GENERAL NURSING SCIENCE 1 STUDY

GUIDE, 2020

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Module Title General Nursing Science 1
Module code MW-GNS-001
Nominal Duration Theory: 70 hours
Practice: 170 hours
Total: 240 hours
NQF credits 24
NQF level 6
Prerequisite modules Admission requirement met
Semester 1 and 2 of first year
Module purpose The purpose of this module is to equip students
with the basic knowledge, skills and attitude to
enable them to provide safe, holistic individual
nursing care in accordance with the nursing
process and in relation to health, wellness and
illness in a health care system.
Summary of learning outcomes On completion of this module the student
should be able to:
LO1: Demonstrate knowledge of the
relationship between nursing and health,
wellness and illness in the provision of nursing
care in an integrated health care delivery
system
LO2: Demonstrate practical competences in
basic nursing procedures to meet basic health
care needs
LO3: Provide holistic individualized nursing
care to the patient or client to promote health
in accordance with the nursing process
LO4: Apply the principles of infection control
in the provision of nursing care
Module content LO1: Demonstrate knowledge of the
relationship between nursing and health,
wellness and illness in the provision of
nursing care in an integrated health care
delivery system
 Interpret related concepts (Health,
health behaviours, health beliefs, health
status wellness, well-being, illness,
acute illness, chronic illness, illness
behaviour, sickness, disease, risk
factors, lifestyle, etiology, adherence)
 Explain the factors that influence
individual’s definition of health
 Discuss the individual’s perception of
health
 Explain the components of wellness

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  Differentiate the internal and external
factors influencing an individual’s
health status
 Outline Suchman’s stages of illness
 Explain the effects of illness on the
client and the family
 Discuss the factors that influence
patients/clients' adherence to health
care
 Differentiate between the types of
health care services and health care
agencies
 Outline the roles and responsibilities of
health care providers to health care
delivery
 Interpret factors affecting health care
delivery
Nominal delivery time 12 hours
LO2: Demonstrate practical competences in
basic nursing procedures to meet basic
health care needs
 Explain related theoretical aspects of
basic nursing care
 Demonstrate practical competence in
basic nursing care to meet basic health
needs
 Apply safety measures to carry out
procedures
Nominal delivery time 18 hours
LO3: Provide holistic individualized nursing
care to the patient or client to promote
health in accordance with the nursing
process
 Interpret related concepts ( nursing
process)
 Explain Maslow’s hierarchy of needs in
relation to the nursing process
 Describe the components/steps/phases
of the nursing process
 Describe the characteristics of nursing
process
 Explain the advantages of the nursing
process
 Explain the significance of a nursing
care plan

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Nominal delivery time
Nominal delivery time
Methods of facilitating learning
Assessment strategy
 Discuss the importance of record
keeping and reporting in the provision
of nursing care
 Explain the importance of good
interpersonal relationship with the
patient/family/community
 Demonstrate skills in the
implementation of the nursing process
in the provision of nursing care
4 hours
LO4: Apply the principles of infection
control in the provision of nursing care
 Interpret related concepts (prevention,
controlling, transmission, droplet
transmission, airborne transmission,
aseptic technique, antiseptic, microbial
agent, Microbistatic agents, infection,
disinfection, contamination,
decontamination, cleaning, sterilization,
 Discuss the components/types of
standard precautions in nursing care
 Describe the principles of health care
waste segregation
 Classify health care waste
4 hours
Learning will be facilitated through the
following activities:
 Lecture method through power point
presentation
 Research assignments
 Class presentations
 Group discussions
 Practical demonstrations and return
demonstrations (simulation)
 Practical assessment of procedures
performed on patients in the wards
The academic performance of students at
AMNS will be assessed on a continuous basis
through written tests, assignments and practical
demonstrations.
There should be a minimum of four (4) theory
assessment marks for General nursing science
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All students would have done all first year
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 practical procedures (100%) for them to
qualify for practical examination (OSCE) at the
end of year 1
Learning resources Prescribed books
1. Berman A Snyder S, 2012, Kozier &
Erb’s fundamentals of Nursing,
concepts, processes and practice. 9th Ed.
New York: Pearson
2. Young A et al, 2003, Juta’s Manual of
Nursing. Vol 1, Basic Nursing, Cape
Town: Juta & Company
3. Brunner L S and Suddarth D S, 1992
The text book of adult Nursing.
Chapman & Hall: London
References
• Kozier B, Erb G & Snyder B. S, 2012
Fundamentals of Nursing, Wesley
Publishing Co: London, 9th edition
• Kozier B, Erb G & Snyder B.S, 2002
Fundamentals of Nursing, Wesley
Publishing Co: London
• Viljoen M J 2000 Nursing assessment:
History taking and physical assessment,
Kagiso tertiary: cape town
• Vlok M E 1998 Manual of Nursing 9th
Edition volume 1 Basic nursing Juta &
co: cape town
• Young A, Van Niekerk C F &
Mogotlane S 2003 Juta’s manual of
nursing volume1 Basic nursing Juta &
co: cape town

LO1: Demonstrate knowledge of the relationship between

nursing and health, wellness and illness in the provision of
nursing care in an integrated health care delivery system
Interpret related concepts (Health, health behaviours, health beliefs, health
status wellness, well-being, illness, acute illness, chronic illness, illness
behaviour, sickness, disease, risk factors, lifestyle, etiology, and adherence)

Health
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The World health Organization (WHO:2006) defines health as a state of complete physical,
mental and social wellbeing and not merely the absence of disease or infirmity (Marie E Vlok,
2012: 35) (Kozier &Erb’s, 2014:323)
Health behaviours
The action people take to understand their health maintain an optimal state of health, prevent
illness & injury & reach maximum physical & mental potential, e.g. eating wisely, exercising,
knowing signs of illness, following treatment advice, avoiding health hazards like smoking,
taking time for resting & relaxation, effective management of time (Kozier & Erb’s, 2014:329)
Health beliefs (Kozier & Erb’s, 2014:329)
These are issues about health that an individual believe are true
Health status (Kozier & Erb’s, 2014:329)
State of health of an individual at a given time
A report of health status may include anxiety, depression or acute illness.
Health status can describe specifics such as pulse, temperature, blood pressure, respirations
Wellness
Is a state of well-being?
It involves being proactive and being involved in self-care activities aimed towards a state of
physical, social, emotional, intellectual, occupational, environmental and spiritual wellbeing
(Kozier & Erb’s, 2014: 324)

Wellbeing is a state of feeling well (Hood, 2009: 185)

Illness
Is a state in which the person’s physical, emotional, intellectual, social, developmental, or
spiritual function is thought to be diminished or reduced (Kozier & Erb’s, 2014:333)
Ill-health
Implies suboptimal functioning due to disease or abnormality (Marie E Vlok, 2012: 35)
Sickness
Includes illness and disease and is a state of social dysfunction which affects the individual’s
relations with others within the society (Marie E Vlok, 2014:35)
Disease
Is described as an alteration in body function resulting in reduction or shortening of a life span
(Kozier & Erb’s, 2014: 333)
Etiology
Is the causation of a disease or condition (Kozier & Erb’s, 2014:333)

Acute illness
Is characterized by symptoms of relatively short duration, which appear abruptly and subside
quickly after medical intervention (Kozier & Erb’s, 2014: 333)
Chronic illness
Is an illness that lasts for an extended period, usually 6 months or longer.
Chronic illnesses have a slow onset and often have periods of remission ( when symptoms
disappear) and exacerbation ( when symptoms reappear (Kozier & Erb’s, 2014: 334)
Illness behaviour (Kozier & Erb’s, 2014: 334)
• When people become ill, they behave in certain ways which is referred to as illness
behaviour
• This involves ways individuals describe, monitor & interpret their symptoms

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 • How people behave when they are ill is affected by age, sex, occupation, socio-economic
status, religion, ethnic origin, psychological stability, personality, education & modes of
coping
Adherence
Is the extent to which an individual’s behaviour, such as taking medication follows
health/medical advice (Kozier & Erb’s, 2014: 332)
Life style
 Refers to a person’s general way of living
 Behaviours and activities over which people have control (Kozier & Erb’s, 2014:329)
 Life style choices may have positive and negative effects on health
 Practices that have negative effects on health are referred to as risk factors
 E.g. overeating, overweight and not getting enough rest (risk factors) are closely related
to developing hypertension, diabetes & heart diseases (Kozier & Erb’s, 2014: 329)
Examples of health life styles
• Regular exercises
• Weight control
• Avoiding eating saturated fats
• Avoiding excessive alcohol and tobacco
• Seat belt use
• Bike helmet use
• Immunization updates
• Regular health maintenance visits for screening and tests, e.g. dental, pap-smear, breast
cancer exam

Explain the factors that influence individual’s definition of health

Socio-economic levels of inequalities:
• Different levels of people have impact on their health
• Individuals with higher socio-economic status are expected to lead a better and healthier
life
• They have a potential for a healthier life when compared to those of lower socio-
economic level.
• A high socio-economic level is also correlated with more active health promotion
behaviour such as regular physical examination, regular visits to the dentists, eating
balanced diets, etc
• People of lower socio-economic level generally have poorer health largely due to
unaffordability of medical health care & other health seeking behaviours
• They may be unemployed or earn very little, under trying conditions
Level of education
• It’s an important factor that influences health
• The better educated an individual is, the healthier they are likely to be
• The better the education level the more likely to adapt healthier behaviours and health life
style
• Health literacy is an important facet of education
• Educated people always acquire relevant health information to lead a health life,
Preventing diseases and effectively manage chronic conditions and promote health in form of:
Growth monitoring Oral rehydration

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Breastfeeding Immunisation
Food supplementation Family planning
Female education
• All the above can be done by people who received certain level of education and
understood the importance of the above health promotions
Social inequalities
• Related to socio-economic levels
• The more affluent an individual or community is the better the level of health
• Poorer members of the community have to contend with the following issues which may
impact negatively on their health:
• They do not have access to health and other facilities such as water, electricity and
sanitation
• They are often unemployed and without resources to pay for visits to doctors or clinics
• They do not have proper housing and are often overcrowded, thus promoting the spread
of diseases, such as TB
• They are often undernourished, which also contributes to poor health and the
development of disease
• They have no voice and are therefore unable to advocate for change
Culture
• This plays an important role in health
• Culture determines the way in which an individual views disease and how that individual
responds when ill

Discuss the individual’s perception of health

Traditionally health is defined in terms of the presence of absence of disease

Florence Nightingale (860/1969) defined health as a state of being well and using every power
an individual posses to the fullest extend
WHO (1948) takes a more holistic view of health “A state of complete physical, mental, and
social wellbeing and not merely the absence of disease or infirmity (Kozier & Erb’s, 2014: 323)
WHO’s definition reflects concern for the individual as a total person functioning physically
psychologically & socially
• People’s lives and their health are affected by everything they interact with, and not only
environmental influences such as climate change, availability of food, shelter, clean air &
water to drink but also other people including family, lovers, employers, coworkers,
friends and associates
Talcott Parson (1951) defined health as the ability to perform and maintain normal role
American Nurses Association (ANA), (1980) defined health as dynamic state of being, in
which the developmental and behavioral potential of an individual is realized to the fullest extent
possible (Kozier & Erb’s, 2014:323)
In 2004 ANA stated that health was an experience that is often expressed in terms of wellness &
illness & may occur in the presence or absence of disease or injury (Kozier & Erb’s, 2014:323)
Virginia Henderson: In 1995 defined health as:
• A quality of life that allows people to work most effectively to attain the highest possible
satisfaction in life

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 • A quality of life which is basic to human functioning and which requires
independence(done alone) and interdependence (done with others)
• A state that may be achieved/maintained if a person has necessary strength, will or
knowledge
A person is said to be independent, whole and complete when they have the following basic
needs:
• Breathing normally
• Eating and drinking adequately
• Eliminating
• Moving and maintaining posture
• Sleeping and resting
• Dressing and undressing
• Maintaining body temperature
• Keeping clean and well groomed
• Avoiding danger and injury to self and to others
• Communicating to express emotion, needs, fears and opinions
• Worshiping according to the particular person’s faith
• Relaxing through recreation and play
• Promoting development and faith
Martha Rogers stated in her publication in 1970 & 1989 that:
• Positive health symbolises wellness
• Health is a value word defined within the individual’s understanding of the concepts of
health illness in relation to high or low value
Betty Neumann (1972-1989) perceived both health and illness as follows:
• Health is a value between wellness and illness
• Wellness is a condition in which all parts and subparts of an individual are in harmony
with the whole system, while illness indicates a lack of harmony
• Betty therefore perceived health as a shifting point between wellness and illness
• She states that optimal wellness results when all the needs of a person are met
• Unmet needs cause a reduction in wellness
• Therefore the individual’s state of wellness-illness may alter at any moment in the course
of life.

