2023/2024 Technical Institute of Nursing - Helwan University PDF

1st year – 1st term Technical institute of nursing Helwan University 2023/2024 1 Prepared by: Assistant Professor Dr/ Manar Fathy Hamza Assistant Professor Dr/ Rasha Awad Assistant Professor Dr/ Sabah Nazeh Mohamed Dr/ Rasha Elsayed Dr/ Ahmed Ali Hafez Mohamed Under supervision of: Professor Dr/ Zienab Hussien Ali 2 Table of contents Topics Page Medical terminology. 4 Introduction to nursing and human needs. 11 Nursing Process 25 Exercises, activity and immobilization. 38 Communication & Documentation. 54 Health, Wellness & Illness 71 Infection control & environmental Safety 82 Vital signs 97 Administration of Medication 115 Admission, transfer & discharge. 126 First Aid: CPR, Chocking &Burn 136 References 158 3 Medical terminology Unit (1) Term Meaning Example 1. Acr/o (Extremities) Acromegaly 2. Cardio/o (heart) Cardiomegaly 3. Cyan/o (blue) Acrocyanosis 4. Cyt/o (cell) Leukocyte 5. Dermat/o, Derm/o (skin) Dermatitis 6. Duoden/o (duodenum) Duodenal ulcer 7. Algia (pain) e.g., neuralgia 8. ectomy (excision of, removal of) e.g., gastrectomy. 9. itis (inflammation of) e.g., acrodermatitis, carditis, gastritis 10. ologist (one who studies, a e.g., cardiologist specialist), 11.ology (study of) e.g., cytology, psychology 12. osis (condition of) e.g., cyanosis 13. ostomy (forming a new opening) Gastrostomy 14. otomy (incision into) Craniotomy 15. megal/ o (enlarged, large, big) Acromegaly 16. Gastr/o (stomach) Gastritis 4 17. Gram/o (record) Electrocardiogram 18. Leuk/o (white) e.g, leukocyte 19. Electr/o (electrical) e.g, (ECG) Electrocardiogram 5 Unit (2) Term Meaning Example 1. Arthr/o (joint) e.g., arthritis 2. Emes/is (vomiting) e.g, hyperemesis 3. Carcin/o (malignancy) Carcinoma 4. Aden/o (gland) e.g., adenoma 5. Cele/o, o/cele (hernia) Hydrocele 6. Cephal/o (head) e.g., encephalitis 7. Chondr/o (cartilage) Chondrocarcinoma 8. Cost/o (ribs) e.g., intercostal 9. Dent/o (tooth) e.g., interdental 10. En--, in-- (inside) Inversion 11. Hyper (over) e.g., hypertension 12. Hypo (under) e.g., hypotension 13. Inter (between) e.g., intercostal 14. Laryng/o (larynx) Laryngoscope 15. Lip/o (fat) Lipoma 16. Oste/o (bone) Osteomyelitis 17. Plast/o (surgical repair) e.g., arthroplasty 18. oma (tumor) e.g., lipoma, 6 carcinoma 19. Prefix (term in the beginning of the word) 20. Suffix (term at the end of the word) 21. Ren/o (kidney) e.g., renal failure 7 Unit (3) Term Meaning Example 1) Abdomin/o (abdomen) Abdominal cavity 2) Centesis (puncture) e.g.cardiocentesis, thoracocentesis 3) Cerebr/o (cerebrum) Cerebrospinal fluid 4) Chol/e (bile, gall) e.g., cholecystitis ,cholecystectomy 5) Crani/o (cranium) Craniotomy 6) Cyst/o (bladder, sac) e.g., cystitis, cystectomy 7) Hydr/o (water) e.g., hydrocephalus 8) Lith/o (stone, calculus) e.g., cholelithliasis 9) Lumb/o (lion) Lumbar puncture 10) Ab-- (away from) e.g., abnormal, Abduction 11) Ad--- (toward) Adduction 12) Supra--- (above) Suprapupic area 13) Meter, metr/o (measure) Thermometer 14) Ot/o (ear) Otitis media 15) Pelv/i (pelvis) Pelvic bone 16) Phob/ia (fear) e.g., hydrophobia 17) Pub/o (pubis) Pubic area 8 18) Py/o (pus) e.g., pyorrhea 19) Rhin/o (nose) e.g., rhinitis, rhinorrhea 20) Therap/o (treatment) e.g., hydrotherapy 21) Thorac/o (thorax) Thoracentasis 9 22) Scope, scopy (examining) e.g., endoscopy 23) Orrhea (flow) Otorrhea 24) Adhesion (adhere) 25) Cerebrospinal (brain & spinal Cerebrospinal fluid cord) 26) Enter/o (intestine) e.g., (gastroenteritis) 10 Unit (4) Term Meaning Example 1- Angi/o (vessel) Angiography 2- Hem/o, hemat/o, (blood) Hematemesis emia 3-Hyster/o (uterus) e.g, hysterectomy 4-My/o (muscle) Electromyography 5-Nephr/o (kidney) Nephritis 6-Brady-- (slow) Bradycardia, Bradypnea 7-Tachy-- (fast) Tachycardia, tachypnea 8-Neur/o (nerve) Neurological system 9-Lys/o (destruction) e.g., hemolysis 10-Poly--- (many) Polyuria 11-Pneum/o, (lung) Pneumonia pneumon/o 12-Ureter/o (ureter) Ureteral stenosis 13-Urethr/o (urethra) Urethral stenosis 14-Ur/o (urine) Polyuria 15-Pepsia (digestion) e.g., dyspepsia 16-Dys-- (difficult, pain) Dysuria 11 17-Hepat/o (liver) Hepatomegaly 18-Macro--- (large) Macrovascular 19-Micro--- (small) Microvascular 12 Unit (5) Term Meaning Example 1-Phas/o (speech) e.g., aphasia 2-Phleb/o (veins) e.g., phlebitis 3-Psych/o (mind) Psychiatric 4-Rect/o (rectum) e.g., rectal temperature 5-Therm/o (heat) Thermometer 6-Stomat/o (mouth) e.g., stomatitis 7-Gnosis (know) e.g., diagnosis 