Wear a mask, eye protection, or a face shield if splashes or sprays of blood, body fluids,
secretions, excretions can be expected.
Wear a clean, non-sterile gown if client case is likely to result in splashes or sprays of blood, body
fluids, secretions, or excretions. The gown is intended to protect clothing.
Handle client care equipment that is soiled with blood, body fluids, secretions, or excretions
carefully to prevent the transfer of microorganisms to others and to the environment.
Handle, transport, and process linen that is soiled with blood, body fluids, secretions, or excretions
in a manner to prevent contamination of clothing and the transfer of microorganisms to others and
to the environment.
Prevent injuries from used equipment, i.e. scalpels or needles, and place in puncture-resistant
containers.

NURSING INTERVENTION TO PROMOTE HEALTHY

PHYSIOLOGIC RESPONSE

Maintaining skin integrity

INTRODUCTION

The skin is the largest organ in the body and serves a variety of important functions in
maintaining health and protecting the individual from injury. Important nursing functions
are maintaining skin integrity and promoting wound healing. Impaired skin integrity is not
a frequent problem for most healthy people but is a threat to older adults; to clients with
restricted mobility, chronic illnesses, or trauma; and to those undergoing invasive health
care procedures. To protect the skin and manage wounds effectively, the nurse must
understand the factors affecting skin integrity, the physiology of wound healing, and
specific measures that promote optimal skin conditions.

Skin

The skin is the largest organ of the body. It serves five major functions:

1. It protects underlying tissues from injury by preventing the passage of microorganisms.

The skin and mucous membranes are considered the body’s first line of defense.

2. It regulates the body temperature. Cooling of the body occurs through the heat loss
processes of evaporation of perspiration, and by radiation and conduction of heat from the
body when the blood vessels of the skin are vasodilated. Body heat is conserved through
lack of perspiration and vasoconstriction of the blood vessels.

3. It secretes sebum , an oily substance that (a) softens and lubricates the hair and skin,
(b) prevents the hair from becoming brittle, and (c) decreases water loss from the skin
when the external humidity is low. Because fat is a poor conductor of heat, sebum

(d) lessens the amount of heat lost from the skin. Sebum (e) also has a bactericidal
(bacteria-killing) action.

4. It transmits sensations through nerve receptors, which are sensitive to pain,

temperature, touch, and pressure.

5. It produces and absorbs vitamin D in conjunction with ultraviolet rays from the sun,
which activate a vitamin D precursor present in the skin.
The normal skin of a healthy person has transient and resident microorganisms that are
not usually harmful. Sudoriferous (sweat) glands are on all body surfaces except the lips
and parts of the genitals. The body has from 2 to 5 million, which are all present at birth.
They are most numerous on the palms of the hands and the soles of the feet. Sweat
glands are classified as apocrine and eccrine. The apocrine glands , located largely in the
axillae and anogenital areas, begin to function at puberty under the influence of androgens.
Although they produce sweat almost constantly, apocrine glands are of little use in
thermoregulation. The secretion of these glands is odorless, but when decomposed or
acted on by bacteria on the skin, it takes on a musky, unpleasant odor. The eccrine glands
are important physiologically. They are more numerous than the apocrine glands and are
found chiefly on the palms of the hands, soles of the feet, and forehead. The sweat they
produce cools the body through evaporation. Sweat is made up of water, sodium,
potassium, chloride, glucose, urea, and lactate.

SKIN INTEGRITY
 Intact skin refers to the presence of normal skin and skin layers uninterrupted

by wounds. The appearance of the skin and skin integrity are influenced by internal factors
such as genetics, age, and the underlying health of the individual as well as

external factors such as activity.

Genetics and heredity determine many aspects of a person’s skin, including skin color,
sensitivity to sunlight, and allergies.

Age influences skin integrity in that the skin of both the very young and the very old is
more fragile and susceptible to injury than that of most adults. Wounds tend to heal more
rapidly in infants and children.

Chronic illnesses and their treatments affect skin integrity. People with impaired peripheral
arterial circulation may have skin on the legs that damages easily. Some medications,
corticosteroids for example, cause thinning of the skin and allow it to be much more readily
harmed. Many medications increase sensitivity to sunlight and can predispose one to
severe sunburns. Some of the most common medications that cause this damage are
certain antibiotics (e.g., tetracycline and doxycycline), chemotherapy drugs for cancer
(e.g., methotrexate), and some psychotherapeutic drugs (e.g., tricyclic antidepressants).
Poor nutrition alone can interfere with the appearance and function of normal skin.

ETIOLOGY OF PRESSURE ULCER

PRESSURE ULCERS

• consist of injury to the skin and/or underlying tissue, usually over a bony prominence, as
a result of force alone or in combination with movement.
• were previously called decubitus ulcers, pressure sores, or bedsores.
• are a problem in both acute care settings and long-term care settings, including homes.
 A Healthy People 2020 proposed objective is to reduce the rate of pressure ulcer–related
hospitalizations among older adults (U.S. Department of Health and Human Services,
2013). One of the national patient safety goals for long-term care settings is prevention of
health care–associated pressure ulcers (The Joint Commission, 2013).

Because pressure ulcers are preventable, public health insurance—and increasing

numbers of private health insurance companies—will no longer reimburse health care
agencies for the cost of treating health care–associated pressure ulcers. In addition,
development of a stage III or IV or unstageable pressure ulcer is considered a serious
reportable event (National Quality Forum, 2013).

Etiology of Pressure Ulcers

Pressure ulcers are due to localized ischemia, a deficiency in the blood supply to the tissue.
The tissue is compressed between two surfaces, usually the surface of furniture such as
the bed or chair and the bony skeleton. When blood cannot reach the tissue, the cells are
deprived of oxygen and nutrients, the waste products of metabolism accumulate in the
cells, and the tissue consequently dies. Prolonged, unrelieved pressure also damages the
small blood vessels.
 After the skin has been compressed, it appears pale, as if the blood had been squeezed
out of it. When pressure is relieved, the skin takes on a bright red flush, called reactive
hyperemia . The flush is due to vasodilation , a process in which extra blood floods to
the area to compensate for the preceding period of impeded blood flow. Reactive
hyperemia usually lasts one half to three quarters as long as the duration of impeded blood
flow to the area. If the redness disappears in that time, no tissue damage is anticipated.
If, however, the redness does not disappear, then tissue damage has occurred.

Anyone who stays in one place for a long time and who cannot change position without help is at
risk of developing pressure sores. The ulcers can develop and progress rapidly, and they can be
difficult to heal.

Sustained pressure can cut off circulation to vulnerable parts of the body. Without an adequate
supply of blood, body tissues can die.

According to Johns Hopkins Medicine, a sore can develop if blood supply is cut off for more than
2 to 3 hours.

Pressure ulcers are usually caused by:

Continuous pressure: if there is pressure on the skin on one side, and bone on the other, the
skin and underlying tissue may not receive an adequate blood supply.

Friction: For some patients, especially those with thin, frail skin and poor circulation, turning and
moving may damage the skin, raising the risk of bedsores.

Shear: If the skin moves one way while the underlying bone moves in the opposite direction, there
is a risk of shearing. Cell walls and minute blood vessels may stretch and tear.

This can happen if a patient slides down a bed or a chair, or if the top half of the bed is raised too
high.
Injured tissue can develop an infection. This can spread, leading to serious illness.

Symptoms

Pressure ulcers can affect patients who are unable to move because of paralysis, illness, or old
age.

Patients who use a wheelchair have a higher risk of developing pressure sores on their:

• buttocks and tailbone

• spine
• shoulder blades
• back of arms or legs

Bed-bound patients are most at risk of developing bedsores on the bony parts of their body, such
as the ankles, heels, shoulders, coccyx or tailbone, elbows, and the back of the head.

Pathogenesis of pressure ulcers

In susceptible individuals, the combination of immobility and extended periods of pressure or

friction over bony prominences leads to reduction in capillary blood flow, tissue hypoxia, and
ischemic tissue injury. This in turn evokes an inflammatory response that further impairs perfusion
and augments soft tissue and skin injury. Current understanding favors a "bottom-up" model of
tissue damage beginning deep in the muscle layer. Muscle is more sensitive to pressure injury
than skin because it is the more metabolically active layer and thus more susceptible to ischemic
injury.

The age and health of overlying skin determine the ease with which ulceration of the
superficial layers occurs. In the elderly, skin and subcutaneous tissue gradually lose
regenerative, protective, and sensory functions. Chronic conditions or intercurrent illness
such as diabetes, arthritis, incontinence, neurologic impairment, cigarette use, and
hypotension are all associated with increased susceptibility and prevalence of pressure
ulcers. As noted, pressure ulcers develop most commonly over the sacrum and coccyx,
hips and buttocks, and heels

• Intensity of pressure and capillary closing pressure

• Duration and sustenance of pressure
• Tissue Tolerance
• Bony prominences are most at risk (sacrum, heels, elbows, lateral malleoli, greater
trochanter, ischial tuberosities
• Pressure ulcer forms as a result of time/pressure relationship
• Greater the pressure and duration of pressure, the greater the incidence of ulcer
formation
•

• Skin and subcutaneous tissue can withstand some pressure

• Tissue will over time become hypoxic and ischemic injury will occur if the pressure
is above 32mmHg and remains unrelieved to the point of tissue hypoxia, the vessel
will collapse and thrombose
• If circulation is restored before this critical point, circulation to tissue is restored
(Reactive Hyperemia) Skin has a greater ability to tolerate ischemia than does
muscle, hence true pressure ulcers begin at bone with pressure related to muscle
ischemia eventually coming through to epidermis (Shear injury) Sacrum and heels
most susceptible
Stages of Pressure Ulcers

The recognized stages of pressure ulcers related to observable tissue damage are shown:

Stage I: nonblanchable erythema signaling potential ulceration.

Stage II: partial-thickness skin loss (abrasion, blister, or shallow crater) involving the epidermis
and possibly the dermis.

Stage III: full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may
extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater
with or without undermining of adjacent tissue.
Stage IV: full-thickness skin loss with tissue necrosis or damage to muscle, bone, or supporting
structures, such as a tendon or joint capsule. Undermining and sinus tracts may also be present.

Unstageable/unclassified: full-thickness skin or tissue loss—depth unknown: Actual depth of the

ulcer is completely obscured by slough (yellow, tan, gray, green, or brown) and/or eschar (tan,
brown, or black) in the wound bed.

Suspected deep tissue injury—depth unknown: purple or maroon localized area of discolored
intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or
shear. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution
may include a thin blister over a dark wound bed. The wound may further evolve and become
covered by thin eschar.
RISK ASSESSMENT TOOLS

Although clients may be at risk for developing a number of different alterations in skin integrity,
the most common and most preventable are pressure ulcers. Several risk assessment tools are
available that provide the nurse with systematic means of identifying clients at high risk for
pressure ulcer development. The tool chosen for use should include data collection in the areas
of immobility, incontinence, nutrition, and level of consciousness.

The Braden Scale for Predicting Pressure Sore Risk consists of six subscales: sensory perception,
moisture, activity, mobility, nutrition, and friction and shear (Figure 36–2 •). A total of 23 points is
possible and an adult who scores below 18 points is considered at risk (Braden & Blanchard,
2007). For best results, nurses should be trained in proper use of the scale.
 Another tool, shown in Table 36–2, is Norton’s Pressure Area Risk Assessment Scoring
System (Norton, McLaren, & Exton-Smith, 1975). It includes the categories of general
physical condition, mental state, activity, mobility, and incontinence. A category of
medications is added by some users, resulting in a possible score of 24. Scores of 15 or
16 should be viewed as indicators, not predictors, of risk.

Categories of skin ulcers

PRESSURE ULCER
-this is also known as Decubitus Ulcer, Pressure Sores, or Bed Sores. This occurs when there is
a continued pressure on a certain area of skin over a long period of time.

- term used to described impaired skin integrity related to unrelieved, prolonged pressure.

-localized injury to the skin and other underlying tissue, usually over a body prominence, as a
result of pressure or pressure combination with shear and friction.

-usually occurs on the lower back, hips, back of the head, shoulders, or heels.

-often seen in bedridden patients or those who are incapable of moving on their own.

-also develops on bony areas since there is little fats that can cushion the skin.

RISK FACTORS FOR PRESSURE ULCER DEVELOPMENT

1. IMPAIRED SENSORY LOSS

-once sensory loss occurred, a person will not feel uncomfortable therefore repositioning is not
often practiced.

2. IMPAIRED MOBILITY

-once the person loses its ability to move, the risk for bedsores is higher.

3. ALTERATION IN LEVEL OF CONSCIOUSNESS

-clients who are confused or disoriented, or who have changing levels of consciousness, are
unable to protect themselves from pressure ulcer development.

4. SHEAR

-when shear is present, the skin and subcutaneous layers adhere to the surface of the bed,
necrosis occurs.

5. FRICTION
-the mechanical force exerted when skin is dragged across a coarse surface such as bed linens.

6. MOISTURE

-presence and duration of moisture on the skin increases the risk of ulcer formation.

CATEGORIES OF SKIN ULCERS

There are many types of skin ulcer which is caused by different

factors but these factors share a common issue; the disruption of blood flow
towards a particular area of the skin.

· ARTERIAL ULCERS

- There are diseases that affect our arteries which hinders them to deliver blood in our body. The
common reason for that is diabetes and atherosclerosis which leads to the hardening of
the arteries. It is mostly dry and is associated to moderate to severe pain. Arterial ulcers
occur in our lower extremities such as in some parts of our feet like the toes or heels.

· VENOUS ULCER

- The walls of our normal veins have these tiny inner structures that serves as a one-way flow
valves to keep the blood flow towards the heart. When our valve system has been damage,
the blood might back up to the veins that will cause pressure and a disruption in our blood
flow. Venous ulcers commonly occurs in people who have varicose veins and it can also
be related to obesity. It is less painful than arterial ulcer and it commonly occurs in our
ankles.

· NEUROPATHIC SKIN ULCER

-also known as Diabetic Foot Ulcers since they are common on the diabetic persons; causes loss
of sensation in the parts of the feet like the heels and soles.
 IMPAIRED SKIN INTEGRITY

TYPES OF WOUND HEALING

· PRIMARY INTENTION HEALING

-occurs where the tissue surfaces have been approximated (closed) and there is minimal or no
tissue loss.

· SECONDARY INTENTION HEALING

-a wound that is extensive and involves considerable tissue loss, and in which the edges cannot
or should not be approximated.

· TERTIARY WOUND HEALING

-wounds that are left open for 3 to 5 days to allow edema or infection to resolve or exudate to
drain and are then closed with sutures, staples, or adhesive skin closures.

PHASES OF WOUND HEALING

· INFLAMMATORY PHASE

-initiated immediately after injury and lasts 3 to 6 days.

· PROLIFERATIVE PHASE

-the second phase in healing, extends from day 3 or 4 to about day 21 postinjury.

· MATURATION PHASE

-begins on about day 21 and can extend 1 or 2 years after the injury.
 TYPES OF WOUND EXUDATE

· SEROUS EXUDATE

-consists chiefly of serum (the clear portion of the blood) derived from blood and the serous
membranes of the body, such as the peritoneum.

· PURULENT EXUDATE

-thicker than serous exudate because of the presence of pus, which consists of leukocytes,
liquefied dead tissue debris, and dead and living bacteria.

· SANGUINEOUS EXUDATE

-consists of large amounts of red blood cells, indicating damage to capillaries that is severe
enough to allow the escape of red blood cells from plasma.

· SEROSANGUINEOUS EXUDATE

-commonly seen in surgical incisions.

COMPLICATIONS OF WOUND HEALING

· HEMORRHAGE

-a dislodged clot, a slipped stitch, or erosion of a blood vessel may cause severe bleeding.

· INFECTION

-when the microorganisms colonizing the wound multiply excessively or invade tissues, infection
occurs.

· DEHISCENCE WITH POSSIBLE EVISCERATION

-dehiscence is the partial or total rupturing of a sutured wound. . Evisceration is the protrusion of
the internal viscera through an incision.
 FACTORS AFFECTING WOUND HEALING

· DEVELOPMENTAL CONSIDERATIONS

-healthy children and adults often heal more quickly than older adults, who are more likely to have
chronic diseases that hinder healing.

· NUTRITION

-malnourished clients may require time to improve their nutritional status before surgery, if this is
possible. Obese clients are at increased risk of wound infection and slower healing
because adipose tissue usually has a minimal blood supply.