The following examples are individuals who say they are health even though they have
physical impairments that some would consider as illness
• A 15 yr old with diabetes takes injectable insulin each morning. He plays on the school
soccer team and is editor of the high school magazine
• A 32 yr old is paralyzed from the waist down and uses a wheelchair for mobility. He is
doing accounting at nearby college
• A 72 yr old takes medication for high blood pressure. She is a member of the golf club,
makes hand crafts for charity and travels 2 months each year
Many people define and describe health as the following:
• Being free from symptoms of disease and pain
• Being able to be active and to do what they want or must do
• Being in good spirit most of the time (Kozier & Erb’s 2014:323)

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Explain the components of wellness

Wellness is a state of well-being

Basic aspects of wellness include :
• Self responsibility
• Daily decision making in the areas of nutrition
• Stress management
• Physical fitness
• Preventive health care
• Emotional health

Anspaugh, Hamrick & Rosato (2009) proposed seven (7) components of wellness:
1. Physical
• The ability to carry out daily tasks
• Achieve fitness
• Maintain adequate nutrition and proper body fat
• Avoid abusing drugs and alcohol or using tobacco products
• Practice positive lifestyle habits
2. Social
• The ability to interact successfully with people and within the environment of which each
person is part
• To develop and maintain intimacy with significant others
• To develop respect and tolerance for those with different opinions with beliefs
3. Emotional
• The ability to manage stress and express emotions appropriately
• Emotional wellness involves the ability to recognize, accept and express feelings and to
accept one’s limitations
4. Intellectual
• The ability to learn and use information effectively for personal, family and career
development
• Intellectual wellness involves striving for continued growth and learning to deal with new
challenges effectively

5. Spiritual
• This is a belief in some force (nature, science, religion, or a higher power) that serves to
unite human beings and provide meaning and purpose to life
• It includes a person’s own morals, values and ethics
6. Occupational
• The ability to achieve a balance between work and leisure time
• A person’s beliefs about education, employment and home influence personal satisfaction
and relationship with others
7. Environmental
• The ability to promote health measures that improve the standard of living and quality of
life in the community
• This includes influence such as food, water and air (Kozier & Erb’s, 2014: 324-325)

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Differentiate the internal and external factors influencing an individual’s
health status
Internal factors (Kozier & Erb’s:327)
• These are factors that cannot be changed
• Exercises and diet (external factors) may be encouraged to influence these internal factors
• These factors are biological, psychological and cognitive
Biological factors
 These are genetic makeup such as sex, age and developmental level influence a person’s
health
 Genetic makeup influence certain characteristics to be passes on to the next generation
 It has been related to susceptibility to specific diseases such as diabetes, hypertension,
breast cancer
 E.g. many people of African heritage have higher incidences of passing on hypertension
or diabetes mellitus
 Genetic predisposition to illness is worse when both parents are from the same genetic
pool
Sex influences the distribution of disease
 Certain genetic diseases are more common in one sex than the other
 Females tend to inherit diseases such as osteoporosis and rheumatoid arthritis
 Males inherit stomach ulcers, abdominal hernias and respiratory disorders
Age is also a significant factor
 Spread of diseases vary with age
 Heart diseases are more common in middle aged males, but less in younger people
 Whooping cough and measles are common in younger children and rare in older people
who would have acquired immunity to them
Developmental level has a major impact on health status
 Infants lack physiological and psychological maturity so their defenses against disease
are lower during the 1st year of life
 Toddlers who are learning to walk are more prone to falls and injuries than older children
 Adolescents who strive to conform to peers are more prone to risk taking diseases such as
STIs
 Declining physical ability, degeneration of body cells and tissues and lowered immunity
make older people more susceptible to diseases

Psychological factors (Kozier & Erb’s :329)

• These are emotional factors influencing health
• These include mind-body interactions
• Mind-body interactions can affect health ether positively or negatively
• Emotional response to stress affects body function
• E.g. a student who is anxious before a test may experience urinary frequency or diarrhea
• An adult worried or under stress may chain smoke or abuse alcohol
• Prolonged emotional distress increase susceptibility to diseases or precipitate it
• Emotional distress influence immune system negatively
• Decreased immunity predispose to infections and diseases

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 • A patient diagnosed with terminal illness may experience fear and depression

Cognitive factors (Kozier & Erb’s:329)

• Also referred to as intellectual/mind set
• These influence health in form of lifestyle choices and spiritual and religious beliefs
• Lifestyle include the person’s general way of living, the behaviours and activities over
which people have control
Lifestyle choices have either negative or positive effects on health
• Practices with negative effects on health are know as risk factors, e.g. overeating, lack of
exercises may lead to heart diseases, diabetes and hypertension; excessive smoking may
lead to lung cancer/cardiovascular diseases
Spiritual and religious beliefs can affect health behaviour
• E.g. Jehovah’s witness oppose blood transfusion
• Some Christians believe that some illnesses are punishment from God
• Some religious groups are strict vegetarians
• Religious Jews perform circumcision on the 8th day on all boy children irrespective of the
baby’s condition (Kozier & Erb’s 2014:327-330)
• Examples of health life styles see slide 23

External factors
• These include physical environment, standards of living, family and cultural beliefs and
social support network
Physical environment
• Malaria occurs in tropical regions
• Pollution of water, air and soil from the environment affect health negatively
• Man-made asbestos causes cancer
• Smokers increases higher incidences of lung cancer to themselves and people around
them
• Direct exposure to ultraviolet from the sun causes skin cancer to light skinned people
• Environmental contamination from pesticides and chemicals to control weeds and plant
diseases can be found in plants and animals that people eat as food

Standards of living (Kozier & Erb’s: 330)

• Reflecting occupation, income & education is related health, morbidity and mortality
• Hygiene, food habits, and ability to seek health care advice and follow health regimens
vary among high income and low income groups
• Low income families often spend their income on food and housing than seeking health
care
• May have no money for transport to go to clinics for checkups only, unless they are sick
• Neither do they have day-offs from work to spare for check ups
• Most of their efforts are exerted on survival than prevention of illness
• The environmental conditions of impoverished areas have a bearing on overall health
• Slum neighborhoods are overcrowded and in a state of deterioration
• Sanitation services tend to be inadequate
• Streets strewn in garbage and pests are common

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 • Fires and violence may be frequent
• Recreation facilities are limited, forcing children to play in streets and alleys
• Occupational roles may expose people to certain illnesses, e.g. industrial worker may be
exposed to agents that can cause burns, cancer, etc
• Higher pressure social/occupational roles predispose to stress-related illnesses & diseases
• Such roles may encourage overeating or social use of drugs or excessive alcohol

Family & cultural beliefs (Kozier & Erb’s:330)

• The family passes on patterns of daily living and lifestyles to offspring
• E.g. a man who was abused as a child may physically abuse his own children
• Physical/emotional abuse causes long term health problems
• Emotional health depends on a social environment that is free of excessive tension and
does not isolate the person from others
• Open communication, sharing & love foster the fulfillment of the person’s potential
• Culture & social interactions influences how a person perceives, experiences & copes
with health & illness
• Each culture has ideas about health and are passed from parents to children
• Cultural rules, values & beliefs give people a sense of being stable and health
• The challenge of old beliefs & values by young generation may give rise to conflict,
instability and insecurity in turn contributing to illness.

Social support networks (Kozier & Erb’s:330)

• Having a support network (family & friends) & job satisfaction helps people avoid illness
• Supports help individual to confirm that illness exists
• People with inadequate support networks allow themselves to become increasingly ill
before they seek therapy/treatment
• Support people provide the motivation for an ill person to become well again

Outline Suchman’s stages of illness

There are five (5) stages of illness according to Suchman namely:

• Stage 1: Symptoms experience
• Stage 2: assumption of the sick role
• Stage 3: Medical care contact
• Stage 4: Dependent client role
• Stage 5: Recovery or rehabilitation (Kozier & Erb’s 2014: 334-335)
Not all clients progress through each stage.
For example:
• Clients who experience a heart attack is taken to the emergency department
• And immediately enters stage 3 & 4, medical care contact and dependent client role
• Other clients may progress through only the 1st & 2nd stages and then recover

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Stage 1: symptoms experience
• At this stage the person comes to believe something is wrong
• Either someone significant mentions that the person looks unwell, or the person
experience some symptoms such as pain, rash, cough, fever or bleeding
Stage 1 has three aspects
1. The physical experience of symptoms
2. The cognitive aspect (interpretation of the symptoms in terms that have some meaning to
the person
3. The emotional response (e.g. fear or anxiety)
During this stage:
• The unwell person usually consult others about the symptoms or feelings, validating with
supportive people that symptoms are real
• Sick person may seek home remedies
• If self-management is ineffective, the individual enters the next stage

Stage 2: Assumption of the sick role

• The individual now accept the sick role and seek confirmation from friends and family
• Often people continue with self-treatment and delay contact with health professional
• People may be excused from normal duties and role expectations
• Emotional response such as withdrawal, anxiety, fear, and depression are not uncommon
depending on the severity of the illness, perceived degree of disability, and anticipated
duration of illness.
• When symptoms or illness persist or increase, the person is motivated to seek
professional help.

Stage 3: Medical care contact

• Sick people seek the advice of the health professionals, either on their own initiative or at
the urging of the significant others
• When people seek professional advice they are really asking for the three types of
information:
• Validation of real illness
• Explanation of the symptoms in understandable terms
• Reassurance that they will be alright or prediction of what the outcome would be
• The health professional may determine that the client does not have an illness or that the
illness is present and may even be life threatening.
• The client may accept or deny the diagnosis
• If diagnosis is accepted the client usually follows the prescribed treatment plan.
• If not accepted client may seek advice from other health professionals who will provide a
diagnosis that fit the client’s perceptions

Stage 4: Dependant client role (:335)

• After accepting the illness and seeking treatment the client becomes dependant on the
health professional for help
• People vary in giving up their independence particularly in relation to life or death

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 • Role obligations such as wage earner, parent, student, sports team member complete the
decision to give up independence
• Most people accept their dependence on the primary care provider, although they retain
varying degrees of control over their own lives
• Example: some clients request precise information about their disease, treatment and its
cost and may delay the decision to accept treatment until they have all this information
• Others prefer that the primary care provider proceed with treatment and do not request
additional information
• For some illness may meet dependence needs that have never been met and thus provide
satisfaction
• Others have minimal dependence needs and do everything possible to return to
independent functioning.
• A few may even try to maintain independence to the detriment of their recovery

Stage 5: Recovery or rehabilitation (:335)

• At this stage client is expected to relinquish the dependent role and resume former roles
and responsibilities
• People with acute illness, time as an ill person is generally short and recovery is usually
rapid
• Most find it relatively easy to return to their former lifestyles
• Clients who have long term illnesses, and must adjust their lifestyles may find recovery
more difficult
• Clients with a permanent disability, this final stage may require therapy to learn how to
make major adjustments in functioning

Explain the effects of illness on the client and the family

• Illness brings change in both the involved individual and in the family
• The changes vary depending on:
 Nature, severity & duration of illness
 Attitudes associated with the illness by the client & others
 The financial demands
 The lifestyle changes incurred
 Adjustments to usual roles

Effects on the client (Kozier & Erb: 335-336)

• Ill clients may experience behavioural and emotional changes in self-concept, body
image and lifestyle
• Behavioural & emotional changes associated with short term illness are mild and short
lived
• The individual may become irritable & lack the desire/energy to interact in the usual
fashion with family members & friends
• More acute responses are likely with severe life threatening, chronic or disabling illness
• Anxiety, fear, anger, withdrawal, denial, a sense of hopelessness & feelings of
powerlessness are all common responses to severe or disabling illness
• E.g. a client experiencing a heart attack fears for his life & the financial burden it may
place on his family

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 • A client diagnosed with HIV experiences denial, anger, fear & hopelessness
• Certain illnesses can change the client’s body image or physical appearance, e.g. scars,
loss of a limb/leg
• Client’s self- esteem & self- concept may be affected
Many factors can play a part in low self-esteem and low self-concept:
 Loss of body parts & function
 Pain
 Disfigurement
 Dependence on others
 Unemployment
 Financial problems
 Inability to participate in social functions
 Strained relationships with others
 Spiritual distress
 Nurses need to help clients express their thoughts & feelings
 Provide care that helps clients cope effectively with change
 Individuals are also vulnerable to loss of autonomy (the state of being independent & self
directed without outside control
 Family interactions may change & clients no longer get involved in making family
decisions or even decisions about their own health care
 Nurses need to support clients by providing information to participate in decision making
processes & to maintain a feeling of being in control
 Illness may cause change in the lifestyle
 Apart from participating in treatments & taking medications, the ill person may need to
change diet, activity/exercise, rest and sleep patterns.

Nurses may help clients adjust their lifestyles by these means:

 Providing explanations on necessary adjustments
 Making arrangements to accommodate client’s lifestyle
 Encouraging other health professionals to become aware of the person’s lifestyle
practices & to support healthy aspects of the lifestyle
 Reinforcing desirable changes in practices with a view to making them permanent
part of the client’s lifestyle.

Effects on the family

• A person’s illness affects not only the person who is ill, but also the family & significant
others

The kind of effects & its extend depends on three factors:

• The member of the family who is ill
• The seriousness & the length of the illness
• The cultural & social customs the family follows

The changes that occur in the family include the following:

• Role changes
• Task reassignment and increased demands on time

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 • Increased stress due to anxiety about the outcome of the illness for the client and
conflict about unaccustomed responsibilities
• Financial problems
• Loneliness as a result of separation and pending loss
• Change in social customs (Kozier & Erb’s 2014:336)

Discuss the factors that influence patients/clients' adherence to health care

• Adherence is the extent to which an individual’s behaviour ( taking medication,
following diets, making lifestyle changes) coincides with medical or health advice
• Degree of adherence may range from disregarding every aspect of the recommendations
to following the total therapeutic plan
There are many reasons why some patients adhere and others do not:
 Client motivation to become well
 Degree of lifestyle change necessary
 Perceived severity of the healthcare problem
 Value placed on reducing the threat of illness
 Ability to understand & perform specific behaviours
 Degree of inconvenience of the illness itself or of the regimens
 Beliefs that the prescribed therapy or regimen will or will not help
 Complexity, side effects & duration of the proposed therapy
 Cultural heritage, beliefs or practices that support or conflict with the regimen
 Degree of satisfaction, quality and type of relationship with the health care
provider
 Overall cost of therapy (Kozier & Erb’s 2014: 332)

When a nurse identifies nonadherence, it is important to follow the following steps:

1. Establish why the client is not following the regimens:
• Depending on the reason, the nurse can provide information, correct
misconceptions, attempt to decrease expense, suggest counseling
• Nurse may re-evaluate the suitability of health advice provided
• Nurse may re-pattern & restructure care that suits the client

2. Demonstrate caring
• Show sincere concern about the client’s problems e.g. A client who is not taking his
medication for heart (“I appreciate how you feel about your treatment, but I am very
concerned about your heart”)
3. Encouraging healthy behaviour through positive reinforcement
• If the man who is not taking his heart medication is walking every day, a nurse may say
(“you are really doing well with your walk”)
4. Use aids to reinforce teaching
• Nurse can leave pamphlets for client to read later or make a pill calendar, ( a paper with
date & number of pills to be taken)
5. Establish a therapeutic relationship of freedom, mutual understanding, mutual
responsibility with the client & support persons

17
 • By providing knowledge, skills, & information the nurse give client control over their
health which results in greater adherence (Kozier & Erb’s 2014: 332-333)

Differentiate between the types of health care services and health care
agencies

Types of health care services are described according to levels of disease prevention namely:
1. Primary prevention: Health promotion and ill prevention
2. Secondary prevention: Diagnosis and treatment
3. Tertiary prevention: Rehabilitation, health promotion and palliative care

1. Primary prevention: Health promotion and ill prevention

WHO developed a project called health people 2020 which has four (4) primary goals:
• Increase quality & years of healthy life
• Achieve equity and eliminate health disparities
• Create healthy environments for everyone
• Promote health & quality life across the life span
• Health promotion was slow to develop until the 1980s.
• Since then many people have recognized the advantages of staying healthy & avoiding
illness
• Primary prevention programmes address areas such as:
• Adequate & proper nutrition
• Weight control & exercise
• Stress reduction
• Health promotion activities emphasize the important role clients play in maintaining their
own health
• They need to be encouraged to maintain the highest level of wellness they can achieve
• Illness prevention programmes may be directed at the client or community &
involve such practices as:
• Providing immunizations
• Identifying risk factors for illness and helping
• People take measures to prevent these illnesses from occurring.
• Examples. smoking cessation campaigns and protect the public from ill effects of
second hand smoking, by regulating areas where persons are permitted to smoke
• Illness prevention also includes environmental programmes such as prevention
of air pollution by fumes
• These environmental protective measures are legislated by the government and
lobbied by citizen groups

2. Secondary prevention: Diagnosis and treatment

• In the past the largest segment of health care services has been dedicated to diagnosis &
treatment of illness
• Hospitals and physicians were agencies offering these secondary prevention services