8-Plegia (paralysis) Hemiplegia 9-Gloss/o (tongue) e.g, glossitis, glossectomy 10-Gingiv/o (gums) e.g., gingivitis 11-Ophthalm/o (eye) e.g., ophthalmoscope 12-Viscer/o (gut, content of abdomen) Visceral organs 13-Multi-- (many) Multivitamin 14-Ectopic (misplace) e.g., ectopic pregnancy 15-End/o (inner side) Endocarditis 16-Glyc/o (glucose) Hyperglycemia 17-Heter/o (different) Heterogeneous 18-Hom/o (same) Homogenous 13 19-Auto (self) e.g., autoimmune 20-Circum-- (around) Circumcision 21-Necr/o (dead) Tissue necrosis 22-Per-- (through) Percutaneous 14 Unit (6) Term Meaning Example 1-Stern/o (sternum, breast bone) Sternal bone 2-Anti (against) Anticoagulant 3-Bi-- (two) e.g., bifurcates 4-Contra-- (against) e.g., contraindication 5-Hemi--- (half) Hemiplegia 6-Extra (outside of) Extracellular 7-Intra (inside) Intracellular 8-Post (after) e.g., postoperative 9-Pre (before) e.g., preoperative 10-Semi (half, partial) e.g., semiconscious 11-Sub (under) e.g., subcutaneous 12-Trans (across) 13-Tri (three) e.g., triangle Tricuspid valve 14-Uni-- (one) Unilateral 15-Mal-- (bad, poor) e.g. malnutrition, malodor 16-Pleur/o (pleura) Pleural cavity 17-Corne/o (cornea) e.g., corneal ulcer 19-Tympan/o (ear drum) Tympanic membrane 15 Introduction to nursing and human needs. Outlines: 1- Definition of nursing. 2- Historical perspective of nursing. 3- Nursing as a profession. 4- Nursing code of Ethics. 5- Professional nurse responsibilities. 6- Human Needs. Learning objectives:  Define nursing.  Explain the historical perspective of nursing.  Describe nursing as a profession.  Identify the importance of nursing code of ethics.  List the professional nurse responsibilities.  Discuss the basic human needs. 16 Introduction  Nursing has responded to and always will continue to respond to the needs of its clients. In times of war, nursing has responded by meeting needs of the wounded in the combat zones and in military hospitals.  Nursing is a multidimensional profession. Nursing reflects the needs and values of society, implements the standards of professional performance and the standards of care, meets the needs of each client, and integrates current research and evidence based findings to provide the highest level of care. What is Nursing?  The word "nurse", "nourish" and "nurture" all come from the Latin root "nutrire".  Nursing is an art and science. This means that a professional nurse learns to deliver care artfully with compassion, caring, and a respect for each client's dignity and personhood. As a science, nursing is based upon a body of knowledge that is always changing with new discoveries and innovations. American Nurses Association (ANA) definition of nursing: Nursing is the protection, promotion and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities and populations (ANA, 2003). 17 Certain themes are common to many of these definitions: 1. Nursing is caring. 2. Nursing is an art. 3. Nursing is a science. 4. Nursing is client centered. 5. Nursing is holistic. 6. Nursing is adaptive. 7. Nursing is concerned with health promotion, health maintenance, and health restoration. 8. Nursing is a helping profession.  The Recipients of Nursing are sometimes called consumers, sometimes patients, and sometimes clients.  A consumer is an individual, a group of people, or a community that uses a service or community. People who use health care products or services are consumers of health care.  A patient is a person who is waiting for or undergoing medical treatment and care. The word patient comes from a Latin word meaning "to suffer" or "to bear". Traditionally, the person receiving health care has been called a patient. 18  A client is a person who engages the advice or services of another who is qualified to provide this service. The term client presents the receivers of health care. Historical perspective of Nursing:  The founder of Modern nursing: Florence Nightingale established the first nursing philosophy based on health maintenance and restoration.  She developed the first organized program for training nurses the Nightingale Training school for nurses at St. Thomas' hospital in London (1860). Florence Nightingale  Nightingale was the first practicing nurse epidemiologist, she studied and implemented methods for major reforms in hygiene, sanitation, nursing practice and reduced the mortality rate.  Clara Barton, founder of the American Red Cross, tended soldiers on the battle fields, cleansing their wounds, meeting their basic needs and comforting them in death. 