· LIFESTYLE

-people who exercise regularly tend to have good circulation and because blood brings oxygen
and nourishment to the wound, they are more likely to heal quickly.

· MEDICATIONS

-anti-inflammatory drugs (e.g., steroids and aspirin) and antineoplastic agents interfere with
healing.

RISK FOR INFECTION

· FRICTION

- Is a force acting parallel to the skin surface. Friction can abrade the skin, that is, remove the
superficial layers, making it more prone to breakdown.

· SHEARING FORCE - Is a combination of friction and pressure. It occurs commonly when

a client assumes a sitting position in bed.
· IMMOBILITY - It refers to a reduction in the amount and control of movement a person has.

· INADEQUATE NUTRITION - Prolonged inadequate nutrition causes weight loss, muscle

atrophy, and the loss of subcutaneous tissue. Fecal and Urinary Incontinence - Moisture from
incontinence promotes skin maceration (tissue softened by prolonged wetting or soaking) and
makes the epidermis more easily eroded and susceptible to injury. Any accumulation of
secretions or excretions is irritating to the skin, harbors microorganisms, and makes an
individual prone to skin breakdown and infection.

· DECREASED MENTAL STATUS - Individuals with a reduced level of awareness, for

example, those who are unconscious, heavily sedated, or have dementia, are at risk for
pressure ulcers because they are less able to recognize and respond to pain associated with
prolonged pressure.

· DIMINISHED SENSATION - Loss of sensation reduces a person’s ability to respond to

trauma, to injurious heat and cold, and to the tingling (“pins and needles”) that signals loss of
circulation. Sensory loss also impairs the body’s ability to recognize and provide healing
mechanisms for a wound.

Mobility and Positioning

1. Factors affecting mobility

•Mobility- refers to the ability of a person to move freely

•Immobility- state of not being able to move around

1. Growth and development

person's age, muscoskeletal and nervous system development affects posture,
body proportions, body mass and body movements.

2. Physical Health
Chronic or acute diseases and metabolic functioning may also affect one's
 mobility.

3. Nutrition
Both under nutrition and over nutrition can influence body alignment and mobility.

4. Personal values and attitudes

Values about physical appearance influences some people's participation in
regular exercises.

5. External Factors
Temperature, available facilities and unsafe environment are some of the
external factors that may affect one's mobility.

6. Prescribed Limitations
Limitations to movement may be medically prescribed due to some health
problems.

Reasons for client immobility

1. Psychological Factors
•Depression
•Fear pf getting hurt or falling
•Motivation

2. Physical Changes
• Cardiovascular changes
• Neurological changes
• Musculoskeletal disorders
• Associated pains
3. Environmental Causes
•Lack of handrails on stairs around the commode
•Excessively high/low temperature
•Unavailability of resources

Degrees of immobility
•Improvements in mobility can decrease the incidence and severity of complications, improve
the patient's well-being, and decrease the cost and burden of caregiving.

•Varying degrees of immobility significantly increase the risk of more complications like:
-pressure ulcer
-contractures
-skin breakdown
-urinary tract infections
-pneumonia (and many more)

Physiologic responses to immobility

NURSING INTERVENTION: PHYSIOLOGIC RESPONSES TO IMMOBILITY

1. Identifying the complications of immobility.

2. The complications and hazards associated with immobility and according

to bodily system are described below:

a. Urinary System

b. Gastrointestinal System

c. Musculoskeletal System

d. Respiratory System

e. Circulatory System

f. Metabolic System

g. Integumentary System

h. Psychological Alterations

3. Assess the client for mobility, gait, strength and motor skills
 4. Perform skin assessment and implement measures to maintain skin
integrity and prevent skin breakdown (e.g., turning, repositioning,
pressure-relieving support surfaces)

5. Applying the knowledge of nursing procedures and psychomotor skills

when providing care to clients with immobility.

6. Apply, maintain or remove orthopedic devices (e.g., traction, splints,

braces, casts)

7. Apply and maintain devices used to promote venous return (e.g., anti-
embolic stockings, sequential compression devices)

8. Educate the client regarding proper methods used when repositioning an

immobilized client

1. Maintain the client's correct body alignment

2. Maintain/correct the adjustment of client's traction device (e.g.,
external fixation device, halo traction, skeletal traction)
3. Implement measures to promote circulation (e.g., active or
passive range of motion, positioning and mobilization)
4. Evaluate the client's response to interventions to prevent
complications from immobility

NURSING INTERVENTION: BODY MECHANICS

` Ergonomics and Body Mechanics

1. Assess client ability to balance, transfer and use assistive devices prior
to planning care (e.g., crutches, walker)\

2. Provide instruction and information to client about body positions that

eliminate potential for repetitive stress injuries

3. Use ergonomic principles when providing care (e.g., assistive devices,

proper lifting)
Body mechanics

Ergonomics is a scientific discipline that addresses the human being in the environment
to facilitate human wellbeing. For example, an ergonomically designed computer mouse and
ergonomically and anatomically correct chairs that curve to conform to our normal lumbar curve
are examples of ergonomic principles applied to products that are used in the home and the
workplace.

Body mechanics is the safe use of the body using the correct posture, bodily alignment,
balance and bodily movements to safely bend, carry, lift and move objects and people. An
example of a good body mechanics principle is to push rather then pull objects and people.
Nurses must apply the principles of ergonomics and well as body mechanics in their personal
and professional life.

Assessing the Client Ability to Balance, Transfer and Using Assistive Devices Prior to
Planning Care

Upon admission, and whenever a significant client change occurs, the client's ability to
balance, safely transfer and use assistive devices is assessed and then incorporated into the
client's plan of care. As previously discussed in terms of falls and fall prevention, the nurse
assessing the client may determine that the client is at risk for falls because they lack the
muscular strength, coordination, and/or balance to do so in a safe manner and without injury to
self and the staff that are performing care.

In addition to increasing the client's muscular strength, coordination, and/or balance,

nurses, often in collaboration with a physical therapist and other health care providers, nurses
assess the client's ability to safely use an assistive device such as a walker or a cane to
facilitate their movement and ambulation.

Providing Instruction and Information to Client about Body Positions that Eliminate the
Potential for Repetitive Stress Injuries

In addition to the fact that health care staff must be knowledgeable about and use good
body mechanics and ergonomic principles, clients also need knowledge and skill in content
areas including body position, proper bodily alignment and ways to prevent repetitive stress
injuries.

Some of the common used, anatomically correct positions that are used by patients in
bed are the Fowler's position which is a sitting position with the head of the bed elevated, the
dorsal recumbent position and supine positions which are lying on the back with or without a
pillow for the head, the prone position on the stomach, the lateral position which is a side lying
position with the upper most knee bent and often maintained in that position with a pillow, and
the Sim's position which is a semi prone position.

Repetitive stress injuries, simply defined, are injuries that lead to muscular and
neurological pain and discomfort, stiffness, and cramping as the result of repeated and
repetitive movements and other things that lead to the overuse of a muscle or muscle group.
The most often affected muscles and muscle groups include those of the wrist, forearm, elbow,
fingers, hands, neck and shoulders.

Some of the activities and conditions associated with repetitive stress injuries include:

• Prolonged and intense activity without taking a break from it

• Poor posture and poor bodily alignment
• Stress
• Cold ambient temperatures

Using Ergonomic and Body Mechanics Principles When Providing Care

Body mechanics is the safe use of the body using the correct posture, bodily alignment,
balance and bodily movements to safely bend, carry, lift and move objects and people.

Safe patient handling and the application of the principles of body mechanics protect the
patient and they also protect the nurse. Patients benefit because they are being lifted and
transferred by one or more people who are using the strongest muscles of the body and nurses
benefit because they have avoided patient injury and they have also protected themselves from
sometimes severe and permanent injuries, particularly to their back, which can sometimes
cease the nurse's ability to return to nursing.

In addition to getting the assistance of another or using a mechanical life, nurses should
follow these principles of safe patient handling and body mechanics.

Take the time to do a little bit of muscular warmup and stretching before you attempt to
lift or transfer a person or object. Think about and plan your approach before you attempt to do
it.

Explain what you will be doing and how you will perform the lift or transfer to the client.
Instruct the patient about what you and they will be doing. For example, tell the patient to bend
their knees and press their feet into the mattress and, then on the count of three, tell the patient
that they should push up to the top of the bed as you assist them. Even very weak patients can
help you with a lift or transfer when they know what you are about to do and how they can help
you.

Remain as close to the person or the object, such as a large box, when you are about to
lift it and while you are lifting.
Face the person or object that you are about to lift.
Keep your spine, neck and back straight and aligned throughout the lift or transfer. Do
not twist.
Tuck your chin in and keep your neck and head aligned.
Maintain a wide and secure base of support by keeping your feet apart.
Pivot on your feet in the direction of the move and not against it.
Get a secure and good grip on the object or person that you are about to lift.
Use the long and strong muscles of your arms and legs to lift. Do NOT use back
muscles and.
Use slow, smooth and non-jerky movements.

If your facility requires the use of a back support and/or you choose to use it, please
understand that these back supports are useful, however, they will not protect you unless you
also use good body mechanics.

There are a number of assistive devices that can be used to safely lift and transfer
patients.
 Mechanical lifts are used mostly for patients who are obese and cannot be safely
moved or transferred by two people, and also for patients who are, for one reason or another,
not able to provide any help or assistance with their lifts and transfers, such as a person who is
paralyzed.

A gait or transfer belt is also used to assist with transfers and lifting. These wide and
sturdy belts are placed around the patient's waist when they stand, transfer and ambulate. They
are very often also used for physical therapy.

Slide boards are particularly useful to move a patient from one flat surface to another.
These boards reduce friction and, therefore, make the move easier and less irritating to the
patient's skin.

B. Activity and Exercise

1. Rehabilitation Concepts

Rehabilitation is a set of measures that assist individuals who experience, or are likely to
experience, disability to achieve and maintain optimal functioning in interaction with their
environments.

Rehabilitation targets improvements in individual functioning – by improving a person’s ability to

eat and drink independently. Rehabilitation reduces the impact of a broad range of health
conditions.

Rehabilitation involves identification of a person’s problems and needs, relating the problems to
relevant factors of the person and the environment, defining rehabilitation goals, planning and
implementing the measures, and assessing the effects. Educating people with disabilities is
essential for developing knowledge and skills for self-help, care, management, and decision-
making.

The rehabilitation process:

1. Identify problems and needs

2. Relate problems to modifiable and limiting factors

3. Define target problems and target mediators, select appropriate measures

4. Plan, implement, and coordinate interventions

5. Assess effects

2. RANGE OF MOTION

Teach the patient about ROM exercises to ensure adequate joint mobility. Patients with
restricted mobility are unable to perform some or all ROM exercises independently. In order to
maintain maximum joint mobility, ROM exercises should be provided and to ensure that patients
routinely receive them, make a schedule at specific times and maybe with another nursing activity
such as during the patient’s bath. This enables the nurse to systematically reassess mobility while
improving the patient’s range of motion.

Passive Range of Motion

Passive ROM occurs around a joint if the patient is not using his muscles to move. The
nurse manually moves the patient’s body while he relaxes. A machine may also be used to provide
passive ROM. For example, after knee replacement surgery, the patient may not be able to use
his muscles to move the knee. The nurse may bend and straighten the patient’s knee, passively
moving his leg. Occasionally, a device called continuous passive motion (CPM) is used to provide
passive ROM.

Passive ROM is usually used during the initial healing phase after surgery or injury. If
paralysis prevents your body from moving normally, passive ROM may also be used to prevent
contractures or skin pressure ulcers.

Active-Assistive Range of Motion

Active-assistive ROM occurs when the patient is able to move his injured body part, but
he may require some help to move to ensure further injury or damage does not occur. The
assistance that helps move his body can come from him or from another person. It may also come
from a mechanical device or machine.
Active Range of Motion

Active ROM occurs when the patient uses his muscles to help move his body part. This
requires no other person or device to help him move. Active ROM is used when the patient is able
to start moving independently after injury or surgery, and little or no protection from further injury
is needed. Strengthening exercises are a form of active ROM.

Parts of the body that can be exercised by the respective range-of-motions are depicted in the
following:
Range-of-motion exercises for the neck.

Range-of-motion exercises for the shoulder.

Range-of-motion exercises for the elbow.

Range-of-motion exercises for the forearm.

Range-of-motion exercises for the wrist.

Range-of-motion exercises for the thumb.

Range-of-motion exercises for the fingers.

 Range-of-motion exercises for the hip.

Range-of-motion exercises for the knee.

Range-of-motion exercises for the ankle.

 Range-of-motion exercises for the foot.

Range-of-motion exercises for the toes.

3. AMBULATION

Prior to assisting a patient to ambulate, it is important to perform a patient risk assessment

to determine how much assistance will be required. An assessment can evaluate a patient’s
muscle strength, activity tolerance, and ability to move, as well as the need to use assistive
devices or find additional help. The amount of assistance will depend on the patient’s condition,
length of stay and procedure, and any previous mobility restrictions.
 a. With assistance

Stop before you begin, you must review the support plan of the client being assisted. Think
about the task, any equipment needed and the readiness of the client. Think about other options
if this task cannot be done safely. Assess the client by watching/talking to them to see if they are
willing and able to participate in the task. Review other options available if client not ready for task.
Talk to supervisor/manager about other options.

Potential hazards

1. Client injury from falling, due to: tripping, walking too fast, unsteady gait.
2. Muscular, soft-tissue or skeletal injury to workers due to being pulled by falling client.
3. Muscular, soft-tissue or skeletal injury to workers due to trying to stop client falling.

Safety provisions

To prevent risk of injury to workers or clients during this manual task:

a. Follow all steps of this Safe Work Instruction (SWI).

b. Attempting to stop a falling client can increase the risk of injury to both the client and the worker.
Resist any attempt to stop a client falling over by grabbing or catching them.

c. Ensure client is wearing appropriate footwear for walking.

d. Check that surface to be walked on is flat and even, remove tripping hazards and avoid inclines
if possible.

e. Check there is enough space for worker to walk beside client while assisting.

f. Communicate with client and other workers at every step of this task.

Instructions:

Set up

1. Refer to client's support plan for specific information.

 Operation

1. Worker to get into position beside client.

• Worker is standing beside client.
2. Position hands to support client while walking.
• Worker is standing beside client.
• To support the client, hold their arm the following way:
• Worker to place hand closest to client underneath the client's elbow for support.

- Worker to place hand furthest from client into the client's palm for support, with the
thumb through the client's palm for the client to grip (not fingers or whole hand).

3. 'Rolling Out' procedure (if required).

• Use 'rolling out' procedure for escaping a thumb grasp by client, if required.
• Little finger leads hand in a rolling out movement that levers out the worker's thumb
without risk of injury from pulling.
• This action is necessary for the worker to avoid being pulled to the ground if client falls,
or if squeezes hand too tight.
4. Walk along with client.
• Worker to take slow, steady steps with client.
• Do not link or grab arms for safety.
• Worker to provide minimum support required to maximize client's independence
(refer to client's support plan).
• Avoid inclines if possible.

b. With walker

If you have had total knee or total hip replacement surgery, or you have another significant
problem, you may need more help with balance and walking than you can get with crutches or a
cane. A pickup walker with four legs will give you the most stability. A walker lets you keep all or
some of your weight off of your lower body as you take steps. With a walker, you use your arms
to support some of your body weight. As your strength and endurance get better, you may
gradually be able to carry more weight in your legs.
 Proper Positioning

1. When standing up straight, the top of your walker should reach to the crease in your
wrist.
2. Your elbows should be slightly bent when you hold the handgrips of the walker.
3. Keep your back straight. Don't hunch over the walker.
4. Check to be sure the rubber tips on your walker's legs are in good shape. If they
become uneven or worn, you can purchase new tips at a drug store or medical supply
store.

Walking

First, position your walker about one step ahead of you, making sure that all four legs of
the walker are on even ground. With both hands, grip the top of the walker for support and move
your injured leg into the middle area of the walker. Do not step all the way to the front. Push
straight down on the handgrips of the walker as you bring your good leg up so it is even with your
injured leg. Always take small steps when you turn and move slowly.

Sitting

To sit, back up until your legs touch the chair. Use your hands to feel behind you for the
seat of the chair. Slowly lower yourself into the chair.

To stand up, push yourself up using the strength of your arms and grasp the walker's
handgrips. Do not pull on or tilt the walker to help you stand up.