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 • Hospitals continue to offer services to clients requiring emergency, intensive and acute
care
• Freestanding diagnostic and treatment facilities have also evolved and serve ever-
growing number of clients Example Magnetic resonance imaging (MRI) and related
radiologic diagnostic procedures are commonly performed at physician or private health
centres
• Similar structures also exist in outpatient surgical units.
• Also included as a health Promotion Service is early detection of disease
• This is accomplished through routine screening of the population with focus on those at
risk of developing certain conditions
• Example of early detection include, regular dental exams from childhood
throughout life and bone density studies for women at menopause to evaluate for
early osteoporosis.
• Community based agencies have become instrumental in providing these
services.
• Example, some clinics provide mammograms and education on early detection of
breast cancer
 Voluntary HIV Testing and Counselling is another example of shift of service to
community-based agencies.
 Some malls and shopping centres have walk in clinics that provide Diagnostic test, such
as screening for cholesterol and High blood pressure

3. Tertiary prevention: Rehabilitation, health promotion and palliative care

 GOAL of Tertiary Prevention: Help people move to their previous level of Health (e.g.,
to their previous capabilities) or to the highest level they are capable of given their
current health status
 Rehabilitative care emphasizes the importance of assisting clients to function adequately
in the physical, mental, social & economic areas of their lives
• Example someone with an injured neck or back may have restrictions in the ability to
perform work or daily activities
• If injury is temporary, rehabilitation can assist in return to former function
• If injury is permanent, rehabilitation assist the client to adjust the way activities are
performed in order achieve maximum abilities
• Rehabilitation may begin in the hospital, but may eventually lead clients back in the
community
• An example of a tertiary mental health prevention is an outreach programme that
follows patients with mental health disorders in the community to ensure that they adhere
to their medication regimens
• These programmes reduce acute psychiatric hospital admissions and long term
institutionalization and enable patients with mental disorders to live independently
• Sometimes patients may not be returned to health
• Home based care programmes under tertiary prevention services can be used
• Patients are provided with comfort and treatment for symptoms, in their homes
(Kozier & Erb’s 2014:124)

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Types of health care agencies
• Public health
• Physicians’ offices
• Ambulatory care centres
• Occupational health clinics
• Hospitals
• Sub-acute care facilities
• Extended (long-term) care facilities
• Retirement and assisted living centres
• Rehabilitation centres
• Home health care agencies
• Day care centres
• Rural care hospice services
• Crisis centres
• Mutual support and self help groups (Kozier & Erb’s 2014: 125-128)

Task: Briefly describe the services provided by the above listed health care
agencies?

Outline the roles and responsibilities of health care providers to health care
delivery
 Types of Health Care Providers
(Multidisciplinary Health Team)
 The providers of health care, also referred to as health care team or health Professional
are: Nurses and health personnel from different disciplines who coordinate their skills to
assist clients and their support persons.
 Mutual Goal is to: restore all clients’ health and promote wellness. The choice of
personnel for a particular client depends on the needs of the client

1. The Nurse (Kozier & Erb’s 2014: 128)

The role of the Nurse varies with the needs of the client, the nurse’s credentials, and the type of
employment setting.

A Registered Nurse (RN):

• Assess a clients health status
• Identifies health problems
• Develops and Coordinates Care
A Licensed Vocational Nurse (LVN) in some states known as a Licensed Practical Nurse
(LPN)
 Provides direct care under the direction of a RN, physician, or other licensed
practitioner. As Nursing Roles have expanded new dimensions for Nursing Practice
have been established. Nurses can pursue a variety of practice specialties (e.g.,
Critical care, Mental Health, Oncology).
Advanced Practice Nurses (APNs)
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  Provide direct client care as Nurse Practitioners, Nurse Midwives, Certified
Registered Nurse Anaesthetists, and Clinical Specialists. These Nurses have
Education and Certifications that depending on state regulations-may allow them to
provide Primary Care, prescribe medications and receive third-party (insurance)
reimbursement directly for their services

2. Alternative (Complementary) Care Provider (Kozier & Erb’s 2014: 129)

• Refers to those practices not commonly considered part of Western medicine.
• Chiropractors, herbalists, acupuncturists, massage therapists, reflexologists, holistic
health healers, and other health care providers are playing increasing roles in the
contemporary health care system.
• These providers may practice alongside Western health care providers, or clients may
use their services in conjunction with, or in lieu of Western therapy

3. Case Manager (Kozier & Erb’s 2014:129)

• Role is to ensure that clients receive fiscally sound, appropriate care in the best setting.
• This role is often filled by the member of the health care team who is most involved in
the clients care.
• Depending on the clients concerns the case manager may be a Nurse, Social worker, an
occupational therapist, physical therapist or any member of a health care team
4. Dentist (Kozier & Erb’s 2014:129)
• Diagnose and treat mouth, jaw, and dental problems.
• Dentist (and their dental hygienists) are also actively involved in preventive measures to
maintain healthy oral structures (e.g., teeth and gums)
5. Dietitian or Nutritionist (Kozier & Erb’s,2014:129)
• Dietitian: Has special knowledge about the diets required to maintain health and to treat
disease
• In hospitals generally are concerned with therapeutic diets, supervise the preparation of
meals to ensure that clients receive proper diet
• May design special diets to meet nutritional needs of individual clients
• Nutritionist: has special knowledge about nutrition and food.
• Nutritionist in community setting recommend healthy diets and provides broad advisory
services about the purchase and preparation of foods. Community Nutritionists often
function at the preventive level. To promote health and prevent disease
• Example: advising family about balanced diets for growing children and pregnant
women
6. Emergency Medical Personnel (Kozier & Erb’s, 2014:129)
• Several categories of providers are associated with ambulance or medical service
agencies (e.g., fire departments) that provide first –responder care in the community.
Titles, education, and certification vary for emergency medical technicians (EMTs) and
paramedics. In general they are trained to assess, treat, and transport clients with medical
emergency, accident or trauma
7. OCCUPATIONAL THERAPIST (OT) (Kozier & Erb’s, 2014:129)
• Assist clients with impaired function to gain skills to perform activities of daily living.
• Example: OT may teach a man with severe Arthritis in his arms and hands how to adjust
his kitchen utensils so that he can continue cooking.

21
 • OT teaches skills that are therapeutic and at the same time provide some fulfilment for
Example: Weaving is a recreational activity but also exercises the Arthritic man’s arms
and hands
8. PARAMEDICAL TECHNOLOGIST (Kozier & Erb’s, 2014:129)
PARAMEDICAL: Means having some connection with medicine
Three (only) kinds of Paramedical Technologist in the expanding field of Medical Technology
• Laboratory Technologists
• Radiologic Technologists
• Nuclear Medicine Technologist
Laboratory Technologists:
• Examine specimens such as urine, feaces, blood and discharges from wounds to provide
exact information that facilitates the medical diagnosis and prescription of the therapeutic
regimen
The Radiologic Technologist:
 Assists with a wide variety of X-Ray film procedures, from simple chest radiography
to more complex fluoroscopy
The Nuclear Medicine Technologist:
 Uses Radioactive substances to provide diagnostic information and can administer
radioactive materials as part of a therapeutic regimen

9. PHARMACIST (Kozier & Erb’s 2014: 129)

• Prepares and dispenses Pharmaceuticals in hospital and community settings.
• Their role in monitoring and evaluating the actions and effects of medications on clients
is becoming increasingly prominent
A Clinical Pharmacist is a Specialist who guides primary care providers in prescribing
medications.
• Pharmacists also work directly with clients and with other health care team members to
ensure safe integration of medications into the clients comprehensive health plan
EXAMPLE:
An Anaesthesiologist (MD), a Neonatal Care Nurse, or a Respiratory Therapist may be
responsible for assisting a newborn baby with breathing problems. All providers perform client
teaching

10. PHYSICAL THERAPIST (Kozier & Erb’s :129)

• The licensed Physical Therapist (PT) assists clients with musculoskeletal problems
• Treat movement dysfunctions by means of heat, water, exercise, massage, and electric
current
• Functions include assessing client mobility and strength, providing therapeutic measures
(e.g., exercises and heat applications to improve mobility and strength)
• Teaching new skills (e.g., how to walk with an artificial leg)
• Some PT provides their services in hospitals: independent practitioners establish offices
in communities and serve clients either at the offices or in the home

11. PHYSICIAN (Kozier & Erb’s 2014:130)

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 • Responsible for medical diagnosis and determining the therapy required by a person who
has a disease or injury
• Traditionally their role has been treatment of disease or trauma (injury); now many are
including Health Promotion, and Disease Prevention in their practice
• Some are Primary Care Practitioners (also known as General or Family practitioners)
• Others are specialist such as: Dermatologists, Neurologist, Oncologists, Orthopaedists,
Paediatricians, Psychiatrists, Radiologists or Surgeons to mention a few

Primary Care Physicians are those who provide the first point of contact for most clients and
can include Allopathic (Western) medical doctors (MD)
• Trained in areas such as Internal Medicine, Gynaecology, and Geriatrics and doctors of
Osteopathy (DOs ) a branch of medicine traditionally focused on primary care.
• Differences between allopathic and osteopathic physicians are becoming fewer

12. PHYSICAIN ASSISTANT (PAs) (Kozier & Erb’s 2014:130)

• Perform certain tasks under the direction of a physician.
• They treat certain diseases, conditions, and injury
• In many states nurses are not legally permitted to follow a PAs orders unless co-signed
by a Physician.
• In some settings PAs and Nurse Practitioners have similar Job descriptions

13. PODIATRIST (Kozier & Erb’s 2014: 130)

• Doctors of Podiatric Medicine (DPM) diagnose and treat foot and ankle conditions
• They are licensed to perform surgery and prescribe medications

14. RESPIRATORY THERAPIST (Kozier & Erb’s 2014: 130)

• Skilled in therapeutic measures used in the care of clients with respiratory problems
• These therapists are knowledgeable about oxygen therapy devices, respirators,
mechanical ventilators, and accessory devices used in inhalation
• Respiratory therapists administer many of the pulmonary functions test

15. SOCIAL WORKER (Kozier & Erb’s 2014:130)

• Counsels clients and their support persons regarding problems such as finances, marital
difficulties and adoption of children
• Is not unusual for health problems to produce problems in day-to-day living and vice
versa. For Example: an elderly woman who lives alone and has a stroke resulting in
impaired walking may find it impossible to continue to live in her third –floor apartment.
• Finding a more suitable living arrangement can be the responsibility of the social worker
if the client has no support network in place

16. SPIRITUAL SUPPORT PERSONNEL (Kozier & Erb’s 2014:130)

• Chaplains, pastors, rabbis, priest and other religious or spiritual advisors serves as part of
the health care team by attending to the spiritual needs of clients.
• In most facilities, local clergy volunteer their services on a regular or on-call basis.
• Hospital affiliated with specific religions, as well as many large medical centres have
full-time chaplains on staff

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 • The nurse is often instrumental in identifying the clients desire for spiritual support and
notifying the appropriate person

17. UNLICENSED ASSISTIVE PERSONNEL (UAPs) (Kozier & Erb’s 2014:130)

• UAPs are health care staff who assumes delegated aspects of basic client care. These
tasks include bathing, assisting with feeding, and collecting specimens
• UAP titles include certified Nurse assistants, hospital attendants, nurse technicians,
patient care technicians and orderlies
• Some of these categories of provider may have standardized education and job duties
(e.g., certified nurse assistants) while others do not.
• Parameters regarding nurse delegation to UAPs are delineated by state boards of nursing

Interpret factors affecting health care delivery

1. Increasing Number of Older Adults (Kozier & Erb’s 2014:130)

 Estimated that by year 2020 number of U.S adults over 65 years will be more than 54
million.
 Long-term illnesses prevalent among this group frequently require special housing,
treatment services, financial support and social network
 Frail elderly over age 85 projected to be fastest growing population in US and will be
more than 7 million by 2020 and 9.6 million by 2030
 Because less than 5% of adults are institutionalized with health problems, substantial
home management and nursing support services are required to assist those living in
their homes and communities
 Older adults also need to feel they are part of a community they approaching end of
their lives.
 Special programs are being designed in communities, so that the talents and skills of
this group will be used and not lost

2. Advance in Technology (Kozier & Erb’s, 2014; 130)

• Scientific knowledge and technology related to health care are rapidly increasing
• Improved diagnostic procedures and sophisticated equipment permit early recognition of
diseases that might otherwise have remained undetected
• New medications are continually being manufactured to treat infections and multidrug
resistant organisms
• Surgical procedures involving heart, lungs and liver that were non-existent 20years ago
are common today.
• Laser and microscopic procedures streamline the treatment of diseases that required
surgery in the past
• Computers, bedside charting and ability to store and retrieve large volume of in
databases are common place in health care organization
• As a results of the availability of Internet and World Wide Web access from numerous
public and private locations, clients now have access to medical information similar to
that of health care providers
• These discoveries have changed the profile of the client. Clients are now more likely to
be treated in the community, utilizing resources

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 • Technology and treatment outside the hospital. Example: years ago person having
Cataract surgery had to remain in bed in hospital for 10 days; today most Cataract
removals are performed in outpatient surgery centres
• Technological advances and specialized treatments and procedures may unfortunately
come with high price tag
• Some diagnostic equipment may cost millions of dollars. Due to this expenditure plus the
expense of training specialized personnel to perform the tests, each procedure can cost
consumers hundreds of thousands of dollars

3. Economics (Kozier & Erb’s 2014:131)

• Paying for health care services is becoming a greater problem
• Health care delivery system is very much affected by country's total economic status
(expenses e.g., inpatient hospital expenses 31%, 21% physicians office and clinic
expenses, 10% drugs prescription, home care, emergency department dental services)

Major reasons for cost increases:

• Existing equipment and facilities continually becoming obsolete (out dated) as research
uncover new and better methods in health care. Health care providers and clients want the
latest and best, and replacing equipment costs more each year
Inflation increases all costs\
• Total population is growing, especially the segment of older adults who tend to have
greater health care needs than younger persons.
• Expenses for persons over age 65 are more than twice as much as for those under age 65
• As more people recognize that health is everyone's right, larger number of people are
seeking assistance in health matters
• The relative number of people who provide health care services has increased
• The number of uninsured persons are increasing
• The cost of prescription drugs is increasing. Medicare recipients are eligible for
prescription drugs coverage to help cover some basic and catastrophic medication cost

4. Women's Health (Kozier & Erb’s 2014:131)

• Women's movement has been instrumental in changing health care practices. Example:
• Provision of childbirth services in more relaxed setting such as birthing centres, and
provision of overnight facilities for parents in children's hospital
• Until recently, women health issues focused on reproductive aspect of health,
disregarding many health care concern unique to women
• Investigators beginning to recognize need for research that examines women equally to
men in health issues such as Osteoporosis, Heart disease, responses to various treatment
modalities

• Current provision of health care shows increased emphasis on the psychosocial aspects of
women's health including:
• Impact of career
• Delayed childbirth bearing
• Role of caregiver to older family members
• Extended life span