19  The U.S. congress ratified the American Red Cross in 1882 after 10 years of lobbying by Barton.  The first African- American professional nurse was Mary Mahoney, RN she was concerned with relationships between cultures and races, and as a noted nursing leader, she brought forth an awareness of cultural diversity and respect for the individual regardless of background, race, color or religion. Mary Adelaide Nutting  Mary Adelaide Nutting, a member of the first graduated class at Johns Hopkins Hospital was instrumental in the affiliation of nursing education with universities.  She became the first professor of nursing at Columbia University teachers (1907), she concluded that nursing education needed increased financial support and suggested that the money be given to university schools of nursing. Nursing in Islam:  Rufaidah bint Sa'ad, is recognized as the first Muslim nurse. She was born in Yathrib before the migration of the Prophet Muhammad.  Rufaidah's father was a physician. She learned medical care by working as his assistant. Her history illustrates all the attributes expected a good nurse. She was kind and empathetic. 20  Rufaidah was a capable leader and organizer, able to mobilize and get others to produce good work. She had clinical skills that she shared with the other nurses whom she trained and worked with. She did not confine her nursing to the clinical situation. She went out to the community and tried to solve the social problems that lead to disease. She was both a public health nurse and a social worker. Nursing as a profession:  Nursing is not simply a collection of specific skills, and the nurse is not simply a person trained to perform specific tasks. Nursing is a profession.  When we say a person acts "professionally" for example, we imply that the person is conscientious in actions, knowledgeable in the subject, and responsible to self and others. Professions possess the following characteristics: 1) A profession requires an extended education of its members, as well as a basic liberal foundation. 2) A profession has a theoretical body of knowledge leading to defined skills, abilities, and norms. 3) A profession provides a specific service. 4) Members of a profession have autonomy in decision making and practice. 5) The profession as a whole has a code of ethics for practice. Code of Ethics:  Nursing has a code of ethics that defines the principles by which nurses provide care to their clients. In addition, nurses incorporate their own values and ethics into practice. A code of ethics provides guidelines for safe and compassionate care. Nurses' commitment to a code of ethics guarantees the public that nurses adhere to professional practice standards. 21 Nursing Education: As a profession, nursing requires that its members possess a significant amount of education. A. Professional registered nurse education: There are various educational routes for becoming a professional Registered Nurse (RN).Hospital schools of nursing were developed to educate nurses to work within those institutions. B. The associate degree program: is a 2 years program that is usually offered by a university or junior college. This program focuses on the basic sciences and theoretical and clinical courses related to the practice of nursing. C. The Baccalaureate degree program (Bachelor of science in nursing BSN), usually encompasses 4 years of study in a college or university. The program focuses on the basic sciences and on theoretical and clinical courses, as well as courses in the social sciences, arts and humanities to support nursing theory. Graduate Education: A. Master's education: after obtaining a baccalaureate degree in nursing, a nurse completing a graduate program can receive the degree of master of Science in nursing (MSN). A master's degree in nursing can be valuable for nurses seeking roles of nurse educator, clinical nurse specialist, nurse administrator, or nurse practitioner. B. Doctoral preparation: professional doctor programs in nursing (DSN or DNSc) emphasize the application of research findings to clinical nursing. Continuing and in-service education A. Because nursing is a dynamic profession, continuing education programs help nurses remain current in nursing skills, knowledge, and theory. 