Stairs

Never climb stairs or use an escalator with your walker.

c. With cane

A cane can be helpful if you have minor problems with balance or stability, some weakness
in your leg or trunk, an injury, or a pain. If you are elderly, using a single point cane may help you
to walk more comfortably and safely and, in some cases, may make it easier for you to continue
living independently.

Proper Positioning

1. When standing up straight, the top of your cane should reach to the crease in your
wrist.
2. Your elbow should be slightly bent when you hold your cane.
3. Hold the cane in the hand opposite the side that needs support. For example, if your
right leg is injured, hold the cane in your left hand.

Walking

To start, set your cane about one small stride ahead of you and step off on your injured
leg. Finish the step with your good leg.

Stairs

To climb stairs, place your cane in the hand opposite your injured leg. With your free hand,
grasp the handrail. Step up on your good leg first, then step up on the injured leg. To come down
stairs, put your cane on the step first, then your injured leg and then, finally, your good leg, which
carries your body weight.

d. With crutches

If your injury or surgery requires you to get around without putting any weight on your leg
or foot, you may have to use crutches.

Proper Positioning

1. When standing up straight, the top of your crutches should be about 1-2 inches below
your armpits.
2. The handgrips of the crutches should be even with the top of your hip line.
3. Your elbows should be slightly bent when you hold the handgrips.
 4. To avoid damage to the nerves and blood vessels in your armpit, your weight should
rest on your hands, not on the underarm supports.

Walking

Lean forward slightly and put your crutches about one foot in front of you. Begin your step
as if you were going to use the injured foot or leg but, instead, shift your weight to the crutches.
Bring your body forward slowly between the crutches. Finish the step normally with your good leg.
When your good leg is on the ground, move your crutches ahead in preparation for your next step.
Always look forward, not down at your feet.

Sitting

To sit, back up to a sturdy chair. Put your injured foot in front of you and hold both crutches
in one hand. Use the other hand to feel behind you for the seat of your chair. Slowly lower yourself
into the chair. When you are seated, lean your crutches in a nearby spot. Be sure to lean them
upside down—crutches tend to fall over when they are leaned on their tips.

To stand up, inch yourself to the front of the chair. Hold both crutches in the hand on your
injured side. Push yourself up and stand on your good leg.

Stairs

To walk up and down stairs with crutches, you need to be both strong and flexible. Facing
the stairway, hold the handrail with one hand and tuck both crutches under your armpit on the
other side. When you are going up, lead with your good foot, keeping your injured foot raised
behind you. When you are going down, hold your injured foot up in front, and hop down each step
on your good foot. Take it one step at a time. You may want someone to help you, at least at first.
If you encounter a stairway with no handrails, use the crutches under both arms and hop up or
down each step on your good leg, using more strength.

If you feel unsteady, it may be easier to sit on each step and move up or down on your
bottom. Start by sitting on the lowest step with your injured leg out in front. Hold both crutches flat
against the stairs in your opposite hand. Scoot your bottom up to the next step, using your free
hand and good leg for support. Face the same direction when you go down the steps in this
manner.
e. Wheelchair

Assisting a client to transfer into the wheelchair

1. Make sure that both of the brakes are ‘on’, and the front casters are swiveled forwards.
2. Fold up both footplates and swing them to the sides and out of the way.
3. If possible, get another person to hold the handles of the wheelchair so that it will not
move. If this is not possible then stand behind the chair and hold the handles yourself.
4. Ask the client to stand then, with both hands on the front of the armrests, get them to
lower him/herself onto the seat.
5. Swing the footrests to the front and fold down the footplates. If required, assist the
client to place their feet on the footplates, with their heels well back.
6. Ensure that the client’s elbows are not sticking outside the wheelchair when going
through doorways. Also ensure that their hands are on their laps and not hanging
outside the chair where they can catch in the spokes.

Assisting a client in transferring out of a wheelchair

1. Back the wheelchair so that the front casters swivel forwards.

2. Make sure that both the brakes are on.
3. Fold up both footplates and swing them to the sides, out of the way.
4. If possible, get another person to hold the handles of the wheelchair so that it will not
move. If this is not possible then stand behind the chair and hold the handles yourself.
5. Ask the client to move forwards on the seat.
6. Ask the client to place both feet firmly on the ground, slightly apart and with one foot
further back.
7. Ask the client to place both hands on the front of the armrests, then get them to lean
forwards with their head and shoulders over their knees to give balance. From this
position they should be able to push themselves to standing. Always encourage the
client to take their time with each step of the procedure.

Assisting a client in transferring sideways from a wheelchair to another form of seating

 1. Place the wheelchair alongside, and at 45°, to the chair/toilet/bed/car that they wish to
transfer to.
2. If possible back the wheelchair up slightly so that the front casters swivel forwards.
3. Ensure that both the brakes are on.
4. Fold up both footplates and swing them to the sides out of the way.
5. Remove the armrest on the side to which the client is transferring.
6. If possible, get another person to hold the handles of the wheelchair so that it will not
move. If this is not possible then stand behind the chair and hold the handles yourself.
7. Ask the client to place one hand on the remaining armrest and the other palm down,
on a stable area of the surface they are transferring to.
8. Ask the client to move forwards on the seat.
9. Ask the client to lean slightly forwards, push up and slide their bottom across to the
other surface

4. Nursing Process in Mobility and Exercise

A. Impaired Physical Mobility - limitation in independent, purposeful physical movement of the

body or of one or more extremities.

The goals of interventions are to avoid the hazards of immobility, prevent dependent disabilities,
and assist the patient in restoring, preserving, or maintaining as much mobility and functional
independence

Impaired physical mobility represents a complex health care problem that involves many
different members of the healthcare team. Ongoing assessment is essential in order to identify
potential problems that may have lead to Impaired Physical Mobility.

B. Activity Intolerance - insufficient physiologic or psychological energy to endure or complete

required or desired daily activities.

The common etiology of Activity Intolerance is related to generalized weakness and debilitation
from acute or chronic illnesses. This is mostly observed in older patients with a history of
orthopedic, cardiopulmonary or diabetic problems.
Activity Intolerance is characterized by an altered physiologic response to activity including the
following signs and symptoms:

- Generalized weakness

- Deconditioned state

- Sedentary lifestyle

- Depression

- Lack of motivation

- Prolonged bed rest

- Insufficient sleep

- Imposed activity restriction

- Imbalanced oxygen supply and demand

- Pain

The nursing goals are to reduce the effects of inactivity, promote optimal physical activity, and
assist the patient with maintaining a satisfactory quality of life.

C. Risk for Injury - vulnerable for injury as a result of environmental conditions interacting with
the individual’s adaptive and defensive resources, which may compromise health.

Some factors that may be related to Risk for Injury:

External

- Biological
- Chemical

- Mode of transport or transportation

- Nutrients

- People or provider

- Physical

Internal

- Abnormal blood profile

- Altered clotting factors

- Biochemical, regulatory function

- Developmental age

- Immune-autoimmune dysfunction

- Malnutrition

- Physical

The individual relates fewer or no injuries, as evidenced by the following indicators:

- Patient remains free of injuries.

- Patient explains methods to prevent injury.

- Patient identifies factors that increase risk for injury.

- Patient relates intent to practice selected prevention measures.

- Patient increases daily activity, if feasible.

IV. PROMOTING REST AND SLEEP

Sleep is defined as follows:

→ One of the basic human needs.

→ Characterized by minimal Physical activity, levels of consciousness, changes in the
body’s physiologic processes and decrease in responsiveness to stimuli.

→ It is a state of reduced awareness and responsiveness.

→ It is a state of perceptual disengagement from and unresponsiveness to the
environment.

→ It is a state of unconsciousness

1. PHYSIOLOGY OF SLEEP

a. CIRCADIAN RHYTHM and SLEEP REGULATION

→ Comes from the latin word “circa” which means “around” or
“approximately” and the word “diem” which means “day”
→ 24-hour, day-night cycle.
→ Biorhythm that exists in plants, animals and humans.
→ Suprachiasmatic Nucleus or Nuclei is a small, paired, wing-shaped
structure in the hypothalamus, located at the base of the brain that is
responsible for the regulation of the circadian
→ rhythm.

Tips on how to maintain your circadian rhythm functioning:

1. Stick to a Consistent Sleep Schedule. A regular bedtime is one part of the equation, but
waking up at the same time daily will also help keep your circadian rhythm in check. It may be
tempting to grab some extra shut-eye on weekends, but doing so can throw off your body clock
during the week.

2. Go for an A.M. Walk. In the morning, exposure to the sun (or indoor light), won’t just give
you an energy boost—it can also reset your circadian rhythm. A quick outdoor stroll in the
morning will give you enough sun exposure to signal to your brain that it’s time to start the day.

3. Limit Evening Tech. Bright lights in the evening hours can throw off your body clock by
confusing your brain into thinking it’s still daytime. Try to power-down tech devices at least two
to three hours before bed.

Additional Information:

Infants’ Circadian regularity by the third week of life

By the end of the fourth month, they enter the 24-hour cycle in which they sleep mostly during
the night time.

By the end of the Fifth or sixth month, their sleep-wake pattern are almost like adults.

b. SLEEP REGULATION

Sleep is regulated in two ways:

1. Circadian Clock (Process C)

The suprachiasmatic nucleus (SCN) in the hypothalamus is the pacemaker
that drives various circadian rhythms in the body. The SCN has an intrinsic
pacemaker ability that is due to the activity of certain genes. We know this
because circadian rhythms will persist even when subjects are kept in total
darkness. Under normal conditions, input from the retina to the SCN entrains its
pacemaker to the daily light-dark cycle. The SCN influences the sleep-wake
cycle through indirect connections to the VLPO and LHA nuclei. The SCN also
indirectly regulates secretion of the hormone melatonin by the pineal body. Peak
secretion of melatonin occurs in the dark, and it acts to reinforce the effects of
the SCN on the sleep-wake cycle.

This is what controls the timing of sleep and it coordinates the light-dark cycle of
day and night. Your circadian rhythm is what regulates your body's sleep
patterns, feeding patterns, core body temperature, brain wave activity, and
hormone production over a 24-hour period.
 2. Sleep Homeostasis (Process S)

It is the accumulation of sleep-inducing substances in the brain. It's an internal

biochemical system that operates like a timer, generating homeostatic sleep drive or the
need to sleep after a certain amount of time awake. It effectively reminds the body that it
needs to sleep - so the longer you've been awake, the stronger your desire for sleep
becomes.

c. STAGES OF SLEEP

Electroencephalogram (EEG) is a test that records the electrical signals of the brain. Doctors
use it to help diagnose epilepsy and sleep disorders.

An EEG tracks and records brain wave patterns. Small metal discs with thin wires (electrodes)
are placed on the scalp, and then send signals to a computer to record the results.
NREM sleep is a state of rest wherein electroencephalogram (EEG) activity is higher voltage
and slower compared with activity during waking, and both cortical blood flow and energy use
are reduced.

→ STAGE 1 (Drowsy sleep, Light sleep)

NREM Stage 1 is light sleep where you drift in and out of sleep and can be
awakened easily. The eyes move slowly and muscle activity slows. During this
stage, many people experience sudden muscle contractions preceded by a
sensation of falling −Myoclonic twitches, jerks and seizures due to sudden
muscle contractions or brief lapses of contraction

May last 5-10 minutes.

Brain is producing theta waves.

→ STAGE 2 (light sleep)
Eye movement stops and brain waves become slower with only an occasional
burst of rapid brain waves. The body begins to prepare for deep sleep, as the
body temperature begins to drop and the heart rate slows down.

Lasts for 20 minutes.

Production of brain waves called Sleep spindles.

→ STAGE 3 (slow wave sleep, delta sleep)

Extremely slow brain waves called delta waves are interspersed with smaller,
faster waves. This is deep sleep. It is during this stage that a person may
experience sleepwalking, night terrors, talking during one’s sleep, and
bedwetting. These behaviors are known as parasomnias, and tend to occur
during the transitions between non-REM and REM sleep.

Deep sleep continues as the brain produces delta waves almost exclusively..
Release of growth hormones, Recuperation process and brain function repair
takes place.

Production of Delta Waves.

→ REM SLEEP
Waves mimic activity during the waking state. The eyes remain closed but move
rapidly from side-to-side, perhaps related to the intense dream and brain activity
that occurs during this stage. Cortical blood flow and energy expenditure during
REM sleep are also similar to that seen during wakefulness.

Heart rate increases, blood pressure rises, males develop erections and the body
loses some of the ability to regulate its temperature.

REM sleep happens 90 minutes after you fall asleep.

Brain is more active.

3. FUNCTIONS OF SLEEP

→ Allows the body to undergo recuperation process

→ Avoids immune system disruption
→ Prevents an individual to acquire disease
→ Contribute to growth of an individual
 → Stimulates the brain
→ Improves memory and process of the brain
→ Improves focus and concentration
→ Improves mood and decreases risk of depression

FACTORS AFFECTING SLEEP

Both the quality and the amount of sleep are influenced by various elements. Sleep quality is a
subjective characteristics and is regularly dictated by whether a man awakens feeling lively or
not. Amount of rest is the aggregate time the individual dozes.

Illness

• Illness that causes pain or physical distress (e.g., arthritis, back pain) can result in sleep
problems.
• People who are ill require more sleep than normal, and the normal rhythm of sleep and
wakefulness is often disturbed.
• Respiratory conditions can disturb an individual’s sleep.
• Shortness of breath often makes sleep difficult, and people who have nasal congestion
or sinus drainage may have trouble breathing and hence may find it difficult to sleep.
• People who have gastric or duodenal ulcers may find their sleep disturbed because of
pain, often a result of the increased gastric secretions that occur during REM sleep.
• Certain endocrine disturbances can also affect sleep.
• Hyperthyroidism lengthens presleep time, making it difficult for a client to fall asleep.
Hypothyroidism, conversely, decreases stage 3 sleep.
• Women with low levels of estrogen often report excessive fatigue. In addition, they may
experience sleep disruptions due, in part, to the discomfort associated with hot flashes
or night sweats that can occur with reduced estrogen levels.
• Elevated body temperatures can cause some reduction in delta sleep and REM sleep.
• The need to urinate during the night also disrupts sleep, and people who awaken at
night to urinate sometimes have difficulty getting back to sleep.

Environment
 • Environment can promote or hinder sleep.
• Any change—for example, noise in the environment—can inhibit sleep.
• The absence of usual stimuli or the presence of unfamiliar stimuli can prevent people
from sleeping.
• Hospital environments can be quite noisy, and special care needs to be taken to reduce
noise in the hallways and nursing care units.
• Discomfort from environmental temperature (e.g., too hot or cold) and lack of ventilation
can affect sleep.
• Light levels can be another factor. A person accustomed to darkness while sleeping may
find it difficult to sleep in the light.
• Another influence includes the comfort and size of the bed.
• A person’s partner who has different sleep habits, snores, or has other sleep difficulties
may become a problem for the person also.

Lifestyle

• Following an irregular morning and night time schedule can affect sleep.
• Moderate exercise in the morning or early afternoon usually is conducive to sleep, but
exercise late in the day can delay sleep.
• The person’s ability to relax before retiring is an important factor affecting the ability to
fall asleep.
• Wearing dark wrap-around sunglasses during the drive home and light-blocking shades
can minimize the alerting effects of exposure to daylight, thus making it easier to fall
asleep when body temperature is rising.

Emotional Stress

• Stress is considered by most sleep experts to be the one of the greatest causes of
difficulties in falling asleep or staying asleep.
• Hellhammer and Schubert (2013) have identified that a constant exposure to stress will
increase the activation of the hypothalamic–pituitary–adrenal (HPA) axis leading to sleep
disorders.
 • Anxiety increases the norepinephrine blood levels through stimulation of the sympathetic
nervous system. This chemical change results in less deep and REM sleep and more
stage changes and awakenings.

Stimulants and Alcohol

• Caffeine-containing beverages act as stimulants of the central nervous system (CNS).

• Drinking beverages containing caffeine in the afternoon or evening may interfere with
sleep.
• People who drink an excessive amount of alcohol often find their sleep disturbed.
• Alcohol disrupts REM sleep, although it may hasten the onset of sleep..

Diet

• Weight gain has been associated with reduced total sleep time as well as broken sleep
and earlier awakening.
• Weight loss, on the other hand, seems to be associated with an increase in total sleep
time and less broken sleep.