25
5. Uneven Distribution of Services (Kozier & Erb’s 2014:131)
• Serious Problems in distribution of health services exist in U.S
Two facets of this problem are:
• Uneven distribution
• Increased Specialization
• In some areas particularly remote and rural locations, number of health care professionals
and services available to meet the health care needs of individual is insufficient
• Long distances to obtain health care services needed mostly in rural areas
• High number of nurses in town than in rural areas
• High number of Physicians in town than in districts.
• Both hospitalist and intensive are physicians assume care of hospitalized client instead of
Primary Care Physicians
• An increased number of health care personnel provide specialized services.
• Specialization can lead to fragmentation of care and often increased of cost of care

6. Access to Health Insurance (Kozier & Erb’s 2014:132)

• Access to health insurance big challenge to individual.
• Without health assurance people receive less preventive care, delay or avoid care and
medication, are diagnosed later in their illnesses, and have higher mortality
• Because of low or absent reimbursement for services, primary care providers may
hesitate to provide care otherwise indicated\
• Lack of health insurance is related to income. Most family living in poverty have no
health insurance coverage
• Low income has been associated with relative higher rates of infectious diseases (e.g.,
TB, AIDS) problems with substance abuse, rape, violence, and chronic diseases.
• Thus, those with greatest need for health care are often those least able to pay for it
• Even though some government assistance is available, eligibility for government
insurance programs and benefits varies consider ability from state to state

7. The Homeless and the Poor (Kozier & Erb’s 2014:132)

• Due to the conditions in which homeless live (shelters, street, parks, cars, tents, street)
their health problems are often exacerbated (worsened) and sometimes become chronic
• Physical, mental, social and emotional factors create health care challenges for the
homeless and the poor
• These persons may lack convenient or timely transportation to health care facilities-
especially if repeated visits are necessary.
• Limited access to health care services significantly contributes to the general poor health
of the homeless and poor in the U.S

Factors Contributing to Health problems of the Homeless and the Poor:

• Poor physical environment resulting in increased susceptibility to infections
• Inadequate rest and privacy
• Improper nutrition
• Poor access to facilities for personal hygiene
• Lack of social support, inconsistent health care

26
 • Difficulty with adherence to treatment plans

8. Health Insurance Portability and Accountability Act (Kozier & Erb’s, 2014:133)
• One of the major alterations in how health care is practiced maybe attributed to the
Health Insurance Portability and Accountability Act of 1996 (HIPAA)
• New regulations instituted to protect the privacy of individuals by safeguarding
individually identifiable health care records including those housed in electronic media

Example: Intent of HIPAA Regulation

• Provides individuals with more control over their health information
• Establishes limits for appropriate use and release of health care information
• Requires health care providers and their agents to comply with safeguards to protect
individual privacy related to health care info

HIPAA Regulation
• Delineates a set of civil and criminal penalties holding HIPAA regulation transgressors
accountable for actions if the clients health care privacy is violated
• Protection of individual medical records extends not only to clinical health care sites but
also to other health care providers such as pharmacies, laboratories, and third –party
payers
• Each health care provider dealing with client health care information must, by HIPAA
regulations provide for secure limited access to that information
• This is accomplished by restricting access to only those individuals who truly need to
possess the information to help client, by locking documents in files cabinets and by
limiting computer access to health care files
• The regulated privacy has altered the way health care providers share information
• Each client is provided a notice of privacy practices for each type of health care provider.
These clearly state how and under what conditions individuals health care records will be
shared with other persons or agencies

9. Demographic Changes (Kozier & Erb’s, 2014:133)

• The characteristics of the North American family have changed considerably in the past
few decades. The numbers of single-parents families and alternative family structures
have increased markedly
• Most of single-parent families are headed by women, many of whom work and require
assistance with child care or when child is sick at home
• Recognition of the cultural and ethnic diversity of the U.S is also increasing
• Health care professional and agencies are aware of this diversity and are employing
means to challenges. Example: more agencies are employing nurses who are bilingual
and who can communicate with clients who primary language is not English

LO2: Demonstrate practical competences in basic nursing

procedures to meet basic health care needs

27
TEMPERATURE

Define related concepts

Body temperature is the balance between the heat produced by the body and the heat lost from
the body.
Core temperature
• Is temp in deep tissues of the body
Surface temperature rises and falls in response to environment: Normal range 36⁰C - 37.2⁰ C

Factors affecting body heat production

• Basal metabolic rate (amount of energy used)
• Muscle activity
• Thyroxin output(its energy during digestion)
• Epinephrine (adrenaline) and sympathetic stimulation Stimulate body’s activity)
• Increased temperature of body cells (fever)

Regulation of body temperature

• Sensors or sensory receptor detect cold more than warmth.
• Three physiologic processes increase the body temperature:
1. Shivering increases heat production
2. Sweating is inhibited to decrease heat loss
3. Vasoconstriction decreases heat loss

Heat loss is brought about by:

Heat is transferred from the skin to the environment in the following ways:
• Radiation: If the heat of the body is greater than that of the environment, it is lost from
body to environment as heat waves
• Convection: Heat is lost in the air close to the skin by convectional currents
• Conduction: Heat is lost through transfer by direct contact with cooler objects
• Evaporation: When water inform of sweat dries and evaporates from skin surface, heat
is lost (Vasodilatation)
• Exhalation of warm moist air
• Urine and feaces, which causes a small heat loss
• Receptors (protein cell that send messages within the body) in the body’s core e.g. spinal
cord and in or around the large veins, respond only to the body’s core temperature and
mainly detect cold than warmth
• Hypothalamic integrator which controls temperature is located in the pre-optic area of
hypothalamus.
• When heat is detected heat production is decreased and heat loss is increased.
• When cold is detected heat production is increased and heat loss is decreased.

Factors affecting body temperature

• Age: In infants/elderly, loss of subcutaneous fat & reduced thermoregulatory efficiency
• Diurnal variations (time of the day) temp highest between 20H00-2400 lowest between
04H00-06H00

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 • Exercise raise temp up to between 38.3⁰C -40⁰C
• Hormones: progesterone during ovulation
• Stress: sympathetic increase production of Epinephrine and norepinephrine and increased
metabolism
• Environment: hot environment affect temp regulatory centre

Pyrexia
Is a raised temperature above 37.2C
Causes:
• Infections
• Trauma/injuries
• Dehydration especially in babies
• Heat stroke, failure of temperature regulating capacity
• Neurogenic causes due to brain injuries and operations.
• Hypoxia

Types of pyrexia
• Constant fever: temp fluctuates minimally but always remain above normal e.g. in
typhoid fever
• Continuous pyrexia: Temp is above 37.5
• Hyperpyrexia: temp above 40⁰c
• Hyperthermia: above 38⁰c but below 40⁰c
• Remittent pyrexia: temp fluctuate over 24hrs, all above normal
• Intermittent pyrexia: temp alternate at regular intervals between periods of fever &
normal e.g. in malaria
• Inverse pyrexia: temp rises in the early hours of the morning instead of
afternoon/evening
• Irregular pyrexia: temp rises from hyperpyrexia to sudden drop each time and again
• Fever spike: recurrent sharp rises in body temp
• Heat stroke: heat regulating centre is damaged & fails to regulate temp to normal ranges

Sites for measuring body temperature

 Orally (in the mouth)
 Rectal ( in the rectum/anus)
 Axillary/armpit
 In the ear/tympanic
 In the vagina/vaginal
 On the skin of the forehead
 Over the temporary artery

Types of thermometers
• Mercury-in glass thermometers
• Disposable thermometers
• Electronic thermometers/Tympanic thermometer

29
 • Chemical disposable thermometers
• Temperature-sensitive tape
• Tactile/surface thermometer
• Rectal thermometer
• Pacifier thermometer for infants

Alteration in body Temperature

• Is the failure or the risk of failing to maintain body temperature within normal range
because of internal factors such as the effects of disease
• Hyperthermia is the risk of sustaining a body temperature greater than 37.8 C orally or
38C rectally
• Hypothermia is the risk of sustaining a body temperature lesser than 35⁰ C orally or
35.5C rectally
• Ineffective thermoregulation exists when the client cannot effectively maintain normal
body temperatures in the presence of adverse or changing external factors.

Rigors
• Is a severe reaction of the body to the presence of microbes, parasites, toxins or other
foreign substances in the blood stream, which affects the heat-regulating centre.
• Children often react with convulsion.
• Occurs at the onset of febrile diseases
• With incompatible blood transfusions and impure intravenous solutions containing
pyrogens.
• In septiceamia, pyaemia (pus forming bacteria) and malaria

Three stages of Rigors

Cold stages (1st stage)
• Patient feels cold and shivers to such an extent that his teeth chatter
• Rapid rise in temperature with increased pulse and respiration rates, in spite of feeling
cold
Treatment;
• Take axillary temp and record
• Reassure the patient
• Add extra blankets, hot water bottles and hot drinks are given

Hot stage (2nd stage)

• The patients feels hot and his temperature reaches its peak 40,6⁰C
• Dry, hot and red
• The patient complains of headache

Treatment;
• The axillary temperature is taken and recorded
• Extra blankets and electric pads are removed
• Give cool drinks
• An ice-bag can be placed on the forehead to relieve the headache
• Ventilation is stepped up

30
 • The patient is covered with only a sheet
Sweating stage (3rd stage)
• Temp drops
• Pt perspires profusely and feels exhausted

Treatment:
• While perspiring, draughts should be avoided and the patients kept covered to prevent
sudden cooling down
• The whole face and neck are dried, when beads of perspiration no longer appear on the
forehead, the sweating stage is over.
• The axillary temperature is taken after sweating ceases and recorded
• Hot drinks are given
• Wet sheets and clothes are changed and the patient sponged down with warm water

Pulse
• The pulse is a wave of blood created by contraction of the left ventricle of the heart.
• Stroke volume output is the amount of blood that enters the arteries with each
ventricular contraction.
• Compliance of the arteries is the dispensability, of arteries e.g. their ability to
contract and expand.
• Pulse rhythm: the pattern of the beats & the intervals between the beats
• Dysrhythmia/arrhythmia: an irregular abnormal rhythm of the heartbeat(in arrhythmia
heartbeat may be absent)

Factors affecting pulse rate

• Age: lower in the aged than in young people
• Exercise: increase pulse rate
• Fever: increase pulse rate
• Medications: may increase (amitriptyline) or decrease(digoxin)
• Hemorrhage/hypovolemia/dehydration: increases heartbeat as the body try to
compensate lost fluid
• Stress/emotional state: fear increase pulse rate (adrenaline release)
• Position change: faster in standing position
• Sex: faster in women than men
• Pathology: cardiovascular conditions affect pulse

Average pulse rate per minute

• Males…………...60-100
• Females…….....70-100
• Old people…….60-70/80
• New born baby…..120-160
• 2 years old child….. 90 -140
• 10 years old child…..80 – 120
• Normal pulse rhythm is called sinus rhythm
• Sinus tachycardia pulse is the increase in rate
• Paroxysmal arterial tachycardia is a tachycardia with a rate of approximately 160/bpm

31
 • Bradycardia is a pulse that is too slow for age and physical activity.

Causes of Bradycardia
• Phenomenon in very fit persons with strong heart muscle (sports people).
• Jaundice (liver disorder)
• Increased intracranial pressure
• Drugs: morphine and digitalis
• Heart block: this indicates advanced disease of the heart muscle.

Causes of heart block

Heart block is an abnormal heart rhythm where the heart beats too slowly, which
results in the electrical signals being partially or totally blocked between the upper chambers
(Atria) and lower chambers (ventricles)
Heart block is also called atrioventricular (AV) block
• Inflammation of the myocardium
• Chronic diseases and ischaemia (decreased blood flow/oxygen) of the myocardium
• After open heart surgery where the bundle of his (cardiac muscle fibres that conducts the
electrical impulses that regulate the heartbeat) has been interfered with.

Abnormal force of pulse/heart beat

• A weak, soft, or feeble pulse is due to diminished blood volume and low blood pressure,
which are caused by the following: severe blood loss, secondary shock and dehydration.
• A bounding, full or tense pulse is difficult to compress with the fingers, and is
characteristic of high blood pressure
• Water hammer (Corrigan) pulse. This type of pulse occurs in conditions in which the
aortic valve does not function effectively, causing the blood to flow back into the left
ventricle during diastole(relaxation)
• eg rheumatic fever,
• atherosclerosis,
• syphilis,
• infective endocarditis

Irregularities of heart beat

• Arrhythmia (irregular rhythm of the heart beat)
• Sinus arrhythmia is characterized by an increased pulse rate during inspiration which
slows down during expiration
• Extra systole is characterized by premature pulse beat(s), which is/are sometimes
followed by a compensatory pause
• Pulsus bigeminus is a regular coupled beat
• Atrial fibrillation is a tachycardia of irregular rhythm and irregular force.
• Pulsus alternans. The rhythm of the pulse is irregular but the force is alternating
between strong and weak.

32
Abnormal arterial wall
• A hard wall is due to the replacement of elastic tissue in the middle layer of the arterial
wall by inelastic connective tissue, in which calcium salts may be deposited.
• This is known as arteriosclerosis and is associated with old age and high blood pressure
• Dicrotic pulse is a weak double pulse beat to correspond with a single heart beat.

Sites (Arteries) for taking pulse

• Temporal
• Carotid
• Apical
• Brachial
• Radial
• Femoral
• Posterior tibial
• Pedal (dorsalis pedis)

Respiration
• The term means respiratory movement, i.e. inspiration and expiration, which are
performed by means of the thoracic cage, and whereby oxygen is inhaled, and carbon
dioxide is exhaled.
• Apnea: complete cessation of breathing of temporary nature
• Tachypnea: a fast and shallow respiration rate greater than the normal range per age
• Dyspnea: difficult and laboured breathing
• Bradypnea: abnormal slow respirations
• Orthopnoea: ability to breath only in upright sitting/standing positions or lean forward in
order to relieve Dyspnea

Normal respiration
• Is regular and quiet, taking place at the rate of:
• 10 to 22 per minute in adults,
• 20 to 26 per minute in children 3-6 yrs
• 15 to 20 per minute in children 10 -14 yrs
• 30 to 40 per minute in infants.