22 Continuing education involves formal, organized and educational programs offered by state nurses association and educational and health care institutions. B. An in-service program is held in the institution and is designed to increase the knowledge, skills, and competencies of nurses and other health care professionals employed by the institution. Professional Nursing Responsibilities and Roles: A. In the past, the principal role of nurses was to provide care and comfort as they carried out specific nursing functions. B. Changes in nursing have expanded the role to include increased emphasis on health promotion and illness prevention, as well as concern for the client as a whole. (1) Autonomy and Accountability:  Autonomy is an essential element of professional nursing.  Autonomy means that a person is reasonably independent and self governing in decision making and practice.  Accountability means that the nurse is responsible, professionally and legally, for the type and quality of nursing care provided. (2) Caregiver:  As caregiver, the nurse helps the client regain health through the healing process.  Healing is more than just curing a specific disease, although treatment skills that promote physical healing are important to care givers. (3) Advocate:  In the role of client advocate, the nurse protects the client's human and legal rights and provides assistance in asserting those rights if the need arises. 23  The nurse advocates for the client, keeping in mind the client's religion and culture. (4) Educator:  As an educator, the nurse explains to clients concepts and facts about health, demonstrates procedures such as self-care activities, determines that the client fully understands, reinforces learning or client behavior, and evaluates the client's progress in learning. (5) Communicator:  Nursing involves communication with clients and families, other nurses and health care professionals, resources persons, and the community.  The quality of communication is a critical factor in meeting the needs of individuals, families and communities. (6) Manager:  As a manager, the nurse coordinates the activities of other members of the health care team, such as nutritionists, and physical therapists, when managing care for a group of clients. (7) Decision Maker:  As clinical decision maker, the nurse uses critical thinking skills throughout the nursing process to provide effective care.  Before undertaking any nursing action, whether it is assessing the client's condition, giving care, or evaluating the results of care, the nurse plans the action by deciding the best approach for each client. (8) Administrator:  A nurse administrator manages client care and the delivery of specific nursing services within a health care agency. 24  Nursing administration begins with positions such as the charge nurse or assistant nurse manager. (9) Researcher:  A nurse researcher investigates problems to improve nursing care and to define and expand the scope of nursing practice. (10) Consultant. (11) Counselor.  Counseling is the process of helping a client to recognize and cope with stressful psychological or social problems, to develop improved interpersonal relationships, and to promote personal growth. It involves providing emotional, intellectual, and psychological support. (12) Change agent.  The nurse acts as a change agent when assisting others, that is, clients, to make modifications in their own behavior. Nurses also often act to make changes in a system, such as clinical care, if it is not helping a client return to health. Nurses are continually dealing with change in the health care system. (13) A leader  A leader influences others to work together to accomplish a specific goal. The leader role can be employed at different levels: individual client, family, groups of clients, colleagues, or the community. 25 Settings for Nursing: In the past, the acute care hospital was the main practice setting open to most nurses. Today many nurses work in hospitals, but increasingly they work in clients homes, community agencies, ambulatory clinics, long-term care,health maintenance organization (HMOs), and nursing practice centers. Human Needs  Basic human needs are elements that are necessary for human survival and health (e.g. food, water, safety, and love).  Maslow's hierarchy of needs is a theory in psychology proposed by Abraham Maslow in his 1943 paper "A Theory of Human Motivation" Maslow subsequently extended the idea to include his observations of humans' innate curiosity. 26  According to this model, certain human needs are more basic than others, that is some needs must be met before other needs (e.g. fulfilling the physiological needs before the needs of love & belonging).  