Smoking

• Nicotine has a stimulating effect on the body, and smokers often have more difficulty
falling asleep than nonsmokers.
• Smokers are usually easily aroused and often describe themselves as light sleepers.
• By refraining from smoking after the evening meal, the person usually sleeps better;

Motivation

• Motivation can increase alertness in some situations (e.g., a tired person can probably
stay alert while attending an interesting concert or surfing the web late at night).
 • Motivation alone, however, is usually not sufficient to overcome the normal circadian
drive to sleep during the night. Nor is motivation sufficient to overcome sleepiness due to
insufficient sleep.

Medications

• Some medications affect the quality of sleep.

• Most hypnotics can interfere with deep sleep and suppress REM sleep.
• Beta-blockers have been known to cause insomnia and nightmares.
• Narcotics, such as morphine, are known to suppress REM sleep and to cause frequent
awakenings and drowsiness.
• Tranquilizers interfere with REM sleep. Although antidepressants suppress REM sleep,
this effect is considered a therapeutic action.
• Clients accustomed to taking hypnotic medications and antidepressants may experience
a REM rebound (increased REM sleep) when these medications are discontinued.

COMMON SLEEP DISORDERS

A learning of common sleep disorders can enable nurses to survey the rest complaints of their
customers and, when appropriate, make a referral to a professional in sleep disorder
prescription. Although sleep disorders are typically categorized for the purpose of research as
dyssomnias, parasomnias, and disorders associated with medical or psychiatric illness, it is
usually more appropriate for clinicians to focus on the client’s symptoms (e.g., insomnia,
excessive sleepiness, and abnormal events) that occur during sleep (parasomnias).

Insomnia

• Insomnia is described as the inability to fall asleep or remain asleep.

• Individuals with insomnia do not awaken feeling rested.
• Insomnias the most common sleep complaint in America.
• Acute insomnia lasts one to several nights and is often caused by personal stressors
or worry.
• If the insomnia persists for longer than a month, it is considered chronic insomnia.
 • The two main risk factors for insomnia are older age and female gender (National Sleep
Foundation, n.d.d).
✓ Women suffer sleep loss in connection with hormonal changes (e.g.,
menstruation, pregnancy, and menopause).
✓ The incidence of insomnia increases with age, but it is thought that
this is caused by some other medical condition.
• Treatment for insomnia frequently requires the client to develop new behavior
patterns that induce sleep and maintain it.
• Examples of behavioral treatments include the following:
o Stimulus control: creating a sleep environment that promotes
sleep
o Cognitive therapy: learning to develop positive thoughts and
beliefs about sleep
o Sleep restriction: following a program that limits time in bed in
order to get to sleep and stay asleep throughout the night
(National Sleep Foundation, n.d.e). \

Excessive Daytime Sleepiness

• Clients may experience excessive daytime sleepiness as a result of hypersomnia,

narcolepsy, sleep apnea, and insufficient sleep.

HYPERSOMNIA

• Hypersomnia refers to conditions where the affected individual obtains sufficient sleep at
night but still cannot stay awake during the day.
• Hypersomnia can be caused by medical conditions, for example, CNS damage and
certain kidney, liver, or metabolic disorders, such as diabetic acidosis and
hypothyroidism.

NARCOLEPSY

• Narcolepsy is a disorder of excessive daytime sleepiness caused by the lack of the

chemical hypocretin in the area of the CNS that regulates sleep.
 • Clients with narcolepsy have sleep attacks or excessive daytime sleepiness, and their
sleep at night usually begins with a sleep-onset REM period (dreaming sleep occurs
within the first 15 minutes of falling asleep).
• The majority of clients also have cataplexy or the sudden onset of muscle weakness or
paralysis in association with strong emotion, sleep paralysis (transient paralysis when
falling asleep or waking up), hypnagogic hallucinations (visual, auditory, or tactile
hallucinations at sleep onset or when waking up), and/or fragmented nighttime sleep
• . Their fragmented nocturnal sleep is not the cause of their excessive daytime
sleepiness;.. CNS stimulants such as methylphenidate (Ritalin) or amphetamines have
been used to reduce excessive daytime sleepiness SLEEP APNEA

Sleep apnea

• Sleep apnea is characterized by frequent short breathing pauses during sleep.

• Although all individuals have occasional periods of apnea during sleep,
• more than five apneic episodes or five breathing pauses longer than 10 seconds per
hour is considered abnormal and should be evaluated by a sleep medicine specialist.
• Symptoms suggestive of sleep apnea include loud snoring, frequent nocturnal
awakenings, excessive daytime sleepiness, difficulties falling asleep at night, morning
headaches, memory and cognitive problems, and irritability.
• Three common types of sleep apnea are obstructive apnea, central apnea, and mixed
apnea.
- Obstructive apnea
➢ occurs when the structures of the pharynx or oral cavity block the flow
of air.
➢ The person continues to try to breathe; that is, the chest and
abdominal muscles move.
➢ The movements of the diaphragm become stronger and stronger until
the obstruction is removed.
➢ Enlarged tonsils and adenoids, a deviated nasal septum, nasal polyps,
and obesity predispose the client to obstructive apnea.
- Central apnea
 ➢ is thought to involve a defect in the respiratory center of the brain. All
actions involved in breathing, such as chest movement and airflow,
cease.
➢ Clients who have brainstem injuries and muscular dystrophy, for
example, often have central sleep apnea.

- Mixed apnea
➢ is a combination of central apnea and obstructive apnea. Treatment for sleep
apnea is directed at the cause of the apnea. For example, enlarged tonsils
may be removed.

INSUFFICIENT SLEEP

• Healthy individuals who obtain less sleep than they need will experience sleepiness and
fatigue during the daytime hours.
• Depending on the severity and chronicity of this voluntary, albeit unintentional sleep
deprivation, individuals may develop attention and concentration deficits, reduced
vigilance, distractibility, reduced motivation, fatigue, malaise, and occasionally diplopia
and dry mouth.
• The cause of these symptoms may or may not be attributed to insufficient sleep,
because many Americans believe that 6.8 hours of sleep is sufficient to maintain
optimal daytime performance.
• there is growing evidence that insufficient sleep can have significant deleterious effects.
Staying awake 19 consecutive hours produces the same impairments in reaction times
and cognitive function as a blood alcohol level of 0.05, and staying awake for 24
consecutive hours has the same effects on reaction times and cognitive function as
being legally drunk (with a blood alcohol level of 0.1).
• Nurses who report reduced hours of sleep are more likely to make an error, to have
difficulty staying awake on duty, and to have difficulty staying awake while driving home
from work than those who obtained more sleep.

PARASOMNIAS
 • A parasomnia is behavior that may interfere with sleep and may even occur during
sleep. It is characterized by physical events such as movements or experiences that are
displayed as emotions, perceptions, or dreams.
• The International Classification of Sleep Disorders subdivides parasomnias into three
classes: non–rapid eye movement, rapid eye movement, and miscellaneous with
no specific stage of sleep (Judd & Sateia, 2014).
✓ Parasomnias with non–rapid eye movement are associated with
confusion upon arousal, sleep tremors, and sleep walking.
✓ Parasomnias with rapid eye movement are associated with arousal
disorders such as sleep paralysis. This may be a nightmare disorder with
exaggerated features of REM sleep.
✓ Miscellaneous parasomnias are not associated with any stage of sleep
and may produce nocturnal enuresis or hallucinations. The
miscellaneous parasomnias are often related to a medication, substance
abuse, or a medical disorder.

SLEEP AND THE NURSING PROCESS

ASSESSING

• A complete assessment of a client’s sleep difficulty includes a sleep history, health

history, physical exam, and, if warranted, a sleep diary and diagnostic studies.
• All nurses, however, can take a brief sleep history and educate their clients about
normal sleep
 • A brief sleep history, which is usually part of the comprehensive nursing history, should
be obtained for all clients entering a health care facility. It should, however, be deferred
or omitted if the client is critically ill.
• Key questions to ask include the following:
➢ When do you usually go to sleep?
➢ And when do you wake up?
➢ Do you nap? If so, when?
• If the client is a child, it is also important to ask about bedtime rituals. This information
provides the nurse with information about the client’s usual sleep duration and preferred
sleep times, and allows for the incorporation of the client’s preferences in the plan of
care.
• Loud snoring suggests the possibility of obstructive sleep apnea, and any client replying
yes to this question should be referred to a specialist in sleep disorders medicine..
• any difficulty sleeping, difficulty remaining awake during the day, and/or recent changes
in sleep pattern. This detailed history should explore the exact nature of the problem and
its cause, when it first began and its frequency, how it affects daily living, what the client
is doing to cope with the problem, and whether these methods have been effective..

HEALTH HISTORY

• A health history is obtained to rule out medical or psychiatric causes of the client’s
difficulty sleeping.
• It is important to note that the presence of a medical or psychiatric illness (e.g.,
depression, Parkinson’s disease, Alzheimer’s disease, or arthritis) does not preclude the
possibility that a second problem (e.g., obstructive sleep apnea) may be contributing to
the difficulty sleeping.

PHYSICAL EXAMINATION

• Rarely are sleep abnormalities noted during the physical examination unless the client
has obstructive sleep apnea or some other health problem.
 • Common findings among clients with sleep apnea include an enlarged and reddened
uvula and soft palate, enlarged tonsils and adenoids (in children), obesity (in adults), and
in male clients a neck size greater than 17.5 inches.
• Occasionally a deviated septum may be noted, but it is rarely the cause of obstructive
sleep apnea.

SLEEP DIARY

• A sleep specialist may ask clients to keep a sleep diary or log for 1 to 2 weeks in order
to get a more complete picture of their sleep complaints.
• A sleep diary may include all or selected aspects of the following information that
pertain to the client’s specific problem:
o Time of (a) going to bed, (b) trying to fall asleep, (c) falling asleep
(approximate time), (d) any instances of waking up and duration of these
periods, (e) waking up in the morning, and (f) any naps and their duration
o Activities performed 2 to 3 hours before bedtime (type, duration, and time
o Consumption of caffeinated beverages and alcohol and amounts of those
beverages
o Any prescribed medications, OTC medications, and herbal remedies taken
during the day
o Bedtime rituals before sleep
o Any difficulties remaining awake during the day and times when difficulties
occurred
o Any worries that the client believes may affect sleep
o Factors that the client believes have a positive or negative effect on sleep.
o If the client is a child, the sleep diary or log may be completed by a parent.

DIAGNOSTIC STUDIES

• Sleep is measured objectively in a sleep disorder laboratory by polysomnography in

which an electroencephalogram (EEG), electromyogram (EMG), and electro-oculogram
(EOG) are recorded simultaneously.
• Electrodes are placed on the scalp to record brain waves (EEG), on the outer canthus
of each eye to record eye movement (EOG), and on the chin muscles to record the
structural electromyogram (EMG).
 • The electrodes transmit electric energy from the cerebral cortex and muscles of the face
to pens that record the brain waves and muscle activity on graph paper.
• Respiratory effort and airflow, ECG, leg movements, and oxygen saturation are also
monitored.
• Oxygen saturation is determined by monitoring with a pulse oximeter, a light-sensitive
electric cell that attaches to the ear or a finger.
• . Diagnosing Insomnia, the NANDA International (Herdman & Kamitsuru, 2014)
diagnosis given to clients with sleep problems, is usually made more explicit with
descriptions such as “difficulty falling asleep” or “difficulty staying asleep”; for example,
Insomnia (delayed onset of sleep) related to overstimulation prior to bedtime.
• Various factors or etiologies may be involved and must be specified for the individual.
These include physical discomfort or pain;

Sleep pattern disturbances may also be stated as the etiology of another diagnosis, in which
case the nursing interventions are directed toward the sleep disturbance itself.

Examples include the following:

• Risk for Injury related to somnambulism

• Ineffective Coping related to insufficient quality and quantity of sleep

• Fatigue related to insufficient sleep

• Impaired Gas Exchange related to sleep apnea

• Deficient Knowledge (nonprescription remedies for sleep) related to misinformation

• Anxiety related to sleep apnea and/or the diagnosis of a sleep disorder

• Activity Intolerance related to sleep deprivation or excessive daytime sleepiness.

PLANNING

• The major goal for clients with sleep disturbances is to maintain (or develop) a sleeping
pattern that provides sufficient energy for daily activities.
 • Other goals may relate to enhancing the client’s feeling of well-being or improving the
quality and quantity of the client’s sleep.
• The nurse plans specific nursing interventions to reach the goal based on the etiology of
each nursing diagnosis.
• These interventions may include
➢ reducing environmental distractions,
➢ promoting bedtime rituals,
➢ providing comfort measures,
➢ scheduling nursing care to provide for uninterrupted sleep periods, and
➢ teaching stress reduction,
➢ relaxation techniques, or
➢ good sleep hygiene.

IMPLEMENTING

➢ The term sleep hygiene refers to interventions used to promote sleep.

➢ Nursing interventions to enhance the quantity and quality of clients’ sleep involve largely
nonpharmacologic measures.
➢ These involve health teaching about sleep habits, support of bedtime rituals, the
provision of a restful environment, specific measures to promote comfort and relaxation,
and appropriate use of hypnotic medications.
➢ For hospitalized clients, sleep problems are often related to the hospital environment or
their illness.
➢ Client Teaching Healthy individuals need to learn the importance of sleep in maintaining
active and productive lifestyles. They need to learn
(a) the conditions that promote sleep and those that interfere with sleep,
(b) safe use of sleep medications,
(c) effects of other prescribed medications on sleep,
(d) effects of their disease states on sleep, and
(e) importance of long periods of uninterrupted sleep.

TIPS FOR PROMOTING SLEEP ARE LISTED IN CLIENT TEACHING.

➢ Supporting Bedtime Rituals Most people are accustomed to bedtime rituals or
presleep routines that are conducive to comfort and relaxation.
➢ Altering or eliminating such routines can affect a client’s sleep.
➢ Common prebedtime activities of adults include listening to music, reading,
taking a soothing bath, and praying.
➢ Children need to be socialized into a presleep routine such as a bedtime story,
holding onto a favorite toy or blanket, and kissing everyone goodnight.
➢ Sleep is also usually preceded by hygienic routines, such as washing the face
and hands (or bathing), brushing the teeth, and voiding.
➢ In institutional settings, nurses can provide similar bedtime rituals—assisting with
a hand and face wash, providing a massage or hot drink, plumping pillows, and
providing extra blankets as needed.
➢ Creating a Restful Environment All people need a sleeping environment with
minimal noise, a comfortable room temperature, appropriate ventilation, and
appropriate lighting.
➢ Environmental distractions such as environmental noises and staff
communication noise are particularly troublesome for hospitalized clients.
➢ Environmental noises include the sound of paging systems, telephones, and call
lights; monitors beeping; doors closing; elevator chimes; furniture squeaking; and
linen carts being wheeled through corridors.
➢ Staff communication is a major factor creating noise, particularly at staff change
of shift. To create a restful environment, the nurse needs to reduce
environmental distractions, reduce sleep interruptions, ensure a safe
environment, and provide a room temperature that is satisfactory to the client
➢ The environment must also be safe so that the client can relax. People who are
unaccustomed to narrow hospital beds may feel more secure with side rails.
➢ Additional safety measures include:
• Placing beds in low positions.
• Using night-lights.
• Placing call bells within easy reach.
➢ A concerned, caring attitude, along with the following interventions, can
significantly promote client comfort and sleep:
• Provide loose-fitting nightwear.
• Assist clients with hygienic routines
 • Make sure the bed linen is smooth, clean, and dry.
• Assist or encourage the client to void before bedtime.
• Offer to provide a back massage before sleep.
• Position dependent clients appropriately to aid muscle relaxation,
and provide supportive devices to protect pressure areas.
• Schedule medications, especially diuretics, to prevent
nocturnal awakenings.
• For clients who have pain, administer analgesics
30 minutes before sleep.
• Listen to the client’s concerns and deal with problems as they arise.
➢ The following interventions can be used to keep older adults warm during
sleep:
o Before the client goes to bed, warm the bed with prewarmed bath
blankets.
o • Use 100% cotton flannel sheets or apply thermal blankets between the
sheet and bedspread.
o • Encourage the client to wear own clothing, such as flannel nightgown or
pajamas, socks, leg warmers, long underwear, sleeping cap (if scalp hair
is sparse), or sweater, or use extra blankets.
o Sleep rarely occurs until a person is relaxed. Relaxation techniques can
be encouraged as part of the nightly routine.
o Slow, deep breathing for a few minutes followed by slow, rhythmic
contraction and relaxation of muscles can alleviate tension and induce
calm. Imagery, meditation, and yoga can also be taught.