Types of breathing sounds

• Stridor: a shrill/penetrating harsh sound on inspiration (in laryngeal obstruction)
• Stertor: snoring respirations due to partially obstruction of the upper airway
• Wheezing: continuous high pitched musical/whistling sound on expiration/inspiration
due to narrowed air way
• Bubbling: gurgling sounds when air passes through moist secretions in respiratory tract
• Inter-coastal retraction: in-drawing between the ribs
• Sub-sternal retraction: in-drawing beneath the breast bone
• Nasal flaring: when nostrils widens during breathing

33
Factors that influence respiration

Increased respiration (hyperpnoea)

• Increased oxygen requirement eg in exercise, raised body temperature and emotional
excitement. For every 1°c the temperature rises the respiration goes up 7 times/minimum.
Decreased respiration
• In rest, sleep and subnormal temperature
• Temporary cessation of respiration is called apnea

Types of respiration
Abdominal is usually seen in children and males whom the diaphragm and abdominal muscles
play the major part in respiration.
Thoracic is usually seen in children and males, in whom the principal muscles used being the
inter-coastal muscles

Abnormal respiration

Abnormal rate;
A rate of less than 10 or more than 40 in adults is a serious sign.
Increased rate (tachypnoea) is due to:
• Tuberculosis and pneumonia
• Thoracic and abdominal pain
• Severe haemorrhage and anaemia
• Obstruction of the air passages
Decreased rate is due to:
• Increased intracranial pressure
• Depressed respiration\
• Exposure to cold

Abnormal depth of respiration

Increased or decreased depth may be caused by the following
Deep breathing (hyperpnoea) is due to:
• Respiratory stimulants, eg inhalation of CO2;
• Deep-snoring respiration associated with coma due to alcoholism, uraemia (high levels
of urea in the blood) head injuries and brain diseases;
• Deep-sighing respiration occurs in severe blood loss with oxygen deficiency, and
cyanosis
• Shallow breathing is due to :
• Pain in the chest, eg in pleurisy
• Suppression of the respiratory centre in shock and collapse;
• Severe abdominal pain as a result of peritonitis

34
Shortness of breath (air hunger) on exertion
• Indication of reduced oxygen-carrying capacity of the blood
Causes:
• Diseases of the lungs, eg pneumonia, tuberculosis, chronic bronchitis and
pneumoconiosis(inflammation of the lungs following inhalation of dust)
• Diseases of the heart eg left-sided cardiac failure with pulmonary oedema, and congestive
cardiac failure.

Signs of shortness of breath

• Tightness in the chest with cough, fever and chills
• Tiredness
• Shortness of breathing when lying flat
• Cyanosis
• Wheezy sounds
• Stridor breathing sounds
Dyspnoea is difficult in breathing which takes place with effort.
Causes:
• Obstruction of the airways in the asthma and chronic bronchitis
• Reduced compliance of the lungs in oedema caused by left-sided heart failure
• Mechanical interference with the lungs e.g. in pneumothorax and pleural effusion
• Cyanosis is a blue discoloration of the skin and mucus membranes which begins at the
fingertips, toes, ears and nose and spreads over the entire body.
Central cyanosis is due to accumulation of reduced haemoglobin, the blue colour manifesting
itself when the blood contains 5 grams or more of reduced haemoglobin per 100 ml blood.
Peripheral cyanosis of the hands and feet is due to poor circulation or decreased perfusion at
the periphery.
• Orthopnoea is a condition in which the patient is forced to lean forward in order to
relieve severe dyspnoea.
• Cheyne-stokes respiration is a regular periodic rhythmical respiration-commences
slowly and quietly, and becomes faster and deeper until it reaches a climax, after which
the rate and depth decrease gradually until sometimes even a period of apnoea is reached
Causes:
• heart and kidney diseases
• Brain injuries
• Morphine poisoning

General rules for taking TPR

• The TPR are taken and recorded on the chart and in the temperature book
• The patient must be resting in the recumbent or sitting position
• Abnormalities, especially sudden changes, must be reported immediately
• The temperature, pulse and respiration are usually taken simultaneously.
• The thermometer is placed in the mouth, axillary or groin and left there, while the pulse is
being counted.
• The respiration is counted immediately afterwards, without removing the fingers
• (Marie E Vlok, 1994: 614)

35
Blood Pressure
• Definition: Blood pressure is the pressure which the blood exerts against walls of blood
vessels and according to the type of blood vessel, two main kinds of blood pressure can
be distinguished, arterial and venous
• Arterial blood pressure is the pressure which the blood exerts against the walls of the
large arteries

The reasons for blood being under pressure

• For the blood to circulate at a correct rate for constant supply of oxygen and nourishment
to the tissues
• For capillary and tissue perfusion to take place.
• Nourishing tissue fluid is forced through the walls of the active capillaries and waste
products are forced through the glomerular of the kidneys.
• The pressure on contraction (systole) of the heart is called systolic pressure.
• The pressure during relaxation (diastole) is called diastolic pressure
• Average normal arterial blood pressure (120/80) is as follow:
Systolic blood pressure
• Adult……………110 to 140mm mercury(HG)
• Children………..95 to 110mm mercury (HG)
• One-year old infants…75 to 90 mm mercury (HG)
• New-born infants….65 mm mercury (HG)
Diastolic blood pressure
• Adult……………………..70 to 85 mm mercury(HG)
• Children………………..70 to 80 mm mercury (HG)
• One-year old infants…55 to 65 mm mercury (HG)
• New-born infants….35 mm mercury (HG)
Factors which maintain the normal blood pressure

Cardiac output.
• The peripheral resistance of the arterioles to the flow of the blood.
• The elasticity of the walls of the large blood vessels, especially the aorta.
• The viscosity (thickness) of the blood causes resistance to its flow through the small
blood vessels.
• The total blood volume. Average 5 litres but depends on body mass
Venous blood pressure is the pressure which the blood exerts against the walls of the vein
• Venous pressure ensures the return of the blood to the right atrium and vena-cava.
Factors which maintain the normal venous blood pressure are:
• the remains of arterial pressure after the blood has passed through the resisting
arterioles
• The pumping action caused by contraction of those muscles which lie in close proximity
to the veins, especially those in the lower limbs
The blood volume
• The suctioning action caused by the emptying of the right heart and the reduced intra-
thoracic pressure during inspiration

36
Abnormal Arterial blood pressure
• Hypertension – high blood pressure
• Blood pressure normally rises with age.
• It is therefore important to consider age before considering blood pressure hypertensive.
• 160/100 is accepted abnormally high.
Hypertension affect systolic or the diastolic pressure and this can be due to:
 emotional factors,
 inelastic aorta,/aorta incompetency
 and thyrotoxicosis.
 In hypertension pulse pressure is increased
Hypotension - low blood pressure
Although many people suffer from chronic low blood pressure without fatal results, usually
complaining of:
 merely of tiredness,
 lack of energy and spells of dizziness,
 an acute sudden drop in arterial blood pressure has profound effects on the body.
 This may result in Syncope (fainting)
Factors affecting Blood Pressure

• Age: in older adults the diastolic pressure often increases as a result of the reduced
compliance of the arteries.
• Exercise: physical activity increases both the cardiac output and hence the blood
pressure, thus a rest of 20 to 30 minutes following exercise is required before blood
pressure can be reliably assessed.
• Stress: stimulation of the sympathetic nervous system increases cardiac output and
vasoconstriction of the arterioles, thus increasing the blood pressure.
• However severe pain can decrease blood pressure greatly and cause shock by inhibiting
the vasomotor center and producing vasodilatation.
• Race: black males over 35 have higher blood pressures than in white males of the same
age
• Obesity: pressure is consistently higher in overweight and obese people than of normal
weight
• Sex: After puberty, females usually have lower blood pressure than males of the same
age, this difference is thought to be due to hormonal variations. After menopause, women
generally have higher blood pressure than before
• Medications, many medications may increase or decrease the blood pressure; nurses
should be aware of the specific medications a client is receiving and consider their
possible impact when interpreting blood pressure
• Diurnal variations, blood pressure is usually lowest early in the morning when the
metabolic rate is lowest, then rises throughout the day and peaks in the late afternoon or
early evening

Times when vital signs assessment are performed: (T, P, R & BP)
• On admission to a health facility
• According to nursing or medical orders
• Before or after a patient has reported a change in condition, e.g. feeling hot or cold

37
 • Before or after medicine administration which can affect either pulse or respiration rate
• Before or after surgery procedure
• Before and after nursing interventions, e.g. bed bath
• On discharge, before patient goes home

Urine test
Urinary system consists of 2 kidneys, 2 Ureters, bladder and urethra.
Functions of a kidney
• Waste disposal eg excess water, sodium chloride, urea and toxic substances eg drugs
• Homeostasis- regulatory mechanisms that maintain balance in electrolytes and water in
the intracellular and extracellular components in the body.

Urine formation
• Glomeruli filter off excess water
• The pores do not allow large proteins to pass through which retains essential elements
through selective re-absorption.
• The solutes are protein, water electrolytes, createnine, urea, amino acids, glucose, uric
acid, bicarbonate etc.
• These products pass along the nephron tubules where about 99% of water and solutes are
reabsorbed into the blood stream.
• Anti diuretic hormone (ADH) regulate amount of water to be reabsorbed by means of
osmotic pressure
• The urine is collected in the bladder
• The desire to urinate is caused by the sensory of pressure or reflex stimulation

Some related concepts urinary system

• Micturation: voiding or urination. Is the voluntary process of empting the urinary
bladder
• Incontinence of urine: Inability to control the passage of urine/feaces/stools or both
• Retention of urine: inability to void even though the bladder is full
• Urgency: The feeling of wanting to urinate
• Nocturia: Excessive urination at night
• Polyuria: increased amounts of urinary out-put
• Urine retention: inability of the bladder to empty completely during micturation
• Proteinuria: presence of an abnormal amount of protein in urine
• Oliguria: production of scant urine less than 400mls/ per day due to renal failure.
• Pyuria: pus in urine
• Choluria: Bile in urine
• Anuria: absence or less than 100mls of urine per day complete renal shutdown.
• Dysuria: Painful or difficult to pass urine
• Enuresis: Involuntary passing of urine in children
• Suppression of urine: kidney cannot secrete urine even when the bladder is empty

Factors affecting micturation

• Age: older children above 3 yrs & adults can control urine

38
 • Privacy: private, secure, comfortable places promote micturation
• Position: standing or sitting depending, hosp positions like supine may make micturation
difficult
• The nature of facility: comfortable clean toilets promote voiding than dirty ones
• Mental state: anxiety feelings may change normal habits
• Health: illness that affect muscle tone, mental & psychological state increases
incontinence
• Medication: some medications e.g. diuretics, increases urinary output
• Fluid intake: increased fluid intake increase urine volume & frequency of micturation

Disorders of urine production

Polyuria: production of abnormally large amount of urine exceeding 3000 ml per day.
• Due to intake of too much fluids or alcohol, diabetes mellitus, Diabetes inspidus (dilute
urine & increased thirst)
• Polyuria can cause polydypsia. (Intense thirst) dehydration and weight loss.

Characteristics of normal urine

Physical Properties Observations

Colour clear, straw, amber coloured
Reaction Slightly acidic
Specific gravity 1015-1025 with good fluid intake
Deposits None
Odour Aromatic but not offensive
Daily amount Adults 1000-1500, chn(10yrs) 600mls, babies (180 mls)
Water 96%
Solids 3.7% solids dissolved in water, heavier than water
Inorganic salts phosphates, sulphates, potassium, calcium

Normal variations found in urine

Characteristic Observation & Rationale

1.Colour: Amber/brown- high SG (lack of fluid intake)
Light straw -colorless-low SG (high fluid intake)
Reddish colour -e.g. ate beetroot
Orange/green colour -die from sweets, cakes
Dirty cloud colour –urinary tract infection (UTI)
Blue colour -suspect medications as the cause of this
colour.

2.Reaction: Alkaline due to vegetables//fruits 2- 4hrs after eating

Acidic due to alkaline medicines..e.g. bicarbonate of soda

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 Abnormalities found in urine

Abnormality Causes
Colour
Smokey Small amount of urine
Red Presence of blood in urine
Yellow/brown Presence of bile or infection
Pot wine (coca-cola)…….. Small amount of blood
Milky Urinary tract infection (UTI)
Reaction
Alkaline Bladder infection
Odour/smell
Ammonia Bladder infection
Fishy Bladder infection by e.coli
Sweet Starvation/diabetes mellitus
Deposits
Yellow Bile
Thick yellow Pus
Red/chocolate coloured blood
Volume
Polyuria (3000mls p/d Diabetes mellitus, chronic nephritis, diuretic
Oliguria (100-400mls p/d Renal failure
Anuria (less than 100mls p/d Renal failure
Specific gravity
Low SG (˂1005/1.005 Diluted urine due to increases water intake
Fixed SG (remains at 1.10) Serious degree of renal failure
High SG (˃1025/1.025) Concentrated urine due to reduced water intake

Chemical Analysis

Characteristic Normal Abnormal

1. PH
2. SG (spec/gravity)
3. Leukocytes/Pyuria
4. Glucose (Glycosuria,
Hyperglycemia)
5. Protein
Acidic 5-8 Alkaline, ashy diet, alkaline medics &
vegetables
1.015/ 1. 025 Low SG due to high intake of water
Diabetes mellitus, serious sign of renal
failure & dehydration
None Pus in urine can be in form of
leukocytes due to infection like :
Nephritis, cystitis, UTI & STIs.
None Kidney diseases, Diabetes mellitus
Pregnancy and lactation, shock,
thyrotoxicosis, Cortisone therapy,
Cushing syndrome
None Toxaemia of pregnancy, Black water

40
(proteinuria/Albuminuria)
6. Nitrate
7. Ketones (ketonuria)
8. Urobilinogen/Bilirubin (bile in
urine) Choluria
9.Blood in urine, (Heamaturia)
10. Haemoglobin (Haemoglobinuria)
fever/blood/pus, Congestive heart
failure (CCF)
None Nitrate forming organisms, kidneys
disorders
None Starvation, Diabetes Mellitus, High
protein, fat, low carbohydrate diet
None Altered bile pigment absorbed &
accumulated in blood excreted by liver
than kidneys due to: Hemolytic
Jaundice, liver damage, infective
hepatitis
None Menstruation, Acute nephritis, pyelitis,
Cystitis, Acute attack of high Bp
Tumors of the bladder, urinary tract
infection, Bilharzia
None TB bladder and kidneys, Enlarged
prostate gland, Scurvy of bleeding
disorders, trauma e.g. fractured pelvis,
kidney stones, blood incompatability,
black water fever, extensive burns.
41
Feeding of a patients
General Learning Objective: Student nurse should have knowledge that food has important role
in patient recovery.
Specific objectives:
 Define related concepts
• Normal diet used in hospital
• Planning the menu
• Prevention of food contamination
• Hand feeding of helpless patients
• Observations to be made regarding taking of meals
• Diet with special meals

Introduction
• Food plays an important role in pts recovery.
• Sick people are given diet that may be either full, light, soft, liquid or special

Define the concepts

• Full diet: Any kind of food prepared in any kind
• Light diet: easily digestible diet
• Soft diet: a full or light diet which has been minced to make chewing easy
• Special diet: modified diet for the purpose of therapy
• Liquid diet: Given by mouth or nasogastric tube

Planning the menu

Five basic food groups are:
• 1.Proteins e.g. meat chicken, fish eggs etc
• 2. Carbohydrates, e.g. rice maize, potatoes
• 3. Energy giving e.g. animal &vegetable fats
• 4. Mineral and vitamins e.g. fruits and mineral rich food
• 5. Water
Breakfast: meat or fish, Tea coffee milk with porridge, bread , protein, jam or butter
Lunch: meat or fish
• Potatoes/sweet
• Green or yellow vegetable
• Raw vegetable (lettuce/carrots)
• Desserts or fruits
Super: Meat fish, cheese or egg dish vegetable soup
• Bread butter jam coffee or tea

Prevention of food contamination

Common causative organisms for food poisoning are :
• salmonella
• E Coli
• Staphylococcus Aureus from raw meat,
• infected hospital kitchens

42
Methods of ensuring food safety
• Persons with wounds on hand should not work with food
• Wash crockery and cutlery should properly
• Food, crockery and cutlery protected from insects
• Vegetable/fruits/ salads washed properly
• Kitchen staff should be tested every 3-6 months specimen of feaces, throat swab for
culture

Hand feeding of helpless patients

The following patients are fed:
• Gravely ill patients and mentally ill with a feeder and serviette
• Patient who lie in recumbent/supine position
• Whose eyes are closed/blind
• Unable to use hands or arms
• Young children
Feeding procedure
• Stand or sit near to the bed.
• The patient must not get the impression that the nurse is in hurry.
• Patient should be informed about the nature of the food and given chance to chew and
swallow.
Observations to be made
• Appetite of very ill, emaciated/wasted e.g. HIV patients and the amount taken
• Signs and symptoms of vomiting, flatus pain after meals
• Special care of patients on insulin that they have eaten to prevent hypoglyceamia

Diet with special meals

• Disturbed metabolism eg digestive and kidney diseases needs special diets with regard to
energy value and one or more constituents

Energy modifications
A high joule diet: used in emaciated patient eg TB HIV a high kilo joule can be added to a
liquid diet in combination with ordinary diet. It contains butter, oils, sugar, full cream milk,
cheese, peanut etc
Low joule diet (reducing diet): Used for obesity accompanied by Diabetes mellitus, gout, renal
failure, congestive cardiac failure, chronic cholecystitis, hypertension.
Food with moderate joule content; Brown bread, potatoes carrots, skimmed milk, lean meat,
fish, eggs, fruit and green peas.