Maslow's hierarchy of needs is useful for designating priorities of care.  Basic physiological and safety needs are usually the first priority, especially when a client is severely dependent physically. The hierarchy of basic human needs includes five levels of priority. 27  The most basic, or first level include physiological needs, such as air, water, and food.  The second level includes safety and security needs which involve physical and psychological security.  The third level contains love and belonging needs, including friendship, social relationships and sexual love.  The fourth level encompasses esteem and self-esteem needs, which involve self-confidence, usefulness, achievement, and self-worth.  The final level is the need for self-actualization, the state of fully achieving potential and having the ability to solve problems and cope realistically with life's situations. 1) Physiological needs  Physiological needs are the physical requirements for human survival. If these requirements are not met, the human body cannot function properly and will ultimately fail. Physiological needs are thought to be the most important; they should be met first. Air, water, and food are metabolic requirements for survival in all animals, including humans. 2) Safety needs  With their physical needs relatively satisfied, the individual's safety needs take precedence and dominate behavior. In the absence of physical safety – due to war, natural disaster, family violence, childhood abuse, etc. – people may (re-)experience, post-traumatic stress disorder. 3) Safety and Security needs include:  Personal security  Financial security  Health and well-being 28 4) Love and belonging  After physiological and safety needs are fulfilled, the third level of human needs is interpersonal and involves feelings of belongingness. This need is especially strong in childhood and can override the need for safety.  Deficiencies within this level of Maslow's hierarchy can impact the individual's ability to form and maintain emotionally significant relationships in general, such as: Friendship Intimacy, Family. 5) Esteem  All humans have a need to feel respected; this includes the need to have self- esteem and self-respect. Esteem presents the typical human desire to be accepted and valued by others.  People often engage in a profession or hobby to gain recognition. These activities give the person a sense of contribution or value. Low self-esteem or an inferiority complex may result from imbalances during this level in the hierarchy. 6) Self-actualization  Maslow describes this level as the desire to accomplish everything that one can, to become the most that one can be Individuals may perceive or focus on this need very specifically.  For example, one individual may have the strong desire to become an ideal parent. In another, the desire may be expressed athletically. For others, it may be expressed in paintings, pictures, or inventions. As previously mentioned, Maslow believed that to understand this level of need, the person must not only achieve the previous needs, but master them. 29 30 Objectives By the end of this lecture every student will be able to:  Define nursing process.  Explain Advantages of nursing process.  List characteristics of the nursing Process.  Discuss Steps of nursing Process. Outlines  Introduction.  Definition of nursing process.  Advantages of Nursing Process  Characteristics of the nursing Process.  Steps of nursing Process. 31 Nursing Process Nursing process is a deliberate problem-solving approach for meeting people’s health care and nursing needs. The common components of the nursing process are assessment, diagnosis, planning, implementation, and evaluation. ANA’s Standards of Clinical Nursing Practice (2004) includes an additional component entitled outcome identification and establishes the sequence of steps in the following order: assessment, diagnosis, outcome identification, planning, implementation, and evaluation. Advantages of Nursing Process  Provides individualized care  Client is an active participant  Promotes continuity of care  Provides more effective communication among nurses and healthcare professionals  Develops a clear and efficient plan of care  Provides personal satisfaction as you see client achieve goals  Professional growth as you evaluate effectiveness of your interventions Characteristics of the nursing Process  Cyclic and dynamic nature  Client centeredness  Focus on problem-solving and decision-making  Interpersonal and collaborative style  Universal applicability  Use of critical thinking 32 Steps of the nursing process: 1) Assessment: systematic collection of data to determine patient’s health status and any actual or potential health problems. 