ENHANCING SLEEP WITH MEDICATIONS

• Sleep medications often prescribed on a prn (as-needed) basis for clients include the
sedative-hypnotics, which induce sleep, and antianxiety drugs or tranquilizers, which
decrease anxiety and tension.
• These medications should be administered only with complete knowledge of their
actions and effects and only when indicated.
• Both nurses and clients need to be aware of the actions, effects, and risks of the
specific medication prescribed.
 • Although medications vary in their activity and effects, considerations include the
following:
• Sedative-hypnotic medications produce a general CNS depression and an
unnatural sleep; REM or NREM sleep is altered to some extent and daytime
drowsiness and a morning hangover effect may occur.
• Antianxiety medications decrease levels of arousal by facilitating the action of
neurons in the CNS that suppress responsiveness to stimulation
• Sleep medications vary in their onset and duration of action and will impair
waking function as long as they are chemically active.
• Sleep medications affect REM sleep more than NREM sleep.
• Initial doses of medications should be low and increases added gradually,
depending on the client’s response. Older adults, in particular, are susceptible to side
effects because of their metabolic changes; they need to be closely monitored for
changes in mental alertness and coordination..
• Regular use of any sleep medication can lead to tolerance over time (e.g., 4 to
6 weeks) and rebound insomnia. In some instances, this may lead clients to increase
the dosage. Clients must be cautioned about developing a pattern of drug
dependency.
• Abrupt cessation of barbiturate sedative-hypnotics can create withdrawal
symptoms such as restlessness, tremors, weakness, insomnia, increased heart rate,
seizures, convulsions, and even death. Long-term users need to taper their
medications under the supervision of a specialist.

EVALUATING

• Using data collected during care and the desired outcomes developed during the
planning stage as a guide, the nurse judges whether client goals and outcomes have
been achieved. Data collection may include
(a) observations of the duration of the client’s sleep,
(b) questions about how the client feels on awakening, or
(c) observations of the client’s level of alertness during the day.
• If the desired outcomes are not achieved, the nurse and client should explore the
reasons, which may include answers to the following questions:
o Were etiologic factors correctly identified?
 o Has the client’s physical condition or medication therapy changed?
o Did the client comply with instructions about establishing a regular
sleep/wake pattern?
o Did the client avoid ingesting caffeine?
o Did the client participate in stimulating daytime activities to avoid excessive
daytime naps?
o Were all possible measures taken to provide a restful environment for the
client?

Scenario:

A 36 year old male has been admitted to your medical surgical floor for 23 hour
observation due to exhaustion. The patient reports difficultly falling asleep and then
staying asleep for the past 5 months. He states that ever since he started his new job 5
months ago working the night shift he is getting less and less sleep. In addition, he states
that since his 5th child was born it is loud in his house and he can’t sleep when he gets
home from work. He states he is sometimes pulling 16 hours shifts straight and may be
gets 3 hours of sleep before he has to go back in. Pt admits to dozing off frequently
especially on the job which is why he is came to the hospital because he states he think
he has “narcolepsy or something”. He also report being very agitated at the slightest things
and that him and his wife have been fighting a lot. Pt states his wife says it is like his is a
different person. You note the patient looks very tired with dark circles underneath his
eyes.

Nursing Diagnosis:

Disturbed Sleep Pattern related to lifestyle disruptions as evidence by reports of difficulty

falling and remaining asleep, agitation, dozing during the day, and mood alterations.

Subjective Data:

The patient reports difficultly falling asleep and then staying asleep for the past 5 months.
He states that ever since he started his new job 5 months ago working the night shift he is
getting less and less sleep. In addition, he states that since his 5th child was born it is loud
in his house and he can’t sleep when he gets home from work. He states he is sometimes
pulling 16 hours shifts straight and may be gets 3 hours of sleep before he has to go back
in. Pt admits to dozing off frequently especially on the job which is why he is came to the
hospital because he states he think he has “narcolepsy or something”. He also report
being very agitated at the slightest things and that him and his wife have been fighting a
lot. Pt states his wife says it is like his is a different person.

Objective Data:

A 36 year old male has been admitted to your medical surgical floor for 23 hour
observation due to exhaustion. You note the patient looks very tired with dark circles
underneath his eyes.

Nursing Outcomes:

-The patient will report optimal balance of sleep.-The patient will report less dozing off
during the day.

-The patient will report less agitation.

-The patient will verbalize 4 techniques on how to fall asleep and stay asleep.

-The patient will verbalize 3 side effects of taking a sleep aid.

The patient will verbalize how and when to take a sleep aid and how they are not to be
used on an every day basis.

Nursing Interventions:

-The nurse will assess the patients sleeping pattern and help him develop a sleeping
plan.-The nurse will provide a dark, quiet, and comfortable atmosphere for the patient to
sleep in.

-The nurse will discourage caffeine or large meal intake 2 hours before the patient goes to
sleep.
 -The nurse will educate the patient on 4 techniques on how to fall sleep and stay asleep.
The nurse will educated the patient on 3 side effects of taking a sleep aid.

-The nurse will educate the patient on when to take a sleep aid and how they are not to be
used on an every day basis.

o Were the comfort and relaxation measures effective?

V. COMFORT AND PAIN MANAGEMENT

TYPES OF PAIN

Pain maybe described in terms of duration, location, or etiology.

• Acute pain: when pain lasts only through the expected recovery period from illness,
injury, or surgery.
• Chronic pain: is prolonged, usually recurring or persisting over 6 months or longer, and
interferes with functioning.
• Cutaneous pain: originates in the skin or visceral
• Deep somatic pain: arises from ligaments, tendons, bones, blood vessels, and nerves.
• Visceral pain: results from stimulation of pain receptors in the abdominal cavity, cranium,
and thorax.
• Radiating pain: is perceived at the source of the pain and extends to nearby tissues.
• Referred pain: is felt in a part of the body that is considerably removed from the tissues
causing the pain.
• Intractable pain: is highly resistant to relief.
• Neuropathic pain: is the result of current or past damage to the peripheral or central
nervous system.
• Phantom pain: which ia perceived in a body part that is missing or paralyzed.
THEORIES OF PAIN

1. Intensive Theory (Erb, 1874)

An Intensive (or Summation) Theory of Pain (now referred to as the Intensity Theory) has been
postulated at several different times throughout history. First, conceptualized in the fourth
century BCE by Plato in his oeuvre Timaeus (Plato 1998), the theory defines pain, not as a
unique sensory experience but rather, as an emotion that occurs when a stimulus is stronger
than usual. This theory is based on Aristotle’s concept that pain resulted from excessive
stimulation of the sense of touch. Both stimulus intensity and central summation are critical
determinants of pain. It was implied that the summation occurred in the dorsal horn cells.Arthur
Goldscheider further advanced the Intensity Theory, based on an experiment performed by
Bernhard Naunyn in 1859 [cited in Dallenbach (1939)]. These experiments showed that
repeated tactile stimulation (below the threshold for tactile perception) produced pain in patients
with syphilis who had degenerating dorsal columns. When this stimulus was presented to
patients 60–600 times/s, they rapidly developed what they described as unbearable pain.
Naunyn reproduced these results in a series of experiments with different types of stimuli,
including electrical stimuli. It was concluded that there must be some form of summation that
occurs for the subthreshold stimuli to become unbearably painful.

2. Specificity Theory (Von Frey, 1895)

Specificity theory is one of the first modern theories for pain. It holds that specific pain receptors
transmit signals to a "pain center" in the brain that produces the perception of painvVon Frey
(1895) argued that the body has a separate sensory system for perceiving pain—just as it does
for hearing and vision. This theory considers pain as an independent sensation with specialised
peripheral sensory receptors [nociceptors], which respond to damage and send signals through
pathways (along nerve fibres) in the nervous system to target centres in the brain. These brain
centres process the signals to produce the experience of pain. Thus, it is based on the
assumption that the free nerve endings are pain receptors and that the other three types of
receptors are also specific to a sensory experience.

3. Strong's Theory (Strong, 1895)

This theory states that pain was an experience based on both the noxious stimulus and the
psychic reaction or displeasure provoked by the sensation.

4. Pattern Theory
In an attempt to overhaul theories of somaesthesis (including pain), J. P. Nafe postulated a
“quantitative theory of feeling” (1929). This theory ignored findings of specialized nerve endings
and many of the observations supporting the specificity and/or intensive theories of pain. The
theory stated that any somaesthetic sensation occurred by a specific and particular pattern of
neural firing and that the spatial and temporal profile of firing of the peripheral nerves encoded
the stimulus type and intensity. Goldschneider (1920) proposed that there is no separate system
for perceiving pain, and the receptors for pain are shared with other senses, such as of touch.
This theory considers that peripheral sensory receptors, responding to touch, warmth and other
non-damaging as well as to damaging stimuli, give rise to non-painful or painful experiences as
a result of differences in the patterns [in time] of the signals sent through the nervous system.
Thus, according to this view, people feel pain when certain patterns of neural activity occur,
such as when appropriate types of activity reach excessively high levels in the brain. These
patterns occur only with intense stimulation. Because strong and mild stimuli of the same sense
modality produce different patterns of neural activity, being hit hard feels painful, but being
caressed does not. It suggested that all cutaneous qualities are produced by spatial and
temporal patterns of nerve impulses rather than by separate, modality specific transmission
routes.

5. Central Summation Theory (Livingstone, 1943)

It proposed that the intense stimulation resulting from the nerve and tissue damage activates
fibers that project to internuncial neuron pools within the spinal cord creating abnormal
reverberating circuits with self-activating neurons. Prolonged abnormal activity bombards cells
in the spinal cord, and information is projected to the brain for pain perception.

6. The Fourth Theory of Pain (Hardy, Wolff, and Goodell, 1940s)

It stated that pain was composed of two components: the perception of pain and the reaction
one has towards it. The reaction was described as a complex physiopsychological process
involving cognition, past experience, culture and various psychological factors which influence
pain perception.

7. Sensory Interaction Theory (Noordenbos, 1959)

It describes two systems involving transmission of pain: fast and slow system. The later
presumed to conduct somatic and visceral afferents whereas the former was considered to
inhibit transmission of the small fibers.

8. Gate Control Theory (Melzack and Wall, 1965)

Melzack has proposed a theory of pain that has stimulated considerable interest and debate
and has certainly been a vasy improvement on the early theories of pain. According to his
theory, pain stimulation is carried by small, slow fibers that enter the dorsal horn of the spinal
cord; then other cells transmit the impulses from the spinal cord up to the brain. These fibers are
called T-cells. The T-cells can be located in a specific area of the spinal cord, known as the
substantial gelatinosa. These fibers can have an impact on the smaller fibers that carry the pain
stimulation. In some cases they can inhibit the communication of stimulation, while in other
cases they can allow stimulation to be communicated into the central nervous system. For
example, large fibers can prohibit the impulses from the small fibers from ever communicating
with the brain. In this way, the large fibers create a hypothetical "gate" that can open or close
the system to pain stimulation. According to the theory, the gate can sometimes be
overwhelmed by a large number of small activated fibers. In other words, the greater the level of
pain stimulation, the less adequate the gate in blocking the communication of this information.

There are 3 factors which influence the 'opening and closing' of the gate:

The amount of activity in the pain fibers. Activity in these fibers tends to open the gate. The
stronger the noxious stimulation, the more active the pain fibers.
The amount of activity in other peripheral fibers—that is, those fibers that carry information
about harmless stimuli or mild irritation, such as touching, rubbing, or lightly scratching the skin.
These are large-diameter fibers called A-beta fibers.Activity in A-beta fibers tends to close the
gate, inhibiting the perception of pain when noxious stimulation exists. This would explain why
gently massaging or applying heat to sore muscles decreases the pain.
Messages that descend from the brain. Neurons in the brainstem and cortex have efferent
pathways to the spinal cord, and the impulses they send can open or close the gate. The effects
of some brain processes, such as those in anxiety or excitement, probably have a general
impact, opening or closing the gate for all inputs from any areas of the body. But the impact of
other brain processes may be very specific, applying to only some inputs from certain parts of
the body. The idea that brain impulses influence the gating mechanism helps to explain why
people who are hypnotized or distracted by competing environmental stimuli may not notice the
pain of an injury.

The beauty of theory is that it provides a physiological basis for the complex phenomenon of
pain. It does this by investigating the complex structure of the nervous system, which is
comprised of the following two major divisions:

Central nervous system (the spinal cord and the brain)

Peripheral nervous system (nerves outside of the brain and spinal cord, including branching
nerves in the torso and extremities, as well as nerves in the lumbar spine region)

FACTORS INFLUENCING PAIN

-factors that influence the individual's perception of and reaction to pain include developmental
stage, psychosocial development, and the environment.

Developmental considerations
The age and developmental stage of a client will influence both the reaction to and the
expression of pain. The field of pain management for infants and children has grown
significantly. It is now accepted that anatomical, physiological, and biochemical elements
necessary from pain transmission are present in newborns, regardless of their gestational age.

Psychosocial considerations

Family, culture, religion and other factors influence the individual's ability to express and accept
treatment modalities regarding pain. Ethnic background and cultural heritage have long been
recognized as influencing both a person's reaction to pain and the expression of the pain.
Behavoi related to pain is par of the socialization process.

Environmental considerations

Environment factors will influence a person's ability to identify and seek relief for pain. The
external environment includes a variety of stimuli for pain.

ASSESSING PAIN / PAIN ASSESSMENT

Nurses can help patients more accurately report their pain by using these very specific PQRST
assessment questions:

P = Provocation/Palliation
What were you doing when the pain started? What caused it? What makes it better or worse?
What seems to trigger it? Stress? Position? Certain activities?

What relieves it? Medications, massage, heat/cold, changing position, being active, resting?

What aggravates it? Movement, bending, lying down, walking, standing?

Q = Quality/Quantity
What does it feel like? Use words to describe the pain such as sharp, dull, stabbing, burning,
crushing, throbbing, nauseating, shooting, twisting or stretching.

R = Region/Radiation
Where is the pain located? Does the pain radiate? Where? Does it feel like it travels/moves
around? Did it start elsewhere and is now localized to one spot?

S = Severity Scale
How severe is the pain on a scale of 0 to 10, with zero being no pain and 10 being the worst
pain ever? Does it interfere with activities? How bad is it at its worst? Does it force you to sit
down, lie down, slow down? How long does an episode last?

T = Timing
When/at what time did the pain start? How long did it last? How often does it occur: hourly?
daily? weekly? monthly? Is it sudden or gradual? What were you doing when you first
experienced it? When do you usually experience it: daytime? night? early morning? Are you
ever awakened by it? Does it lead to anything else? Is it accompanied by other signs and
symptoms? Does it ever occur before, during or after meals? Does it occur seasonally?

Documentation
In addition to facilitating accurate pain assessment, careful and complete documentation
demonstrates that you are taking all the proper steps to ensure that your patients receive the
highest quality pain management. It is important to document the following:

Patient’s understanding of the pain scale. Describe the patient’s ability to assess pain level
using the 0-10 pain scale.

Patient satisfaction with pain level with current treatment modality. Ask the patient what
his or her pain level was prior to taking pain medication and after taking pain medication. If the
patient’s pain level is not acceptable, what interventions were taken?
Timely re-assessment following any intervention and response to treatment. Quote the
patient’s response.

Communication with physician. Always report any change in condition.

Patient education provided and patient’s response to learning. Don’t write “patient
understands” without a supportive evaluation such as patient can verbalize, demonstrate,
describe, etc.