43
Low protein diet
Indications:
• Acute renal failure/ nephritis
• Chronic uremia, liver failure, Anuria
Sources:
• Clear soup
• squash,
• pumpkin,
• leafy vegetable e.g. celery,
• cucumber,
• green beans,
• cauliflower
• tomatoes
High protein diet
Used for:
• Cirrhosis of the liver without liver failure
• Infective Hepatitis
• Malignant malnutrition
After major operations:
• Deep extensive burns
• Large pressure sore
• Ulcerative colitis (Inflammation of large intestines)
• AIDS sufferers
Other indications for high protein diet
• Bedridden patients
• Trauma induced stress
• Anorexia nervosa patients
Food with high protein content:
• Milk powdered milk
• egg fish
• meat wheat germ
• Legumes e.g. round nuts, beans etc
High carbohydrate diet
Indications:
• Febrile diseases,
• infective hepatitis,
• cirrhosis of liver,
• modified insulin therapy
Sources:
Sugar, sweets,
Jam, chocolates,
White bread macaroni.
Low carbohydrate diet
Used for:
Diabetes mellitus Anaemia

44
High fat diet
Rich in:
• cream,
• Fried foods,
• dried nuts, excluding beans
Low fat diet
Used for:
• Obesity,
• Gout,
• Obstructive jaundice,
• Hypothyroidism
Fat free diet
Sources:
• Skimmed milk,
• butter milk,
• lean meat,
• fish,
• Egg white
• Bread,
• rice
• macaroni
Food rich in cholesterol
• Egg yolk,
• brain, kidney,
• lungs, fat meat,
• butter, shellfish,
• avocado,
• pears
Plants containing unsaturated fats (low cholesterol sunflower oil, peanuts, maze oil, soya
beans)
Iron modification
Indications:
• Anaemia,
• scurvy,
Food rich in iron:
Liver, kidneys,
Lean meat, heart,
Yolk of eggs, dried legumes,
Raisins, whole wheat
Calcium modification
A low calcium diet contain no milk product
Indication: Hypocalcaemia due to breast and bone cancer
High calcium diet (disease of muscle due to lack of calcium)
Indication: Rickets, tetany, Tuberculosis
Sources: milk, cheese, eggs, dried peas, beans, figs, raisins, cabbage

45
Sodium restriction
• Oedema, cortisone therapy
• Hypertension and renal diseases
Increase salt intake:
• Addison’s disease
• excessive vomiting/ diarrhea
• excessive perspiring to prevent heat fatigue
Vitamin modification
• Indications: Typhoid fever,
• anaemia, TB,
• Chronic nephritis,
• peptic ulcer, ulcerative colitis
High Vitamin C
Indications:
• Scurvy,
• after operations and fractures
• congestive cardiac failure and peptic ulcers
Vitamin B
Indications:
• CCF,
• liver cirrhosis,
• pyelonephritis,
• beriberi,
• Pellagra,
• during antibiotic therapy,
• stomatitis and alcoholism
Fluid restriction
• Acute nephritis
• Anuria
• nephrotic syndrome
Alcohol should be avoided to:
Diabetes mellitus
Hypertension,
Obesity
Polyneuritis,
Cirrhosis of the liver
Infective hepatitis
Peptic ulcers
Gastritis,
Gout
Shock
Heamorrhage

46
Positions in nursing
Various positions are used to place the patient for the purpose of:
Treatment,
Examination,
Operation or comfort,
To promote safety, hygiene, sleep and rest.

TASK: STATE THE POSITIONS USED IN NURSING

Lithotomy: position for exposing the anus vulva and perineum.
• Flexion of the knees and abduction of thighs.
• Patient lies on the back.
Purpose: vaginal, rectal operations and examination of bladder.

Positions used for bedridden patients

• Lateral position
• Semi lateral
• Prone position
• Semi prone/recovery
• Fowler’s position
• Semi fowler’s position
• Supine/dorsal
• Semi dorsal

Positioning unconscious patient

• Semi-prone /recovery position is ideal to prevent respiratory obstruction by relaxed
tongue and by mucus and saliva.
• The patient lies on his side with one firm, waterproof covered pillow under his head.
• The uppermost leg is flexed at the knee and hip, the ‘leg’ portion being supported on a
pillow.
• The bottom leg lies flat on the bed, slightly flexed and behind the uppermost one.
• The buttocks are pulled out so that the patient lies on his hip
• The bottom arm is placed behind the body , care being taken that the patient does not lie
on it.
• The uppermost arm is flexed at the elbow and supported on the pillow.
• The feet are kept in dorsiflexion

Positioning the paraplegic patient

• The aim is prevention of bedsores and hypostatic pneumonia
• Position is changed 2 hourly

47
Pressure areas
Objectives:
Define a pressure sore
Definition
• A pressure sore, a pressure ulcer, bed sore or decubitus ulcer, is a localized tissue
necrosis caused by pressure and ischemia of devitalized tissue.
• These conditions can be caused by insensitivity, malnutrition or obesity associated with a
bony prominence that does not heal in an orderly or timely fashion.

Identify common sites of pressure sores

Common sites for pressure sores are:
• Head
• Shoulders/elbows/scapulae
• Ankles
• Knees
• Buttocks/hips/ischial tuberosity
• Sacrum
• Heel

Provide an overview of pressure sores

• Tissue damage occurs when pressure is exerted on the borne prominences
• When a client is laying or sitting on the bony prominence
• The longer the pressure, the greater the skin breakdown
• When a pressure sore occurs the length of the hospital stay and cost increases
• Pressure sore assessment and inspection on admission is crucial for maintenance of skin
integrity

Classify stages of pressure sores

• Stage 1: Erythematic of intact skin- discoloration, warm and hard skin
• Stage 2: Partial thickness- involving epidermis, dermis, abrasion, blister.
• Stage 3: full thickness- skin damage or necrosis of subcutaneous tissue
• Stage 4: Full thickness- skin loss with extensive destruction necrosis damage to the
muscles, tendons, joints and bones

Identify causes of pressure sores

A. Direct causes
B. contributing factors
C. Predisposing factors

A. Direct causes of pressure sores

• Prolonged pressure on tissues
• Friction- parts of body rub together
• Dampness by urine, feaces, sweats
• Injuries- by sharp fingernails that introduce microbes
• Shearing forces- sliding motion of the body usually affects fat, old or severely ill patients

48
B. Contributing factors
• Restless- friction on injury parts
• Confinement- splints or bedridden
• Lowered resistance-diabetes, cancers
• Obesity or emaciation – too fat, too thin
• Agedness- poor circulation, dry skin

C. Predisposing factors
• Paralysis no pain perception
• Unconscious patients
• confused or disoriented unable to self-protect
• comatose patients do not perceive pain, immobile
• Orthopedic patients
• casts, tractions, orthopaedic devices

Describe prevention and treatment of pressure sores

• Bedding smooth, dry, no crumbs, creases
• Damp soft skin hardened with spirit
• Dry skin kept supple with oils
• Nurses nails cut short
• Early ambulation of post-operative patients
• Massage of pressure sores
• Reposition every 2 hours
• Use of soft mattresses and bed cradles
• Patients not left too long on bedpans
• Report to physician any burning pain

Treatment of pressure sores

• Use of air Rings and Supporting Cushions
• Relieve pressure completely
• Nutrition- high protein, vitamin supplements
• Exercise- Massage, active & passive exercise
• Dressing- aseptic techniques, topical applications remove sloughs (soak in eusol) or
debridement by operation

Oxygen
• Supplied by Afrox in gaseous state in a black , drawn-steel cylinder
• Liquid oxygen is released under pressure and supplied by pipes to the wards
• Pipe line – flush type and surface type
• Aerosol in a nebulizer and for anaesthesia
• Method depends on the condition of patient and cause of hypoxia
• Low and moderate: post-op patient by nasal
• Precise amount can be delivered by venture mask
• Patient with chronic obstructive lung disease receive low-oxygen to prevent elimination
of their stimulus to breathe

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 • If hypoxia is the result of impaired cardiac function deliver by high concentration by non-
re-breathing or partial re-breathing mask.
• Humidity and drugs in aerosol form may be given with oxygen through a variety of
devices, such as aerosol face mask, croupette or T-piece.
• For rapid and shallow breathing –more oxygen
• Deep and slow breathing – less oxygen
• Thorough knowledge of equipment used and the conditions being treated enables the
nurse to care safely and effectively for the patient who requires oxygen.
Outcome
Oxygen administration may relieve:
• hypotension,
• cardiac arrhythmias,
• tachypnea,
• headache,
• disorientation,
• nausea and agitation
• characteristics of hypoxia as well as restore the ability of cell

Dangers of oxygen
• Explosion and fire
• Overheating (in an oxygen tent)
• Carbon dioxide necrosis if oxygen supply fails and a mask is used or if respirations are
shallow
• Blindness in premature infants
• Expansion of ruptured lung if oxygen forced in cannot be exhaled
• Drying of the airway

Rules regarding oxygen cylinder

• Be familiar with the regulations for use of medical gas cylinder- color identification and
storage
• Keep in flat cool free of dust
• To prevent from falling, strap them firmly to an oxygen stand
• Prepare them outside the ward to prevent disturbances
• No oils, grease, lubricants or inflammable material may ever come in contact with valve
regulator
• When in use, pressure gauge (meter) and amount of oxygen to be watched carefully.
• Empty cylinder to be replaced

The toilet of the skin, mouth, hair abdominal care or

pressure parts: (bed bath)
Objectives:
At the end of this unit the student should be able to;
• Learn how to prevent bed sores (pressure sores) in the bedridden patient
• How to bed bath adult patient
• How to care for the mouth of a very sick patient (fed parenterally)

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 • Common lesions found in the mouth of sick people
• How to moisturize a dry mouth and lesions of the mouth
• Recognize infestation by head lice, nits and how to disinfect an infested head.
• How to wash hair of a patient confined to bed

Purpose of bed bath

• To cleanse the skin of dead epithelial cells greasiness, germs, dried sweat, unpleasant
odours and discharges.
• To freshen and make the patient feel hot and clammy as a result of pyrexia. It also helps
to reduce temperature
• To soothe the restless patient and to promote sleep
• To provide the patient with some diversion from monotonous hospital routine
• To give a nurse an ideal opportunity to
• Observe the patient more closely and get to know him
• Change soiled bed clothes and night attire
• Change the patients position, move his body and give a thorough attention to his
pressure parts

Care of bedridden patients

• Immobilized patients are moved and given leg and chest exercises.
• Observations are made,
• bed tied,
• soiled linen changed,
• Patient made comfortable.
• IVI checked.
• Clean patients lockers and replenished water supply

Requirements:
• Clean and soiled linen trolley
• Bowl of water, soaps and non-woven wipe for cleaning lockers
• Plastic garbage
• Clean night attire, pillow cases, sheets, drain ring cushions
• Bottle of spirit
• Camphor
• Talcum powder
• Mercurochrome/ gentian violet (GV)
• Oil/ Vaseline, zinc or lanolin
• Packet of sterile swabs
• Hand scrub
• Packet for used swabs

Procedure:
• Loosen bed linen (stripping)
• Remove pillow as well as ring cushion
• Turn patient one side in order to treat dorsal pressure parts

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 • If the patient has to be washed remove the night attire
• Use oil for dry skin spirit for soft skin or powder to prevent pulling skill
• Massage tissue over the bony pressure parts of sacrum, ischial tuberosity, scapulae,
spinous processes and hips use of circular movement.
• Give exercises e.g. of knee and ankles flexion and rotation to prevent stiffness
• Breathing exercise- put the patient in a sitting up position encourage deep breathing to
prevent hypostatic pneumonia
• Straighten the beddings including the draw sheet replace ring cushion
• Change the position after attending the pressure parts.