2) Diagnosis: Identification of the following two types of patient problems:  Nursing diagnoses: Actual or potential health problems that can be managed by independent nursing interventions  Collaborative problems: Certain physiologic complications that nurse monitor to detect onset or changes in status. 3) Planning: Development of goals, as well as a plan of care to assist patient in resolving diagnosed problems and achieving identified goals and desired outcomes. 4) Implementation: Actualization of plan of care through nursing interventions 5) Evaluation: Determination of patient’s responses to the nursing interventions and the extent to which the outcomes have been achieved 33 Nursing Process 1) Assessment Assessment data are gathered through the health history and the physical assessment. In addition, ongoing monitoring is crucial to remain aware of changing patient needs and the effectiveness of nursing care. Types of Assessments  Initial assessment Initial assessment is performed within a specified time after admission to a health care agency for the purpose of establishing a complete database for problem identification, and future comparison. Problem-Focused Problem-focused assessment is an ongoing process integrated with nursing care to determine the status of a specific problem. Emergency assessment Emergency assessment occurs during any physiologic or psychologic crisis of the client to identify the life-threatening problems and to identify new or overlooked problems. Time-lapsed Time-lapsed reassessment occurs several months after the initial assessment to compare the client’s current status to baseline data previously obtained. Assessment Activities  Collecting data  Organizing data  Validating data  Documenting data 34 Types of data: Subjective Data  Symptoms or covert data  Can be described only by person affected  Includes sensations, feelings, values, beliefs, attitudes, and perception of personal health status and life situations Objective Data  Signs or overt data.  Detectable by an observer.  Can be seen, heard, felt, or smelled.  Obtained through observation or physical examination. Methods of Data Collection Observing Gathering data using the senses. Used to obtain following types of data:  Skin color (vision).  Body or breath odors (smell).  Lung or heart sounds (hearing).  Skin temperature (touch). Interviewing Planned communication or a conversation with a purpose. It's used to:  Identify problems of mutual concern.  Evaluate change.  Teach patient.  Provide support.  Provide counseling or therapy 35 Examining (physical examination) Systematic data-collection method. It uses observatio ,inspection, auscultation, palpation, and percussion  Blood pressure  Pulses  Heart and lungs sounds  Skin temperature and moisture  Muscle strength Light and deep palpation Percussion technique Assessment techniques: Inspection  Uses vision and hearing.  Recognizes normal and abnormal.  Is the simplest of five assessment skills Palpation  Use hands to touch body parts. 36  Use different parts of hands to distinguish texture, temperature and movement.  Hands should be warm, fingernails should be short.  Start with light palpation and end with deep palpation. Types of Palpation 1. Light palpation. 2. Deep palpation 3. Bimanual Palpation Percussion  Tap body with fingertips to produce a vibration.  Sound determines location, size, and density of structures. Types of percussion 1. Direct percussion. 2. Indirect or mediate percussion. 3. Plunt percussion. Types of sounds heard when using percussion: Flat – soft: e.g., thigh area. Dull –medium: e.g., liver. Resonance –loud: e.g., normal lung. Hyperresonance -very loud: e.g., emphysematous lung. Tympany – loud: e.g. puffed-out cheek Auscultation  Involves listening to sounds. 37  Learn normal sounds first before identifying abnormal or variations.  Requires a good stethoscope, concentration and practice. 