6. STRATEGIES FOR PAIN RELIEF

A. Non-invasive Technique/Nonpharmacologic Pain Management

The management of pain without medications. This method utilizes ways to alter
thoughts and focus concentration to better manage and reduce pain.

a. Heat and Cold

• A warm bath, heating pads, ice bags, ice massage, hot or cold compresses, and
warm or cold sitz baths.
• Heat packs can aid relief of chronic musculoskeletal injuries and associated pain
• Icepack can be used to help reduce swelling immediately after an injury
• Relieves pain and promote healing of injured tissues

b. Massage

• Better suited to soft tissue injuries and should be avoided if the pain originates in
the joints
• Comfort measure that can aid relaxation, decrease muscle tension, and may ease
anxiety because the physical contact communicates caring (therapeutic touch)
• Decrease pain intensity by increasing superficial circulation to the area.
 c. Imagery

• Guiding you through imaginary mental images of sights, sounds, tastes, smells,
and feelings can help shift attention away from the pain.
• Imagine something that involves one or all the senses, concentrate on that image,
and gradually become less aware of the pain.
• Thinking of happy thing to ease the pain
• Decrease pain sensation

B. Invasive Techniques/Pharmacologic Pain management

a. Nonopioids (nonsteroidal anti-inflammatory drugs)

• Non-narcotic analgesics
• Useful for management of acute and chronic illness
• Used for mild to moderate pain
• Serves as adjuvant medication for the relief of pain
• Weakens and reduces the levels of chemical mediators produced during
inflammation, relieving symptoms of pain, swelling and redness.
• Weakens the production of prostaglandins enabling the temperature to reduce
towards normal
• Side effects: Gastrointestinal (heartburn or indigestion)
• Examples: aspirin and ibuprofen

b. Opioids

• Major class of analgesics

• Narcotic Analgesic
• Moderate to severe pain
• Produce analgesia by attaching opioid receptors in the brain
• Opioid Agonists
o Bind tightly to mu receptor sites, producing maximum pain inhibition
o Side effects: constipation, sedation, nausea, dizziness, pruritus, and
sedation.
o Examples: codeine, OxyContin, Darvon, Dilaudid, Demerol and Percocet
• Opioid Antagonists
 o Block the mu receptors or are neutral at that receptor but bind at a kappa
receptor site
o Side effects: hepatic damage, joint pain, insomnia, vomiting, anxiety,
headaches and nervousness
o Examples: naloxone and naltrexone
• Opioids with Mixed Agonist - Antagonist effects
o They block the mu receptor site and activate a kappa receptor site.
o Side effects: nausea, drowsiness, dizziness, diaphoresis and clammy skin.
o Examples: Talwin and Stadol

7. NURSING PROCESS AND PAIN

A. Assessment

Accurate pain assessment is essential for effective pain management. Many health
facilities make pain assessment the fifth vital sign. This strategy of linking pain assessment
to routine vital sign assessment and documentation represents a push to make pain
assessment a routine aspect of care for all clients. Pain experience is individually unique, the
nurse who wants to help the patient achieve comfort and pain control need sophisticated pain
assessment skills. Assessing all factors that affect the pain experience such as physiological,
psychological, behavioral, emotional, and sociocultural is essential to provide optimal pain
control. Pain is complex and difficult to interpret and requires a reliable assessment tool.

Pain Assessment

In pain assessment, the nurse should provide an opportunity for clients to express
in their own words how they view the pain and the situation. This will help the nurse
understand what the pain means to the client and how the client is coping with it.

Components of Pain Assessment

■ Location: Where is your discomfort?

■ Quality: Tell me what your discomfort feels like.

■ Intensity: On a scale of 0 to 10, with “0” representing no pain (substitute the term client
uses, e.g., “no burning”) and “10” representing the worst possible pain (e.g., “burning
sensation”), how would you rate the degree of discomfort you are having right now?

■ Pattern

a. Time of onset: When did or does the pain start?

b. Duration: How long have you had it, or how long does it usually last?

c. Constancy: Do you have pain-free periods? When? And for how long?

■ Precipitating factors: What triggers the pain or makes it worse?

■ Alleviating factors: What measures or methods have you found helpful in lessening or
relieving the pain? What pain medications do you use?

■ Associated symptoms: Do you have any other symptoms (e.g., nausea, dizziness,
blurred vision, shortness of breath) before, during, or after your pain?

■ Effects on ADLs: How does the pain affect your daily life (e.g., eating, working, sleeping,
and social and recreational activities)?

■ Past pain experiences: Tell me about past pain experiences you have had and what
was done to relieve the pain.

■ Meaning of pain: What does this pain mean to you? Does it signal something about the
future or past? What worries or scares you the most about your pain?

■ Coping resources: What do you usually do to help you deal with pain?

■ Affective response: How does the pain make you feel? Anxious? Depressed?
Frightened? Tired? Burdensome?
B. Diagnosis

Pain is a complex phenomenon that its analysis often requires multi-disciplinary

collaboration. When writing a diagnostic statement, the nurse should specify the location.
The diagnostic statement and the plan of care should identify the following:

■ Type of pain

■ Etiologic factors

■ Patient’s behavioral, physiologic, and affective responses

■ Other factors affecting pain stimulus, transmission, perception, and response

C. Planning

Developing a plan of care that demonstrate the nurses’ commitment to assist the patient
to develop effective pain management strategy. The established goals for the client will vary
according to the diagnosis and its defining characteristics. Specific nursing interventions can be
selected to meet the individual needs of the client.

D. Implementing

Pain management is the alleviation of pain or a reduction in pain to a level of comfort that
is acceptable to the client. Nursing management of pain consists of both independent and
collaborative nursing actions. In general, noninvasive measures may be performed as an
independent nursing function, whereas administration of analgesic medication generally requires
medical order from a primary care provider. However, because many analgesics are ordered to
be administered on a prn basis, the decision to administer the prescribed medication frequently
requires the nurse to make a judgment regarding the dose amount and time of administration.
Recent changes to the way prn range orders are written provide more structure than in the past.
However, professional nursing judgment remains a key factor in relieving pain by determining
which medication in what dosage would best meet the client’s comfort needs.
E. Evaluation

The goals established in the planning phase are evaluated according to specific desired
outcomes. To determine the effectiveness of pain relief strategies; time, onset of pain, activity
before pain, pain relief measure, and duration of pain are obtained during this process. Evaluation
is directed toward the changing nature of the pain experience, the treatment modalities, and the
patient’s and family’s response to the plan of care.

NURSING CARE PLAN

Altered Comfort: Pain

ASSESSMENT

Subjective Data

Pt stated the she is “So sore in the mornings” that she doesn’t want to do anything.

Pt also said that sometimes the pain creeps up on her and she doesn’t recognize it until she’s
curled up in bed.

Pain on waking 3 (0-5)

Objective Data

20 yoF

B/P 118/63
HR 85

RR 20

Ox3

2 days post op- JPDrain placement

Lungs clear bil, ant/post

Hypoactive BS x4

Pt guarding and grimacing,

Holding Mom’s hand to sit up.

DX:

Peritonitis

Ruptured appdx.

DIAGNOSIS

Alteration in Comfort/ Pain r/t Disease process, surgical incision, and tissue damage

PLANNING

Client Goals/Outcome Criteria

Short-term Goal:

1. Patient’s rating on pain scale within 1 hr of intervention.

2. Diminished or Absent nonverbal indicators (grimace, abd guarding) within 1hr of intervention.
Long-term Goal:

1. Client will verbalize 2 non-medication ways of pain relief by discharge.

2. Client will ask for medications when she first notices pain increasing, or when she knows she
has activity scheduled by discharge.

IMPLEMENTATION

Nursing Actions

1. Will perform baseline assessment with appropriate pain scale.

Rationale: Will help determine the effectiveness of interventions.

2. Reassess client q1-2h.

Rationale: Will prevent client from suffering from pain for prolonged amt of time.

3. Instruct Pt in methods to splint.

Rationale: Splinting reduces pain on movement, coughing, and deep breathing.

4. Explain all procedures

Rationale: Information helps minimize anxiety, which can exacerbate discomfort.

5. Provide Pt with games, books, movies, and phone.

Rationale: Activities provide distractions from pain.

6. Show Pt various positions she may use to reduce pain and discomfort.

Rationale: Minimize pressure on bones, joints, muscles and skin.

EVALUATION

Observations/Conclusions

• Patient started off day sleeping in till 10am and not wanting to get OOB. Pain 3 (0-5). 30
mins after receiving Ibuprofen 600mg pt was much more cooperative and relaxed.
• Reported Pain of 1 (0-5).
• We talked about the importance of positioning, splinting, keeping busy, and also the
medication options she had available.
• Pt verbalized 2 non-medication relief measures to me.
• She took a nap after lunch and reported her pain increasing to a 2(0-5).
• Discussed asking for medication when she needs it or before she knows she has an
activity coming up or will be sleeping for any length of time.
• Also talked about indicators that her pain meds were wearing off, or her pain level was
beginning to increase.
• Her Pain level decreased to a 0(0-5) after receiving 325mg of Acetaminophen.
• Short-term Goal: met and continuing.
• Long-term Goal: Partially met and continuing.
• Needs revision concerning bathing care of JPDrain related to comfort.

CARE OF DYING CLIENT

I. GRIEF

- It is the total response to the emotional experience related to loss.

- It is manifested in variety of ways that are unique to an individual and based on personal
experiences, cultural expectations, and spiritual beliefs (Farber et.al., 1999)

- Bereavement: includes grief and mourning – the inner feelings and outward reactions of
the survivor (ELNEC, 2000); it is the subjective response experienced by the surviving
loved ones after the death of a person with whom they have shared a significant
relationship.

- Mourning: behavioral process through which grief is eventually resolved or altered.

Loss and Grief

Loss: the actual or potential situation in which something that is valued is changed, no
longer available or gone; can be viewed as situational or developmental.
 Types:

Actual loss – can be recognized by others.

Perceived loss – experienced by one person by cannot be verified by others.
Anticipatory loss – experienced before the loss actually occurs.
Death: inevitable; fundamental loss, both for the dying person and for those who survive.

Sources of loss:

Aspect of self: changes the person’s body image even though the loss may not be obvious,

Loss of an external object: loss of inanimate object that have importance to the person
and the loss of animate (live) objects.

Separation from an accustomed environment: separation from the (familiar) environment

and people who provide security.

Loss of loved or valued person: a permanent and complete loss.

*Factors influencing the loss and grief response: age, significance of the loss, culture, spiritual
beliefs, gender, socioeconomic status support systems, and cause of the loss or death.

*Manifestation of grief that would be considered normal: verbalization of the loss, crying, sleep
disturbance, loss of appetite and difficulty concentrating.

*Some symptoms that accompany grief: anxiety, depression, weight loss, fatigue, dyspnea,
palpitations, mental disturbances, difficulty in swallowing, blurred vision, vomiting, fainting and
dizziness.

Types of Grief:

Abbreviated grief - brief but genuinely felt.

Anticipatory grief - is experienced in advance of the event.

Disenfranchised grief - occurs when a person is unable to acknowledge the loss of a

person; characterized by extended time of denial, depression, severe physiologic
symptoms or suicidal thoughts
Pathogenic or Dysfunctional grief - unhealthy grief which may be unresolved or inhibited.
Unresolved grief -is extended in length and severity.

Inhibited grief - many of the normal symptoms of grief are suppressed and other effects,
including somatic or experienced.

II. STAGES OF GRIEF

Engel's theory

(1954); Engel's Stages of Grieving theory describes these steps in this proper sequential
order: Shock and disbelief; developing awareness, restitution, resolving the loss,
idealization and outcome
 b. Kubbler-Ross’s Stages of Grief

The framework for Kubbler-Ross's theory (1969) is behavior oriented and includes 5 stages:

Denial - individual acts as though nothing has happened and may refuse to believe or
understand that a loss has occurred.

Anger - the individual resists the loss and may strike out at everyone and everything.
Bargaining- the individual postpones awareness of the reality of the loss and may deal in
a subtle or overt way as through the loss can be prevented.

Depression - the person finally realizes the impact and significance of the loss the
individual may feel overwhelming lonely and withdrawal from interpersonal interaction.

Acceptance - the individual accepts the loss and begins to look to the future.
III. GRIEF PROCESS

grief and the grieving process are characterized with suffering, despair, sleep impairments,
pain, distress, anger, detachment, guilt, and even personal growth.

Bowlby describes Four Phases of Mourning:

Bowlby’s attachment theory (1980) is the foundation for his theory in mourning.

Attachment is described as an instinctive behavior that the leads in the development of

affectional bonds between children and their primary caregiver

Numbing: may last from a few hours to a week or more and maybe interrupted by period
of extremely intense emotion; it is the briefest phase of mourning.
Yearning and searching: arouses emotional outbursts of tearful sobbing and acute
distress in most person.

Disorganization and despair: and individual may endlessly examine how and why the loss
occurred.

Reorganization: may require as much as a year or more, the person beings to accept
unaccustomed roles, acquire new skills, and build new relationships.
Worden’s Four Tasks of Mourning (1982)

implies that persons who mourn can be actively involved by helping themselves and be
assisted by outside intervention.

Phase I: experiencing numbness and denying the loss.

Phase II: emotionally yearning for the loss loved one and protesting the permanence of
death.

Phase III: experiencing cognitive disorientation and emotional despair with difficulty
functioning in the everyday world.

Phase IV: Reorganizing and reintegrating the sense to pull life back together.

The Grief Process

Kobler-Ross's Five Bowlby's Four Phases of Worden's Four Tasks of

Stages of Dying Mourning Mourning
- Denial Numbing Accepting the
- Anger reality of a loss
- Bargaining
- Depression
- Acceptance Yearning and Working through
searching the pain of a grief

Disorganization and Adjusting to the

despair environment
without the
deceased
Reorganization

Emotionally
relocating the
deceased and
moving on life.

POSTMORTEM CARE
 When a client dies in a hospital setting, the nurse is the one who provides postmortem
care. It is important for the nurse to care for the client’s body with dignity and sensitivity and in
a manner consistent with the client’s religious or cultural beliefs. After death the body
undergoes many physical changes. For that reason, care must be provided as soon as possible
to prevent tissue damage or disfigurement of body parts.
Care of the body after death (postmortem care) is an essential component of the total care of
the patient and surviving family members and friends.
Physical care of the body is based on certain changes that take place at a fairly predictable
rate, depending on body temperature at the time of death, and environmental temperature once
death has taken place. The size of the body and the presence or absence of bacterial infection
also influence these changes:
1. Rigor Mortis
The stiffening of the body that occurs about 2 to 4 hours after death.

It results from a lack of adenosine triphosphate (ATP), which causes the muscles to
contract, which in turn immobilizes the joints.

It starts in the involuntary muscles (heart, bladder, and so on), then progresses to the
heart, neck, and trunk, and finally reaches the extremities.

Because the deceased person’s family often wants to view the body, and because it is
important that the deceased appear natural and comfortable, nurses need to position
the body, place dentures in the mouth, and close the eyes and mouth before rigor mortis
sets in.

Rigor mortis usually leaves the body about 96 hours after death.

2. Algor Mortis
The gradual decrease of the body’s temperature after death.

When blood circulation terminates and the hypothalamus ceases to function, body
temperature falls about 1˚C (1.8˚F) per hour until it reaches room temperature.

Simultaneously, the skin loses its elasticity and can easily be broken when removing
dressings and adhesive tape.

3. Livor Mortis
After blood circulation has ceased, the red blood cells break down, releasing hemoglobin,
which discolors the surrounding tissues.

This discoloration appears in the lowermost or dependent areas of the body.

 Tissues after death become soft and eventually liquefied by bacterial fermentation. The hotter
the temperature, the more rapid the change. Therefore, bodies are often stored in cool places to
delay this process. Embalming prevents the process through injection of chemicals into the body
to destroy the bacteria.
Nursing personnel may be responsible for care of a body after death. Postmortem care should
be carried out according to the policy of the hospital or agency. Because care of the body may be
influenced by religious law, the nurse should check the client’s religion and make every attempt
to comply.

If the deceased’s family or friends wish to view the body, it is important to make the
environment as clean and comfortable.

All equipment, soiled linen, and supplies should be removed from the
bedside.

Some agencies require that all tubes in the body remain in place; in other
agencies, tubes may be cut to within 2.5 cm (1 in.) of the skin and taped in
place; in others, all tubes may be removed.

Positioning
Normally the body is placed in a supine position.

Arms either at the sides, palms down, or across the abdomen.

One pillow is placed under the head and shoulders to prevent blood from
discoloring the face by settling in it.

The eyelids are closed and held in place for a few seconds so they remain
closed.

Dentures are usually inserted to help give the face a natural appearance.

The mouth is then closed.

Make them look good.

 Soiled areas of the body are washed; however, a complete bath is not
necessary, because the body will be washed by the mortician (also referred
to as an undertaker), a person trained in care of dead.

Absorbent pads are places under the buttocks to take up any feces and
urine released because of relaxation of the sphincter muscles.

A clean gown is placed on the client, and the hair is brushed and combed.

All jewelry is removed, except a wedding band in some instances, which is

taped to the finger.

The top bed linen are adjusted neatly to cover the client to the shoulders.

Soft lighting and chairs are provided for the family.

When the family is done it is time for your patient to leave.

In the hospital, after the body has been viewed by the family, the
deceased’s wrist identification tag is left on and additional identification tags
are applied.

The body is wrapped in a shroud, a large piece of or cotton material used

to enclose a body after death.