References
• Kozier B, Erb G & Snyder B, 2012 Fundamentals of Nursing, Wesley Publishing Co:
London
• Kozier B, Erb G & Snyder B, 2002 Fundamentals of Nursing, Wesley Publishing Co:
London
• Viljoen M J 2000 Nursing assessment: History taking and physical assessment, Kagiso
tertiary: cape town
• Vlok M E 1998 Manual of Nursing 9th Edition volume 1 Basic nursing Juta & co: cape
town
• Young A, Van Niekerk C F & Mogotlane S 2003 Juta’s manual of nursing volume1
Basic nursing Juta & co: cape town

LO3: Provide holistic individualized nursing care to the

patient or client to promote health in accordance with the
nursing process
Interpret related concepts (nursing process)
Nursing process is systematic, rational method of planning & providing individualized nursing
care
Purpose:
• To identify a pt’s health status & actual or potential health care problems or needs
• To establish plans to meet the identified needs
• To deliver specific nursing intervention to meet those needs

Explain Maslow’s hierarchy of needs in relation to the nursing process

Basic Human Needs
Needs: Refer to things you must have to survive (food. . .)
Want: Things you would like to have ( Music. . .)
Holism: A theory where all living organism are seen as interacting, unified, wholesome that are
more than the sum of its parts (Kozier & Erb’s: 2014:298)

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Maslow’s five Levels in ascending order
1. Physiological needs: Air, food, water, shelter, rest, sleep, activity, & normal temperature-
very important for survival
2. Safety and security needs: physical & psychological safety
3. Love and belonging needs: giving & receiving affection, attaining a place in a group &
maintaining the feeling of belonging
4. Self-esteem needs: feeling of independence, competence, self-respect & appreciation
5. Self-actualization: after self-esteems are met, a person will strive to develop maximum
potential, qualities & abilities

Maslow’s hierarchy of needs

Characteristics of basic human needs pg 301
• People meet their needs relative to their own priorities e.g. Parents giving up their hard
earned money to their children to cope with city life
• Although basic needs generally must be met, some needs can be deferred e.g. Patient
sharing rooms until get well
• Failure to meet needs results in one or more homeostatic ( a tendency to maintain a state
of balance ) imbalance which can lead to illness
• A need can make itself felt by internal/external stimuli..e.g. seeing food/digestion-feeling
hungry
• Perceived needs can be responded in several ways to meet them..e.g. what you want to
eat at lunch etc
• Needs are interrelated. e.g. need for hydration is influenced by need of elimination of
urine
• NB!! Although we may want to fulfill our basic needs, the country’s law must be
respected.
• Therefore, satisfy your basic needs without harming others and yourself.
(Kozier & Erb’s, 2014: 298-301)

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Describe the components/steps/phases of the nursing process

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Decision making
The process of establishing criteria to develop & select alternative courses of action
Intuition
The understanding or learning of things without the conscious use of reasoning ( based on
knowledge & experience)
Example: when a Lecturer asked you to come to the office, you may think you have done
something wrong

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Database
All information about a client, including nursing health history, physical Assessment,
examination, history, physician history, lab & diagnostic results

Describe the components/steps/phases of the nursing process

The five (5) steps/phases of the nursing process:
• Assessment
• Diagnosis
• Planning
• Implementing
• Evaluation ( Kozier & Erb’s 2014: 194)

1. ASSESSMENT (Kozier & Erb’s 2014: 195-213)

The process of collecting, organizing, validating, and recording data about client’s health
status.
Purpose:
• To establish database on client response concern, illness & to manage health care needs
Actions/activities involved:
• obtain nursing health history
• Conduct physical exam assessment
• Review client record
• Literature review
• Consult support persons
• Consult health professional
Types of Data in nursing process
• Subjective data: Referred to as symptoms, data only from a person affected/pt
• Objective data: Referred to as signs, data, detectable by the observer/nurse, measurable,
can be tested against accepted standards..can be heard, smell, felt & seen. E.g Bp 100/80,
Respirations 24/min, yellow discoloration, pallor of palms, pt’ is sweating etc
Sources of data
• Primary source: directly gathered from the pt
• Secondary source: From supporting people, e.g husband/wife/parent/guardian/family,
health care team, literature/journal, client’s previous records
Data collection Methods:
• Observation
• Interviewing (open & Close ended questions)
• Physical examination

ASSESSMENT: Validating Data

Def: The act of double-checking or verifying data to confirm that it is accurate and factual.
It helps the nurse to ensure that:
• information is complete,
• Objective & related subjective data agree,
• Obtain additional info that may have been overlooked,

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 • Differentiate between cues(internal e.g fatigue/uncomfortable symptoms or external e.g
advice, reminder postcards, illness of family member, mass media campaign) &
inference( nurses interpretation/conclusions about the cues
• Avoid nurses to jump into conclusion & focus on wrong detection

2. NURSING DIAGNOSIS
Nursing Diagnosis (Kozier & Erb’s 2014:216-230)
Is the nurse’s clinical judgment about patient, family/community to actual and potential
health problems or process which gives basis for selecting nursing interventions for the
desired outcomes which the nurse is accountable for?
Aim: To identify patient strengths and health problems that can be prevented/resolved by
nursing/collaborative interventions
Actions:
• interpret and analyze data
• Compare data against standards
• Identify gaps and inconsistencies
• Formulate nursing diagnosis
• Document nursing diagnosis

Types of nursing Diagnosis:

• Actual diagnosis: present problems at the time of assessment
• Risk/Potential diagnosis: problems that are likely to occur especially if present problems
are not addressed correctly
• Health promotion diagnosis: client preparedness to implement and improve the health
condition. e.g. Readiness to exercises
• Wellness diagnosis: When the patient is well..e.g. readiness to resume work

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 Actions/activities involved:
• Set priorities, goals,
• write desired outcomes,
• select interventions,
• consult,
• write interventions,
• communicate care plans

Types of planning
• Initial planning: Made during the first assessment on admission
• Ongoing planning: done by all nurses who work with the patient, after new info is
collected & evaluated pt’s responses to Rx.
Reasons for ongoing planning:
• To check if the health status changed
• To set priorities,
• Decide which problem to focus on
• Coordinate nurses’ activities- to solve patient’s problems at each contact

Developing nursing care plans

Nursing care plan can be:

• Informal nursing care plan: e.g. thinking of what do without writing it down and not
organized
• Formal nursing care plan: written/computerized organized information
• Standardized care plan: formal plan that specifies nursing interventions for a group of
clients with common needs. E.g TB pts may need mask as most are coughing

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 • Individualized care plan: Meets individual needs that are not addressed by standardized
care plan.

Formats for Nursing Care plans

Differ from one agency to another but may have the following:
• Problem/nursing Diagnosis
• Goal/desired outcome
• Nursing interventions
• Evaluation

Actions/activities:
• Reassess & update data base,
• perform planned intervention,
• communicate actions implemented:
• Document care and response
• Verbal report

Types of implementing Skills

• Cognitive skills: problem solving, decision making skills, critical thinking skills
&creativity
• Interpersonal skills: verbal & non verbal skills people use when interacting directly with
one another. E.g. in Communication
• Technical Skills: hands-on skills such as giving injection, bandaging, doing full wash
e.t.c.

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Process of implementing
The process of implementing care normally includes the following:
• Reassess the patient
• Determine the nurse’s need for assistance
• Implement the nursing interventions
• Supervise the delegated care; Senior check if everything is done correctly& timely
• Document nursing activities

Actions/activities
• Collaborate with patient/client
• Judge if desired outcomes are met
• Make decision about problems
• Modify care plan/interventions, terminate PRN
• Document achievements

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Key points
Note: -To collect accurate data you must be aware of your own biases, values, beliefs & to
separate facts from inference, interpretation & assumptions e.g nurse think the pt who hold his
arm to the chest have pain
- To build an accurate database you must validate assumptions regarding physical emotions.
E.g why the patient is holding his arm to the chest. Patient’s answer validate your
assumptions

Describe the characteristics of nursing process

• These characteristics enable the nurse to respond to the changing health status of the
patient
• Data from each phase provide input into the next phase e.g. findings from evaluation
phase feed back into assessment , so nursing process is a regularly repeated sequence of
events (Cycle)
• The nursing process is client centered, the nurse organizes plan of care according to client
problems
• The nursing process focus on problem solving
• Decision making is involved in every phase of the nursing process
• The nursing process is interpersonal and collaborative.
• It requires a nurse to communicate directly and continuously to patients and
families to meet their needs
• It also requires the nurses’ collaboration with other health care team in a joint
effort to provide quality patient care
• Nursing process is used as framework/tool for nursing care in all types of health care
settings with pts of all age groups (Kozier & Erb’s 2014: 194)

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Explain the advantages of the nursing process
• To establish a database about the pt’s responses to health concerns or illness & the ability
to manage health care needs
• To identify pt’s strengths & health problems that can be prevented or resolved by
collaborative & independent nursing interventions
• To develop a list of nursing and collaborative problems
• To determine whether to continue, modify or terminate the plan of care
• To assist the pt to meet desired goals/outcomes, promotes wellness, prevent illness &
disease, restore health and facilitate coping with altered functioning
• To develop an individualized care plan that specifies pt goals/desired outcomes and
related nursing interventions
• To establish a complete database for problem identification, reference & future
comparison
• To determine the status of a specific problem identified in an earlier assessment
• To identify life threatening problems
• To identify new or overlooked problems
• To compare the pt’s current status to baseline data previously obtained
(Kozier & Erb’s 2014:195-197)

Explain the significance of a nursing care plan

• Nursing care plans are an important part of providing quality pt care
• They help to define the nurses’ role in the pts’ treatment
• They provide consistency of care to all pts
• They allow the nursing team to customize its interventions for each pt.
• A formal nursing care plan can be used as a valuable tool for effective communication in
nursing
• Nursing diagnoses are standardized to ensure quality care
• Nursing interventions are tailored to meet the physical, psychological and social needs of
the individual pt
• Nursing care plan is a comprehensive tool that contains all the relevant information about
a pt’s diagnosis, goals of treatment, specific interventions including the observations
needed and plan for evaluation.

Discuss the importance of record keeping and reporting in the provision of

nursing care
Patients’ records are kept for various purposes:
• Communication: the record serves as the vehicle by which different health professionals
who interact with the pt communicate with each other. This prevents repetition & delays
in client care
• Planning pt care: each health professional uses data from the pt’s records to plan care
for that pt. nurses use baseline & ongoing data to evaluate the effectiveness of the nursing
care plan
• Auditing health agencies: an audit is a review of pt’s records for quality assurance
purposes.

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 • Research: the information contained in a record can be valuable source of data for
research.
• The treatment plans for a number of pts with the same health problems can yield
information helpful in treating other patients.
• Education: students in health disciplines often use patient records as education tools.
• A record can provide a comprehensive view of the pt, the illness and effective treatment
strategies.
• Reimbursement: for a facility to obtain payment through government the pt’s records
must contain correct codable diagnosis
• Legal documentation: The patient’s records is a legal document and is admissible in
court as evidence
• Health care analysis: information from patient’s records may assist health care planners
on their budget for next procurement of patient’s needs

Explain the importance of good interpersonal relationship with the

patient/family/community
• Fewer health problems
• Overall physical and emotional happiness
• Gives sense of purpose in life e.g. the closeness you feel with family and friends is an
essential part of your social support
• The presence of family constitutes an important source of psychological stability for the
patient as well as source of support for better recovery, since it helps him to maintain a
contact with his house and friends.
• Effective communication – both intra-hospital and inter-hospital is important for health
care providers to protect their patients
• Effective communication can also help to foster good relationship among staff which can
in turn improve morale and efficiency in the care of their patients
• Patients benefit fro increased access to their medical histories, which reduces chances for
medical diagnosis errors
• When a satisfactory interpersonal relationship is formed, self-identity is established,
health personality develops, and levels of self-fulfillment and happiness increase
• Patients get ongoing treatment support from family after discharge from hospital, as well
as for chronic conditions

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Demonstrate skills in the implementation of the nursing process in the
provision of nursing care
This means nursing processes in action:
Objectives
• At the of this session students will be able to know the characteristic of nursing processes
• Examine the steps of the nursing process

Characteristic of nursing process

(Kozier & Erb’s 2014:194)
• Data from each phase provide input for the next phase
• Client centered
• It’s an adaption of problem solving and system theory-parallel to but separate from the
process used by physicians.
• All start with data gathering and analysis, but medical model focuses on
physiological systems and disease process while nursing is directed toward a client’s
responses to real/potential disease.
• Decision making is involved in every phase
• Nursing process is interpersonal and collaborative
• The universally applicable of nursing process means that it is used as a framework for
nursing care in all types of health care setting and client of all age groups
• Nurses must use a variety of critical thinking skills to carry out the nursing process.

Types of Data
(Kozier & Erb’s 2014:197)
• Subjective data: Referred to as symptoms/covert data only from a person affected
• Objective data: Referred to as signs or overt data, detectable by the observer (nurse),
measurable, can be tested against accepted standards can be heard, smell, felt and seen.

SOAP formula
• SOAP is party of assessment, under history taking, (Kozier & Erb’s
29014:98)
• S-subjective data- quote what the Pt said “I have pain on my left leg” says the pt..or
pateint said I have pain on my leg.
• O-Objective data (what you see, hear, feels, smell, via observation, physical exam)
• A-Assessment ( can be carried out during implementation and evaluation)
• P-Planning

TASK/ACTIVITY
 Mr. Zulu, a 30 year old man is admitted with pyrexia, productive cough, tachypnea , and
labored respirations. In taking a nursing history, Nurse Garcia, RN, finds that Mr. Zulu
has had a “chest pain” for two weeks, and has been experiencing shortness of breath. This
morning he is still pyretic and experiencing “pain” in his “lungs”

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 1. What would be included in the assessment phase?
- Temperature
- Pulse
- Respirations
- Blood pressure
- Skin
- SPO2
- Chest inspection, auscultations, percussions,

2. What would be your nursing diagnosis and why?

• Infective airway clearance related to accumulated mucus obstructing airway
• Hypoxia related to obstructed airway

3. What would you include in your planning as a student nurse assigned to Mr

Zulu?
Care plan: Restore effective breathing lung ventilation for Mr. Zulu by considering nursing him
in semi-fowler position, give oxygen therapy or suctioning, deep coughing and breathing
exercises, discuss with the Dr
Control temperature – tepid sponging, removing some cloths/ blankets, opening windows, air
cons, fans, administer antipyretics
Fluid intake: why needed here? –pyrexia, skin was dry, enough fluid may assist mucus removal

4. What would be your plan of actions?

After explaining the procedure, Mr. Zulu agrees to practice deep breathing exercises 4hrs daily,
Offer fluids and patient verbalize the need of fluids/being in semi-fowler position, oxygen etc.,
carry out new Dr’s orders
Modify nursing care plan-increase or decrease deep breathing exercises, positions, etc

5. What can be done to ensure that the next night shift knows what happened?
• Inspection- no retracted chest
• Auscultation- chest clear
• Percussion- normal sounds
• TPR, SP02( peripheral capillary oxygen saturation) the amount of oxygen in the
circulating blood – normal
• Skin texture soft, good hydration

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LO4: Apply the principles of infection control in the
provision of nursing care
Interpret related concepts (prevention, controlling, transmission, droplet
transmission, airborne transmission, aseptic technique, antiseptic, microbial
agent, Microbistatic agents, infection, disinfection, contamination,
decontamination, cleaning, sterilization

Prevention: Activities directed toward the protection from or avoidance of potential health risk
Controlling: Prevents or stops the spread of infections in health care settings
Antiseptic: Free from contamination caused by harmful microorganism such as bacteria, virus
Transmission: The passing of microorganisms from the infected host to a particular individual
or group, regardless of whether the other individual was previously infected
Aseptic technique: Practices that maintain freedom from infection or infectious material
Airborne transmission: Disease that can be passed from one individual to the other through air
by respiratory droplets such as coughing
Droplet transmission: Infection transmitted by airborne droplets of saliva, sputum containing
infectious microorganisms
Disinfection: Is the process of removing or destroying infectious pathogens from hospital
instruments and equipment
Microbicidal agent: An agent that kills/destroys microorganisms, e.g. bacteria, viruses, fungi
Microbistatic agents: These inhibits growth without killing
Infection: Infection-the disease process produced by microorganisms
Contamination: The action or state of making impure or pollute with infectious bacteria
Decontamination: The process of removal of infectious substances from a surface
Nosocomial infection: Infection acquired by a patient while in hospital
Cleaning: Is a method of disinfecting living tissues and inanimate objects
Sterilization: The process of removing or destroying all pore forming microorganisms from
hospital instruments and equipment
(Marie E Vlok, 2012: 393-398)