Identification is applied to the outside of the shroud.

The body is taken to the morgue if arrangements have not been made to
have a mortician pick it up from the client’s room.

Nurses have a duty to handle the deceased with dignity and label the corpse appropriately.
Mishandling can cause emotional distress to survivors. Mislabeling can create legal problems if
the body is inappropriately identified and prepared incorrectly for burial or a funeral
NURSING PROCESS AND GRIEF

Nursing assessment of the client

experiencing a loss includes:
(a) Nursing History
(b) Assessment of Personal
Coping Resources
(c) Physical Assessment
Assessing

During the routine health assessment of

every client, the nurse poses questions
regarding previous and current losses.
The nature of the loss and the significance
 of such losses to the client must be
explored.

If the client reports significant losses, it

is important to examine how the client
usually copes with loss and what
resources are available to assist the clients
in coping.

In assessing the client’s response to a

current loss, the nurse may identify
complicated grief best treated by a health
care professional who is expert in assisting
such clients.
Nursing diagnoses (NANDA International
2007) relating specifically to grieving
include the following:
Grieving: A normal complex
process by which individuals,
families, and communities
incorporate an actual, anticipated,
or perceived loss into their daily
lives.

Complicated Grieving: A disorder

that occurs after the death of a
significant other, in which the
experience of distress
accompanying bereavement fails
to follow normative expectations
and manifests in functional
Diagnosing
impairment.

Interrupted Family Processes: If

the loss has such impact on the
individual and family that usual
effective roles and interactions are
negatively affected.

Risk-prone Health Behavior: If

the client has great difficulty
placing the loss in appropriate
perspective to his or her other life
activities.

Risk for Loneliness: Related to

the loss of relationship with others.
 Goals for clients who are grieving the
loss of body function or body part:
(a) To adjust to the changed
ability
(b) To redirect both physical and
emotional energy into
rehabilitation

Goals for clients who are grieving the

loss of a loved one or thing:
(a) To remember them without
Planning feeling intense pain
(b) To redirect emotional energy into
one’s own life
(c) To adjust to the actual or
impending loss.
Planning for Home Care: Clients who
have sustained or anticipate a loss may
require ongoing nursing care to assist
them in adapting to the loss. In preparation
for home care, the nurse reassesses the
client’s abilities and needs.

The skills most relevant to situations of

loss and grief are:
Attentive listening

Silence

Open and closed questioning

Paraphrasing

Clarifying and reflecting feelings

Implementing Summarizing

Less helpful to clients are:

Responses that give advice and
evaluation

Interpretation and analyzation

Unwanted assurance
 Communication with grieving clients needs
to be relevant to their stage of grief. In
addition to using effective communicating
skills, the nurse implements a plan to
provide client and family teaching and to
help the client work through the stages of
grief.

Facilitating Grief Work

Explore the client’s ethnic, cultural,
religious, and personal values in
the expression of grieving.

Teach the client or family what to

expect in the grief process.

Encourage the client to express

and share grief with support
people.

Teach family members to

encourage the client’s expression
of grief.

Encourage the client to resume

normal activities on a schedule that
promotes physical and psychologic
health.

Providing Emotional Support

Use silence and personal presence

along with techniques of
therapeutic communication.

Acknowledge the grief of client’s

family and significant others.

Offer choices that promote client

autonomy.

Provide appropriate information

regarding how to access
community resources.
Evaluating the effectiveness of nursing
Evaluating care of the grieving client is difficult
because of the long-term nature of the life
 transition. Criteria for evaluation must be
based on goals set by the client and family.

If outcomes are not achieved, the nurse

needs to explore why the plan was
unsuccessful.

Anticipatory Grieving
The process of disengaging or “letting go” that occurs before an actual loss or death has
occurred.

For example, once a family receives a terminal diagnosis, they begin to process of saying
good-bye and completing life affairs.

Purposes:
For those who are dying, anticipatory grief provides an opportunity for
personal growth at the end of life, a way to find meaning and closure.

For families, this period is also an opportunity to find closure, to reconcile

differences, and to give and grant forgiveness.

For both, it is a chance to say goodbye.

The process becomes more stressful when the client is unable to make decisions due to
deterioration in health. Unless guided by a client’s explicit decisions regarding end-of-life
care, the family assumes the responsibility of deciding whether to continue life-sustaining
measures.

By the time the actual moment of death arrives, much of the shock, denial, and tearfulness
have already been experienced.

There are risks in anticipatory grieving:

Family members may withdraw emotional from the client too soon, leaving
the client with no emotional support as death approaches.

There may also be complications if a person who was thought to be near death
survives:

Family members may then have difficulty reconnecting and may even
resentful that the person has lived past life expectancy.
Dysfunctional Grieving
Outside the normal response range and may be manifested as exaggerated grief, prolong
grief, or absence of grief.

May be stuck in one stage of grief.

Grief is extended, unsuccessful use of intellectual and emotional

responses by which individuals attempt to work through the process of
modification.

Occurs when an individual gets stuck in the grief process and becomes depressed and is
unable to express feelings.

Cannot find anyone in daily life who acts as the listener he or she needs.

Lacks the reassurance and support to trust the grief process and fails to believe that he
or she can work through the loss.

Signs, Symptoms, and Behaviors:

Acquisition of symptoms belonging to the last illness of the deceased.

Alteration in relationships with friends and relatives.

Lasting loss of patterns of social interaction.

Actions detrimental to one’s social and economic well-being.

Agitated depression with tension, insomnia, feelings of worthlessness,

bitter self-accusation obvious needs for punishment and even suicidal
tendencies.

A feeling that the death occurred yesterday, even though the loss took
place a month ago.

Unwillingness to move the possessions of the deceased after a reasonable

time.

Inability to discuss about the deceased without breaking down, particularly

after a year after the loss.

Radical changes in lifestyle.

Exclusion of friends, family members or activities associated with the

deceased.

VI. Recording, Reporting and Documentation

 A record, also called a chart or client record, is a formal, legal document that provides
evidence of a client’s care and can be written or computer based. Although health care
organizations use different systems and forms for documentation, all client records have similar
information. The process of making an entry on a client record is called recording, charting, or
documenting.
Client records are kept for a number of purposes including communication, planning
client care, auditing health agencies, research, education, reimbursement, legal documentation,
and health care analysis.
A number of documentation systems are in current use: the source-oriented record; the
problem-oriented medical record; the problems, interventions, evaluation (PIE) model; focus
charting; charting by exception (CBE); computerized documentation; and case management.
A. Subjective Information, Objective information, Assessment, Plan, Implement and
Evaluate (SOAPIE)
S—Subjective data consist of information obtained from what the client says. It describes the
client’s perceptions of and experience with the problem. Subjective data are included only
when it is important and relevant to the problem.
O—Objective data consist of information that is measured or observed by use of the senses
(e.g., vital signs, laboratory and x-ray results).
A—Assessment is the interpretation or conclusions drawn about the subjective and objective
data. During the initial assessment, the problem list is created from the database, so the “A”
entry should be a statement of the problem. In all subsequent SOAP notes for that problem,
the “A” should describe the client’s condition and level of progress rather than merely
restating the diagnosis or problem.
P—The plan is the plan of care designed to resolve the stated problem. The initial plan is
written by the person who enters the problem into the record. All subsequent plans, including
revisions, are entered into the progress notes.
I—Interventions refer to the specific interventions that have actually been performed by the
caregiver.
E—Evaluation includes client responses to nursing interventions and medical treatments.
This is primarily reassessment data.
B. Focus – Data, Action, Revision (DAR)
Focus Charting Focus charting is intended to make the client and client concerns and strengths
the focus of care. Three columns for recording are usually used: date and time, focus, and
progress notes. The focus may be a condition, a nursing diagnosis, behaviour, a sign or
symptom, an acute change in the client’s condition, or a client’s strength. The progress notes
are organized into (D) data, (A) action, and (R) response, referred to as DAR.

C. Electronic Health Record (EHR)

Electronic health records (EHRs) are used to manage the huge volume of information
required in contemporary health care. That is, the EHR can integrate all pertinent client
information into one record. Nurses use computers to store the client’s database, add new data,
create and revise care plans, and document client progress. Some institutions have a computer
terminal at each client’s bedside, or nurses carry a small handheld terminal, enabling the nurse
to document care immediately after it is given.
D. Problem Oriented Medical Record
The Problem Oriented Medical Record (POMR) is a method of documentation that
emphasizes the client’s problems.
Health care team members monitor and record the progress of a client’s problem. Progress
notes come in various formats or structured notes such as:
SOAP

The acronym SOAP stands for S – subjective data, O – objective data, A – assessment, P –
plan. An I and E are sometimes added in some institutions (SOAPIE), I for intervention and
E for evaluation.
The logic for SOAPIE notes is similar to that of the nursing process. The nurse numbers
each SOAP note and titles it according to the problem on the list.
PIE

It is similar to SOAP charting in its problem-oriented nature. However, it differs from the
SOAP method in that PIE charting has a nursing origin, whereas SOAP originated from
medical records. PIE differs from SOAP notes because the narrative does not include
assessment information. The narrative notes includes P – problem, I – intervention, E –
evaluation, and are numbered or labelled according to the client’s problem.
F – DAR

Focus charting includes the use of DAR notes, which include D – Data, A – Action or
nursing intervention, R – response of the client. DAR notes address client concerns: a sign
or symptom, a condition, a nursing diagnosis, behaviour, a significant event, or a change in
a client’s concerns, not just problem areas.

GUIDELINES/ PROTOCOLS/ TOOLS IN REPORTING RELATED TO CLIENT CARE

Reporting
As nurses, we need to communicate with other members of the health team regarding
informations about our client.

Nurses communicate these informations so that all members of the health team can be
informed so that everyone would be able to make appropriate decisions about a specific
case.

Nurses make mainly 4 types of report;

A. Change-of-shift reports
B. Incident reports
 C. Transfer reports
D. Telephone reports
E.
A report should as much as possible be concise, including pertinent information but no
extraneous detail, whether it is oral or written.

Change-of-shift Reports
The handoff communication or change-of-shift report is given to all nurses on the next shift.

This report is implemented for the nurses and other health team to have a effective
communication on the care that the patient rendered and will recieve.

Change-of-shift reports may be written or orally, either in a face-to-face exchange or by

audiotape recording.

Its purposes are to provide continuity of care for clients by providing critical information
and to promote client safety and best practices.

The nurse must focus on the needs of the client and not become distracted by irrelevant
information.

Reports are sometimes given at the bedside, and clients as well as nurses may participate
in the exchange of information.

A variety of handoff communication tools have been develpped to facilitate consistency in

communication. Examples include, but are not limited to, the “I PASS the BATON,” “I-
SBAR,” “PACE,” or the “Five-P’s.”

Incident Reports
An incident is any event that is not consistent with the routine operation of a health care
unit or routine care of a client.

Analysis of imcident reports helps provide identification of trends in system and unit
operations that provide justifications for changes in policies procedures or for in-service
seminars.

Transfer Reports
These are reports given whenever patients has been transferred to other health care unit.
 To promote continuity of care, these can be given by phone or in person.

These are some informations that one includes when giving a transfer report;

1. Client's name, age, primary physician or health care provider, and medical diagnosis
2. Summary of progress up to the time of transfer
3. Current health status
4. Allergies
5. Emergency code status
6. Family support
7. Current nursing diagnoses, problem and care plan
8. Critical assesments or interventions to be completed shortly after transfer
9 Need for any special equipment, sucrh as isolation equipment, suction
equipment, or traction.

The nurse needs an opportunity to ask questions about the client's status after completion
of the transfer report.

Written documents must include a record of information reported.

Telephone Reports
A report that is frequently used by health professionals to relay informations about a client
through telephone.

A nurse recieving a telephone report should document the date, time, name if person who
gave infos and the subject of the information recieved, and the sign the notations.

To ensure accuracy, a nurse or a reciever should need to repeat it back to the sender

When giving this kind of report to a primary care provider, it is important that the nurse
must be concise and accurate.

SBAR communication is often used for telephone reports.

Usually include the client's name and medical diagnosis, changes in nursing assessment,
vital signs related to baseline vital signs, significant laboratory data and related nursing
interventions.

I-SBAR Communication Tool

A communication tool for reporting

Identify, Situation, Background, Assessment, Recommendations

Is a mnemonic created to improve safety in the transfer of critical information

 Originates from SBAR, the most frequently used mnekonic in health and other high risk
environment.

Health practictioners are using ISBAR as a tool to aide the safe transfer of patient
information in clinical handover.

I = Identify
To ensure that accurate identification of those participating in handover and of the patient
established.

S = Situation
States your name, unit, client's name

Briefly states the problem

B = Background
State the client admission diagnosis and date of admission.

State pertinent medical history

Provide brief summary of treatment to date

Code status

A = Assessment
Vital signs

Pain scales

Is there a change from prior assessment?

R = Recommendation
State what you would like to see done or specify that the care provider needs to come and
assess the client.

Ask if health care provider wants to order any test or medications.

Ask health care provider wants to order any test or medications

Ask health care provider if she wants to be notified for any reason.

Ask, if no improvement, when you should call again.

ETHICO-MORAL AND LEGAL CONSIDERATIONS IN THE PRACTICE OF NURSING

Ethico-Moral and Legal Considerations in the Practice of Nursing

Patient Bill of Rights: Magna Carta of Patients Rights

Most recently introduced by Senator Pia Cayetano. Section 15 Article II of the

Constitution provides that "(t)he State shall protect and promote the right to health of the people
and instill health consciousness." In addition, Section 11 of Article 12 states that "(t)he State
shall adopt an integrated and comprehensive approach to health and development which shall
endeavor to make essential goods, health and other social services available to the people at
affordable costs.
To give substance and spirit to the above constitutional precepts, the bill seeks to
provide a "Magna Carta of Patients Rights and Obligations". Under this proposal, the duties and
responsibilities of the government vis-a-vis the people's concomitant rights and obligations are
stressed in order to give them decent, humane and quality health care.
The proposed measure provides for individual and societal rights, as well as the bill also
proposes a grievance mechanism wherein any complaint arising premises considered,
immediate passage of this bill is earnestly sought obligations of patients, health care
practitioners and health care institutions from violations of any of the rights of patients shall first
be submitted for mediation.
AN ACT
PROCLAIMING THE RIGHTS AND OBLIGATIONS OF PATIENTS, PROVIDING A
GRIEVANCE MECHANISM THEREOF AND FOR OTHER PURPOSES
Be enacted by the Senate and House of Representatives of the Philippines in Congress
assembled:

SECTION 1. Short Title. - This Act shall be known as the "Magna Carta of
Patient's Rights and Obligations of 2008."

SEC. 2. Declaration of Policy. - It is hereby declared the policy of the State

to promote the right to health of the people and instill health consciousness among
them. It shall likewise protect and enhance the right of all people to human dignity
thereby establishing the Magna Carta of Patient's Rights and Obligations in order to
ensure a decent, humane and quality Health Care for.all patients and Health Care
Providers.

SEC. 3. Definition of Terms.

 Sec. 4. Individual Rights of Patients. - The following individual rights of Patients shall be
respected by all those involved in the delivery of Health Care services:

1. Right to Appropriate Medical Care and Humane Treatment. - Every person has a right to
health and medical care corresponding to his state of health, without any discrimination and
within the limits of the resources, manpowerand competence available for health and medical
care at the relevant time. The patient has the right to appropriate health and medical care of
good quality. In the course of such, his human dignity, convictions, integrity, individual needs
and culture shall be respected. If any person cannot immediately be given treatment that is
medically necessary he shall, depending on his state of health, either be directed to wait for
care, or be reffered or sent for treatment elsewhere, where the appropriate care can be
provided. If the patient has to wait for care, he shall be informed of the reason for the delay.
Patients in emergency shall be extended immediate medical care and treatment without any
deposit, pledge, mortgage or any form of advance paymentfor treatment.

2. Right to Informed Consent. - The patient has a right to a clear, truthful and substantial
explanation, in a manner and language understandable to the patient, of all proposed
procedures, whether diagnostic, preventive, curative, rehabilitative or therapeutic, wherein the
person who will perform the said procedure shall provide his name and credentials to the
patient, possibilities of any risk of mortality or serious side effects, problems related to
recuperation, and probability of success and reasonable risks involved: Provided, That the
patient will not be subjected to any procedure without his written informed consent, except in the
following cases:

a) in emergency cases, when the patient is at imminent risk of physical injury, decline Of death
if treatment is withheld or postponed. In such cases, the physician can perform any diagnostic
or treatment procedure as good practice of medicine dictates without such consent;
b) when the health of the population is dependent on the adoption of a mass health program to
control epidemic;
c) when the law makes it compulsory for everyone to submit a procedure;
d) When the patient is either a minor, or legally incompetent, in which case. a third party
consent Is required;
e) when disclosure of material information to patient will jeopardize the success of
treatment, in which case, third party disclosure and consent shall be in order;
f) When the patient waives his right in writing.

Informed consent shall be obtained from a patient concerned if he is of legal age and of sound
mind. In case the patient is incapable of giving consent and a third party consent is required.
the following persons, in the order of priority stated hereunder, may give consent:
i. spouse;
ii. son or daughter of legal age;
iii. either parent;
iv. brother or sister of legal age, or
v. guardian

If a patient is a minor, consent shall be ottained from his parents or legal guardian. If next of
kin, parents or legal guardians refuse to give consent to a medical or surgical proceoure
necessary to save the life or limb of a minor or a patient incapable of giving consent, courts,
upon the petition of the physician or any person interested in the welfare of the patient, in a
summary proceeding, may issue an order giving consent.

3. Right to Privacy and Confidentiality. - The privacy of the patients must be assured at all
stages of his treatment. The patient has the right to be free from unwarranted public exposure,
except in the foHowing cases: a) when his mental or physical condition is in controversy and the
appropriate court, in its discretion, order him to submit to a physical or mental examination by a
physician; b) when the public health and safety so demand; and c) when the patient waives this
right in writing.

The patient has the right to demand that all information, communication and records pertaining
to his care be treated as confidential. Any health care provider or practitioner involved in the
treatment of a patient and all those who have legitimate access to the patient's record is not
authorized to divulge any information to a third party who has no concern with the care and
welfare of the patient without his consent, except: a) when such disclosure will benefit public
health and safety; b) when it is in the interest of justice and upon the order of a competent court;
and c) when the patients waives in writing the confidential nature of such information; d) when it
is needed for continued medical treatment or advancement of medical science subject to de-
identification of patient and shared medical confidentiality for those who have access to the
information.

Informing the spouse or the family to the first degree of the patient's medical condition may be
allowed; Provided That the patient of legal age shall have the right to choose on whom to
inform. In case the patient is not of legal age or is mentally incapacitated, such information shall
be given to the parents, legal guardian or his next of kin.

4. Right to Information. - In the course of his/her treatment and hospital care, the patient or
his/her legal guardian has a right to be informed of the result of the evaluation of the nature and
extent of his/her disease, any other additional or further contemplated medical treatment on
surgical procedure or procedures, including any other additional medicines to be administered
and their generic counterpart including the possible complications and other pertinent facts,
statistics or studies, regarding his/her illness, any change in the plan of care before the change
is made, the person's participation in the plan of care and necessary changes before its
implementation, the extent to which payment maybe expected from Philhealth or any payor and
any charges for which the patient maybe liable, the disciplines of health care practitioners who
will fumish the care and the frequency of services that are proposed to be furnished.

The patient or his legal guardian has the right to examine and be given an itemized bill of the
hospital and medical services rendered in the facility or by his/her physician and other health
care providers, regardless of the manner and source of payment.He is entitled to a thorough
explanation of such bill.

The patient or hislher legal guardian has the right to be informed by the physician or his/her
delegate of hisJher continuing health care requirements following discharge, including
instructions about home medications, diet, physical activity and all other pertinent information to
promote health and well-being.

At the end of his/her confinement, the patient is entitled to a brief, written summary of the
course of his/her illness which shall include at least the history, physical examination,
diagnosis, medications, surgical procedure, ancillary and laboratory procedures, and the plan of
further treatment, and which shall be provided by the attending physician. He/she is likewise
entitled to the explanation of, and to view, the contents of medical record of his/her confinement
but with the presence of his/her attending physician or in the absence of the attending
physician, the hospital's representative. Notwithstanding that he/she may not be able to settle
his accounts by reason of financial incapacity, he/she is entitled to reproduction, at his/her
expense, the pertinent part or parts of the medical record the purpose or purposes of which he
shall indicate in his/her written request for reproduction. The patient shall likewise be entitled to
medical certifICate, free of charge, with respect to his/her previous confinement.

5. The Right to Choose Health Care Provider and Facility. - The patient is free to choose the
health care provider to serve him as well as the facility except when he is under the care of a
service facility or when public health and safety so demands or when the patient expressly
waives this right in writing.

The patient has the right to discuss his condition with a consultant specialist, at the patient's
request and expense. He also has the right to seek for a second opinion and subsequent
opinions, if appropriate, from another health care provider/practitioner.

6. Right to Self-Determination. - The patient has the right to avail himself/herself of any
recommended diagnostic and treatment procedures.Any person of legal age and of sound mind
may make an advance written directive for physicians to administer terminal care when he/she
suffers from the terminal phase of a terminal illness: Provided That a) he is informed of the
medical consequences of his choice; b) he releases those involved in his care from any
obligation relative to the consequences of his decision; c) his decision will not prejudice public
health and safety.

7. Right to Religious Belief. - The patient has the right to refuse medical treatment or
procedures which may be contrary to his religious beliefs, subject to the limitations described in
the preceding subsection: Provided, That such a right shall not be imposed by parents upon
their children who have not reached the legal age in a life threatening situation as determined by
the attending physician or the medical director of the facility.

8. Right to Medical Records. - The patient is entitled to a summary of his medical history and
condition.He has the right to view the contents of his medical records, except psychiatric notes
and other incriminatory information obtained about third parties, with the attending physician
explaining contents thereof. At his expense and upon discharge of the patient, he may obtain
from the health care institution a reproduction of the same record whether or not he has fully
settled his financial obligation with the physician or institution concerned.

The health care institution shall safeguard the confidentiality of the medical records and to
likewise ensure the integrity and authenticity of the medical records and shall keep the same
within a reasonable time as may be determined by the Department of Health.

The health care institution shall issue a medical certificate to the patient upon request.Any other
document that the patient may require for insurance claims shall also be made available to him
within forty-fIVe (45) days from request.

9. Right to Leave. - The patient has the right to leave hospital or any other health care
institution regardless of his physical condition: Provided. That a) he/she is informed of the
medical consequences of his/her decisionl b) helshe releases those involved in his/her care
from any obligation relative to the consequences of his decision; c) hislher decision will not
prejudice public health and safety.

No patient shaD be detained against hi$/her will in any health care institution on the sole basis
of his failure to fully settle his financial obligations. However, he/she shall only be allowed to
leave the hospital provided appropriate arrangements have been made to settle the unpaid
bills: Provided. further, That unpaid bills of patients shall be considered as loss income by the
hospital and health care provider/practitioner and shall be deducted from gross income as
income loss only on that particular year.
10. Right to Refuse Participation In Medical Research. - The patient has the right to be advised
if the health care provider plans to involve him in medical research, including but not limited to
human experimentation which may be performed only with the written informed consent of the
patient: Provided, That, an institutional review board or ethical review board in accordance with
the guidelines set in the Declaration of Helsinki be established for research involving human
experimentation: Provided, further, That the Department of Health shall safeguard the
continuing training and education of fUture health care provider/practitioner to ensure the
development of the health care delivery in the country: Provided, fUfthermore, That the patient
involved in the human experimentation shall be made aware of the provisions of the
Declaration of Helsinki and its respective guidelines.

11. RIght to Correspondence and to Receive Visitors. - The patient has the right to
communicate with relatives and other persons and to receive visitors subject to reasonable
limits prescribed by the rules and regulations of the health care institution.

12. Right to Express Grievances. - The patient has the right to express complaints and
grievances about the care and services received without fear of discrimination or reprisal and to
know about the disposition of such complaints.Such a system shall afford all parties concerned
with the opportunity to settle amicably all grievances.

13. RIght to be Informed of His Rights and Obligations as a Patient. - Every person has the right
to be informed of his rights and obligations as a patient.The Department of Health,in
coordination with heath care providers, professional and civic groups, the media, health
insurance corporations, people's organizations,local government organizations, shall launch
and sustain a nationwide information and education campaign to make known to people their
rights as patients, as declared in this Act Such rights and obligations of patients shall be posted
in a bulletin board conspicuously placed in a health care institution.

It shall be the duty of health care institutions to inform of their rights as well as of the institution's
rules and regulations that apply to the conduct of the patient while in the care of such institution.

Informed Consent

Autonomy
Comes from the Greek word autos meaning self and namos meaning governance. It
involves self -determination and freedom to choose and implement one’s decision, free from
deceit, duress, constraint or coercion (informed consent).
In the domain of health care, respect for a patient’s autonomy includes actions, such as:
Obtaining informed consent for treatment

Facilitating patient choice regarding treatment options

Allowing the patient to refuse treatment

 Disclosure by the provider of personal medical information

Diagnosis

Treatment operations to the involved patient

Maintaining confidentiality

Restrictions in autonomy may occur in cases where there is a potential for harm to others
through communicable diseases or acts of violence. People basically lose their autonomy or
right to self - determination in such instances
The person making the decision must be deemed competent.
He/she must have the intellectual capacity to make a rational decision and he/she must
be of legal age.

The decision should be of his/her own free will and he/she should not be coerced or put
under duress to do so.

Every adult of sound mind must have the right to determine what should be done to
his/her body.

Nature of Consent
Consent is an authorization, by a patient or a person authorized by law to give the consent on
the patient’s behalf, therefore dubbing an action performed on the patient as consensual rather
than the opposite –non –consensual.
There are two types of consent: express and implied. Express consent may take the
form of either an oral or written agreement. Usually, the more invasive a procedure and/or the
greater the potential for risk to the client, the greater the need for written permission. Implied
consent exists when the individual’s nonverbal behavior indicates agreement.
Informed Consent
It is established principle of law that every human being of adult years and sound mind has the
right to determine what shall be done with his own body. He may choose whether to be treated
or not to and to what extent, no matter how necessary the the medical care, or how imminent
the danger to his life or health.
Informed consent has 3 major elements:
1. The consent must be given voluntarily.
2. The consent must be given by a client or individual with the capacity and
competence to understand.
3. The client or individual must be given enough information to be the ultimate
decision maker.
 4. The law says that a “reasonable amount” of information is required for the client to
make an informed decision. The general guidelines for essential elements necessary for
disclosure:

The diagnosis or condition that requires treatment

The purposes of the treatment
What the client can expect to feel or experience
The intended benefits of the treatment
Possible risks or negative outcomes of the treatment
Advantages and disadvantages of possible alternatives to the treatment (including no
treatment)

The consent signed by the patient or his authorized representative/legal guardian upon
admission is for the initial diagnosis and treatment. Any subsequent treatments or operations
require individual, informed consent. It is our job as the nurse to secure consent upon
admission.

Battery –the intentional touching or unlawful beating of another person without

authorization to do so is a legal wrong.

Proof of Consent
Consent is usually secured by the nurse upon admission, this is usually for diagnostic
procedures and initial treatment. To substantiate and avoid tort, consent usually requires a
written authorization. This serves as proof that the patient is adequately informed and consents
to the followig procedure to be performed, along with its respective risks.

Who Must Consent

Normally, consent is given by the patient in his own behalf. However, if he/she is
incompetent or physically unableand is not an emergency case, consent must be taken from
who the client’s autonomy is passed to.
Consent of Minors

Usually the parents decide in their behalf. In the circumstance that the minor is
married ir emancipated, parental consent is not needed.
Consent of Mentally Ill

A mentally incompetent person cannot legally consent to medical or surgical

treatment due to their incapability to process the essential information regarding the
procedure. The autonomy/ authority is passed to their parents or respective legal
guardian.
Emergency Situation

No consent is necessary because inaction may cause greater injury. However, if

time is available and an informed consent is possible, it is best to be taken for the
protection of all parties involved.
 Consent for Sterilization

The husband and the wife must consent to the procedure if the operation is
primarily to accomplish sterilization. When the sterilization is medically necessary and
the sterilization is an incidental result, the patient’s consent alone is sufficient.
Proxy Consent/Legally Acceptable Representative

A substitute for informed consent and is sought when acquiring informed consent
is impossible. It is the process by which people with the legal right to consent to medical
treatment for themselves or for a minor or a ward delegate that right to another person.

For the ethical and legal use of proxy consent, two conditions must be present:
1. The patient or client cannot offer informed consent
2. The person offering the consent ought to determine what the incompetent
person would have decided were he or she able to make the ethical decision.

Proxy Consent for Adults: Health Care Power of Attorney –This is usually used by
patients who want medical care but are concerned about who will consent if they are
rendered temporarily incompetent by the medical care.

Refusal to Consent
A mentally and legally competent patient has the right to refuse any medical procedure
or action no matter how necessary nor imminent the danger to his/her life or health if he fails to
submit to treatment.
If after an in-depth explaination regarding the necessary details and information
regarding the procedure have been discussed and the patient still refuses to sign the consent
form, the patient should be made to fill out a release form to protect the hospital and agency and
its personnel from any liability that may result from the patient’s refusal. Refusal to sign a
consent form is automatically reflected in the patient’s chart.

Data Privacy Law

NPC Draft Implementing Rules of the Data Privacy Act, June 17, 2016. Republic of the
Philippines NATIONAL PRIVACY COMMISSION Metro Manila Implementing Rules and
Regulations of Republic Act No. 10173, known as the “Data Privacy Act of 2012”. Pursuant to
the mandate of the National Privacy Commission to administer and implement the provisions of
the Data Privacy Act of 2012, and to monitor and ensure compliance of the country with
international standards set for data protection.
 Nurses are legally and ethically bound to protect the patient’s chart from unauthorized
persons. Permission has to be taken from the hospital authorities for authorization to secure any
information from the patient’s chart.

Right to Privacy
This right includes privacy of one’s thoughts, opinions, physical presence, and privacy of
one’s records. The subject has the freedom to decide the time, the extent and circumstance
he/she will willingly share his/her presence, thoughts, beliefs, attitudes, and behavior with
others.
Right to Confidentiality and Anonymity of Data
Data about the research subjects shall be handled confidentially and should only be
made available to research staff and reported anonymously. Data shall not be used other than
the specific purpose that the subject gave consent to and shall not be made public.
Invasion of Right to Privacy and Breach of Confidentiality
Nurses may become liable for invasion of right to privacy if they divulge information from
a patient’s chart to improper sources or unauthorized persons. Publication of any picture of a
patient or revelation of the contents of the patient’s reccords without the patient’s consent
constitute tort.

Code of Ethics for Nurses

The professional Code of Ethics for Filipino nurses provides direction for the nurses to
act morally. It strongly emphasizes the four-fold responsibility of nurses:
to promote health, prevent illness, alleviate suffering and restore health; the universality
of the nursing practice, the scope of their responsibilities to the people they serve, to
their coworkers, to society and environment, and to their profession
Timeline
Prior to 1984

Code of Ethics used by Filipino Nurses was the code promulgated by International
Council of nurses

1982
The Philippine Nurse’s Association Special Committee under the chairmanship of
Dean Emeritus Julita V. Sotejo, developed a Code of Ethics for Filipino nurse

Approved by the House of Delegates of the Philippine Nurses Association

Not implemented.

1984

The Board of Nursing, Professional Regulation Comission adopted the Code of Ethics of
the International Council of Nurses through Board Resolution No.633

Added “promotion of spiritual environment” as the fifth-fold responsibility of the nurse.

Included in The Scope of Nursing Act of 2002 R.A. No. 9173

1989

Code of Ethics promulgated by the Philippine Nurses Association was approved by the
Professional Regulation Comission.

Recommended for use through Board Resolution No.1955

1990

Approved by the general assembly of the Philippine Nurses Association during the
Nurses week convention on October 25.

Amended Code of Ethics for Registered Nurses

Pursuant to Section 3 of Republic Act No. 877 (Philippine Nursing Law), and Section 6 of
P.D. No.223, the amended Code of Ethics for Nurses recommended and endorsed by the PNA
was adopted to govern the practice of nursing in the Philippines.
A new Code of Ethics for Registered Nurses has been promulgated by the Board of
Nursing, I coordination and in consultation with Accredited Professional organization (PNA). In
its formulation, the Code of Good Governance for the Professions was adopted and integrated.
After consultation on October 23, 2003 at Iloilo City , the Code was adopted under
Republic Act 9173 and promulgated by the Board of Nursing under Resolution No. 220 Series of
2004 on July 12, 2004.
Philippine Professional Nursing Road map (Career Path)