Infection Control
Objectives
• Define related concepts
• Identify risks for nosocomial infections
• Explain nursing strategies to prevent infections
• Correctly implement aseptic practices
• Explain the dressing room principles
• Differentiate hospital waste according to color coding
Universal precautions are techniques to be used by both pts and health care providers to
decrease the risk of transmitting unidentified pathogens
Sterile/sterility completely free from all organisms or pathogens that cause infections
Nosocomial infection is infection acquired by a pt while in hospital

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Iatrogenic infections arises due to diagnostic or therapeutic procedures,
Exogenous infections arises from non-normal flora
Endogenous infection- normal flora becomes altered & overgrowth results
Infection-the disease process produced by microorganisms
Asepsis- freedom from infection or infectious material
Aseptic technique- practices that maintain freedom from infection or infectious material
Sterile field: Microorganism-free area (all organisms).
Standard precautions -the risk of caregiver exposure to pt body tissues & fluids rather than the
suspected presence or absence of infectious organisms
• That determines the use of clean gloves, gowns, masks, and eye protection.
Surgical asepsis- practices that keep an area or object free of all microorganisms; also called
sterile technique e.g. aseptic techniques, use of sterile dressing materials/packs, sterilization
process of equipments’.
Medical asepsis- all practices intended to confine a specific microorganism to a specific area,
limiting the number, growth, and spread of microorganisms e.g. routine hand washing, changing
of bed linens, using clean medication cups etc

Patients at risk for acquiring nosocomial infections:

• Critically ill patients,
• Immune compromised patients
• Pts who underwent more invasive procedures
• Overuse of antibiotics
• Pace of activities in a unit
• Using the same gloves on different patients
• Improper barrier nursing
• Improper isolation procedures

Types of microorganisms causing infection :

• Bacteria
• Viruses
• Fungi
• Parasites
• Protozoa
• Amoeba

Nursing Strategies to prevent cross infection in a ward:

• Provide and maintain a clean environment
• Washing hands thoroughly before and after every procedure
• Handle soiled linen with gloves
• Putting on PPEs, e.g. gloves when conducting procedures
• Wash & disinfect reusable instruments before sending to CSSD
• Dispose of all used sharps in a safety box
• Isolate all patients with infectious diseases to prevent cross infection and nosocomial
infections

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Nursing procedures in infection control:
• Cleaning- rinse contaminated objects-wash with soap & warm water-use brush-rise
object in warm water-dry.
• Disinfection & sterilization- enough concentration, duration, surface area, temp,
presence of soap- (some cause disinfectants to be ineffective),presence of organic
materials e.g. blood, pus, saliva etc
• Hand washing- when visible soiled, before & after touching a pt, before performing
invasive procedures, after removing gloves(consider routine & aseptic hand washing)
• Isolation practices- use single room per client, door must be closed, explain and offer
the pt a mask if suffering from airborne disease, wash hands, dispose contaminated items,
knowledge of disease process.
• Gowning- protect health workers & visitors against infection, blood or body fluids, they
can be disposable or reusable-open at the back with a neck tie, long enough to cover outer
garments, long sleeve, with tight-fitting cuffs, carefully remove to prevent contamination
of the uniforms, hands and dispose them accordingly
• Mask- To be worn when splashing of blood or body fluids is anticipated, it protect
against air born microorganism, it should be tightly fit on the mouth & nose, fits below
the glasses, talking should be minimized, dispose a moisture mask, and never reuse face
mask.
• Surgical mask- gives extra protection against small droplets infections that remain
suspended in the air & travel a longer distance.
• Gloves - Prevent transmission of pathogens by direct and indirect contacts, use when
having broken skin, when performing vein-puncture, touching body fluids and when
inexperienced!! Use a pair per patient, discard accordingly,
• Transporting Clients- pt with infective air-born diseases to leave their rooms for
essential purposes only e.g operation, diagnostic procedures.
• Nurse to use standard precautions, offer pt a clean gowns, masks, tissues/a bag to dispose
secretions on the way,
• use extra layer of blanket on a stretcher or wheelchair,
• notify personnel where you are taking the patient, clean the equipment after use, discard
all items accordingly
Donning & removing of PPE such as mask, gloves, gown & eye wear
• To remove soiled PPE, remove gloves first since they are the most soiled.
• Remove protective eye wear and dispose them properly.
• Remove the gown when preparing to leave the room
• Remove the mask at the doorway to the client’s room.
(Kozier 2008, pp 191/693)

Managing equipment used for isolation cases:

• Place garbage and soiled disposable equipment including dressings and tissues in the
plastic bag that lines the waste container.
• Put all non disposable or reusable equipment that are visibly soiled in labeled bag before
removing it from the client’s room, send it to a central processing area for
decontamination.(CSSD) (e.g. glass bottles or jars)
• Bag soiled clothing before sending it home or to the agency laundry

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 • Disassemble special procedure trays into component parts.
• Handle soiled linen as little as possible and with the least agitation possible before
placing it in the laundry hamper.
• All laboratory specimens must be handled with care when collecting specimens to avoid
contaminating yourself and other staffs.
• Non disposable used thermometers are generally disinfected after use
• Place needles, syringes and sharps into a puncture-resistant container.

Maintaining a sterile field:

Sterile field is a microorganism- free area
Principles and practices of surgical asepsis:
• All objects used in a sterile field must be sterile.
• Sterile objects become unsterile when touched by unsterile objects.
• Sterile items that are out of vision or below the waist or below table level are considered
unsterile.
• Sterile objects can become unsterile by prolonged exposure to airborne microorganisms.
• Moisture that passes through a sterile object draws microorganisms from unsterile
surfaces above or below to the sterile surface.
• The edges of a sterile field are considered unsterile.
• The skin cannot be sterilized and is unsterile.
• Conscientiousness, alertness; and honesty are essential qualities in maintaining surgical
asepsis. (2008 Kozier page: 696)
• Every nurse is required to go through principles and practices of surgical asepsis

Dressing room principles:

• These rooms should be disinfected by nursing personnel on a daily basis.
• Ensure that cleaners clean floors.
• Wear disposable unsterile gloves to prepare biocide D solution for daily use in a clean
container supplied by the pharmacy .
• Pour solution in clean container for the purpose of cleaning and disinfection.
• Use a clean cloth to disinfect areas.
• Wear disposable unsterile gloves and first wipe all surface areas (working areas)with
damp cloth.
• Disinfect working areas with alcohol 70% solution after each procedure or when surface
was in contact with a patient.
• Discard solution at the end of the working day.
• Put all non disposable or reusable equipment that visibly soiled in labeled bag and send to
CSSD for sterilization

Classify health care waste

Medical waste:
• Medical waste that is produced during the process of medical research, diagnosis or
treatment.
• This include discarded sharps, blood and blood products
• Human anatomical remains and pharmaceutical waste

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Cytotoxic waste: Waste material that is or has been contaminated and become toxic to body
cells, with cytotoxic drugs during preparation, transportation or administration .
Biological waste: This include pathological and biopsy specimen, tissue, organs that was
removed during surgery, birth or autopsy.
Pharmaceutical waste: These are pharmaceuticals that have
 Passed their shelf life
 Been returned by patients
 No longer comply to the requirements of the ministry.
Bio-hazardous waste: Refers to medical waste which is contaminated with blood, body
fluids e.g. Urine bags, tubes, bandages, gauze and sanitary pads.
Kitchen waste : this is left over food, expired food etc.
Laundry waste: Laundry in the hospital include blankets, bed sheets, gowns, patient clothing
etc.
Household waste: Refers to items such as paper, paper plates, drape papers.

Describe the principles of health care waste segregation

Black: Household waste

Yellow: Left -over food
Red: Biohazards/bloody infectious waste
Green: Soiled linen
Clear: Laboratory Specimens

NB! You should know their usage and the responsible person to handle them

Discuss the components/types of standard precautions in nursing care

Review standard precautions
 ALL persons should do for ALL patients to prevent health care associated infection.
 A set of measures that ALL staff should apply to ALL patients.
 They prevent patients from getting healthcare associated infections from both recognized
and unrecognized sources.
 They are the basic level of infection control precautions which are to be used in the care of
all patients.

Key elements of standard precautions

1. Hand hygiene
• Washing hands is a major component and one of the most effective methods.
• Wash hands before and after any direct patient contact
• Whether or not gloves are worn.
• Immediately after gloves removed.
• Before handling an invasive device.
• After touching blood, body fluids, secretions, excretions, non-intact skin and
contaminated items, even if gloves are worn.
• During patient care, when moving from a contaminated to a clean body site of the patient.

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 • After contact with inanimate objects in the immediate vicinity of the patient.

NB! Your five (5) moments for hand hygiene

2. Gloves
• Wear gloves for direct contact with blood, body fluids, secretions, excretions, mucous
membranes, no-intact skin.
• Change between tasks and procedures on the same patient after contact with potentially
infectious material.
• After use.
• Before touching non-contaminated items and surfaces
• Before going to another patient.
3. Facial protection (eyes, nose, and mouth)
• Wear a surgical or procedure mask and eye protection (eye visor, goggles,
• A face shield to protect mucous membranes of the eyes, nose, and mouth during activities
that are likely to generate splashes or sprays of blood, bloody fluids, secretions, and
excretions.
4. Gown
• Wear to protect skin and prevent soiling of clothing during activities that are likely to
generate splashes or sprays of blood, body fluids, or secretions.
5. Prevention of needle stick and injuries from other sharp instruments
• Discard sharps safely.
• Never resheath (recap) needles.
• Place all sharps directly into a sharps bin/ safety box.
• Discard safety box when two-third full.
• Clean used instruments

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6. Respiratory hygiene and cough etiquette
• Cover mouth and nose when coughing/sneezing with tissue or mask;
• Dispose of mask and tissues; and
• Perform hand hygiene after contact with respiratory secretions.
• Place acute febrile respiratory symptomatic patients at least 1 meter away from others in
common waiting areas, if possible.
7. Environmental cleaning
• Use adequate procedures for the routine cleaning and disinfection of environmental and
other frequently touched surfaces.
8. Linen
• Handle, transport and process used linen in a manner which:
• Prevents skin and mucous membrane exposures and contamination of clothing.
• Avoids transfer of pathogens to other patients and or the environment.
9. Waste disposal
• Ensure safe waste management.
• Treat waste contaminated with blood, bloody fluids, secretions and excretions are clinical
waste, in accordance with local regulations.
• Human tissues and laboratory waste that is directly associated with specimen processing
should
• Also be treated as clinical waste.
• Discard single use items properly

10. Patient care equipment

• Handle equipment soiled with blood, bloody fluids, secretions, and excretions in a
manner that prevents skin and mucous membrane exposures, contamination of clothing
and transfer of pathogens to other patients or the environment.
• Clean, disinfect, and reprocess reusable equipment appropriately before use with another
patient.
References
 Universal precautions guideline.

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HAND WASHING
Objectives
At the end of this lesson a pupil enrolled nurse will be able to:
 Conduct correct hand washing within 10 minutes
 Apply correct hand washing techniques
 Demonstrate practical competence in hand washing.

Introduction
• Appropriate hand washing can minimize micro-organisms acquired on the hands by
contact with body fluids and contaminated surfaces.
• Hand washing breaks the chain of infection transmission and reduces person-to-person
transmission.
• Hand washing is the simplest and most cost-effective way of preventing the transmission
of infection and thus reducing the incidence of health care associated infections.
Purposes of hand wash
• To reduce the number of microorganisms on the hand
• To reduce the risk of transmission of microorganisms
• To reduce the risk of contamination among clients
• To reduce the risk of transmission of infectious organisms to oneself
The principles of hand washing
• Wash hands under running water
• Apply soap to all surfaces thoroughly, from the tips of the fingers to the elbows
• Check fingernails; these should be kept short and clean
• Hold hands up when rinsing soap off the arms so that water does not flow over the
washed areas.
• Close the tap with elbows so that hands are not contaminated
• Dry hands with paper towels from fingers to elbows
(Young, Van Niekerk, Mogotlane 2003:271)

Hand washing practices

There are three types of hand washing namely:
• Social hand washing
• Antiseptic hand washing
• Surgical hand washing
Social Hand washing
Social hand washing occurs:
− Before and after meals
− After using the toilet
− Giving medication
− Before handling food
− Contact before, between and after with patients,
− After bed making and
− When hands are visibly dirty.

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(MOHSS : Infection Control Guideline 2010:22-26)
Antiseptic Hand washing
Antiseptic hand washing should be practiced:
− Before and after a shift
− Before and after aseptic procedure (dressings and injections)
− Before performing invasive procedure
− Before attending to immune- compromised patient,
− After handling contaminated materials, such as bedpans or urinals,
even when wearing gloves
− When entering and leaving high risk areas.
Surgical Hand washing
− Surgical hand washing is an integral practice before the commencement of sterile surgical
procedure in theatre.

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Support effective hand washing practice
Water should be freely running and have a comfortable temperature
Soap:
 Liquid soap for social hand wash
 Antibacterial soap for HCW in a bottle with pump action recommendable on
antiseptic hand washing.
 Bar soap not recommended ( should it be used keep in soap containers with
drainable holes)
 Towels: only disposable towels wide enough to dry and clean properly.
 Bins: Be lid pedal operated to prevent re-contamination of hands.
Hand and skin care
 Skin act as a natural defence against infection, any break or lesion provide opportunity
for entry of pathogens
 Cuts and abrasions should be kept clean and covered with a water proof plaster when
on duty
• Apply glycerine to prevent cracking of hands
Gloves should be worn when appropriate to protect hand

N.B: Wearing of gloves is not a substitute for hand washing.

Nails should be kept short at all times, and nail polish is not allowed as it harbours micro-
organisms.
N.B: Artificial nails are not allowed
Hand drying
Improper hand drying re-contaminates hands:
 always use disposable towels and follow hand washing technique
 Use of communal towels is not recommended
Jewellery: (watches and rings)- avoid wearing them as they can damage integrity of gloves
and interfere with proper hand washing
• Contribute to increased bacterial growth, and cause injury to patients during care.

Don’ts of hand washing

• Do not wash hands in standing water (water in a basin) as organisms may survive in the
water, even if antiseptic is added
• Do not use dirty soap to wash hands.
• Do not dry hand with cotton towels (breeding ground for organisms as it becomes wet
and several people are using it throughout the working day)
• Do not neglect hand wash when gloves were worn.
• The wearing of gloves is never a substitute for hand washing
References
(Kozier & Erb’s 2014: 688-712)

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