2) Diagnosis After completion of the health history and physical assessment, nurses organize, analyze, synthesize, and summarize the data collected and determine the patient’s need for nursing care. Actual Diagnosis  Problem present at the time of the assessment  Presence of associated signs and symptoms  Ex.: (ineffective breathing pattern). Risk Diagnosis Problem does not exist and presence of risk factors Components of a Nursing Diagnosis  Problem  Etiology  Defining characteristics Problem Statement (Diagnostic Label): Describes the client’s health problem or response. Etiology (Related Factors and Risk Factors): Identifies one or more probable causes of the health problem Defining Characteristics: Cluster of signs and symptoms indicating the presence of a particular diagnostic label (actual diagnoses). 38 3) Planning Once the nursing diagnoses have been identified, the planning component of the nursing process begins. This phase involves the following steps: 1. Assigning priorities to the nursing diagnoses and collaborative problems. 2. Specifying expected outcomes. 3. Specifying the immediate, intermediate, and long term goals of nursing action. 4. Identifying specific nursing interventions appropriate for attaining outcomes. 5. Identifying interdependent interventions. 6. Documenting nursing diagnoses, collaborative problems, expected outcomes, nursing goals, and nursing interventions on the plan of nursing care. 39 7. Communicating to appropriate personnel any assessment data that point to health care needs that can best be met by other members of the health care team. Setting Priorities  Assigning priorities to the nursing diagnoses and collaborative problems is an effort by nurse and patient or family members. Consideration must be given to the urgency of the problems, with the most critical problems receiving the highest priority.  Maslow hierarchy of needs provides one framework for prioritizing problems, with importance being given first to physical needs. Establishing Goals  Goals (immediate, intermediate, and long-term) and the nursing actions appropriate for attaining the goals should be identified. Goals are patient- centered and (SMART): Specific, Measurable, Attainable, Relevant, Time Bound.  Immediate goals are those that can be attained within a short period. Intermediate and long-term goals require a longer time to be achieved and involve preventing complications and other health problems and promoting self-care and rehabilitation.  For example, goals for a patient with a nursing diagnosis of impaired physical mobility related to pain and edema following total knee replacement may be stated as follows: 1. Immediate goal: Stands at bedside for 5 minutes 6 to 12 hours after surgery. 2. Intermediate goal: Ambulates with walker or crutches in hospital and home. 3. Long-term goal: Ambulates independently 1 to 2 miles each day 40 Determining Nursing Actions  Interventions should identify the activities needed and who will implement them. Determination of interdisciplinary activities is made in collaboration with other health care providers as needed.  The nurse identifies patient teaching as needed to assist patient in learning certain self-care activities. 4) Implementation  Implementation phase involves carrying out the proposed plan of nursing care. Nurse assumes responsibility for implementation and coordinates activities of all those involved in implementation, including patient and family, other members of nursing team, and other members of health care team, so that the schedule of activities facilitates the patient’s recovery.  While implementing nursing care, nurse continually assesses patient and his or her response to nursing care.  Implementation focus on resolving patient’s nursing diagnoses and collaborative problems and achieving expected outcomes, thus meeting patient’s health needs.  Examples of nursing interventions are promoting physical and psychological comfort; supporting respiratory and elimination functions; facilitating ingestion of food, fluids, and nutrients; managing patient’s immediate surroundings; providing health teaching; promoting a therapeutic relationship; and carrying out a variety of therapeutic nursing activities. Evaluation Evaluation, the final step of the nursing process, allows nurse to determine patient’s response to nursing interventions and the extent to which the bjectives have been achieved. The plan of nursing care is the basis for evaluation. 41 The nursing diagnoses, collaborative problems, priorities, nursing interventions, and expected outcomes provide the specific guidelines that dictate the focus of the evaluation. 42 43 Exercises, activity and immobilization General objective: By the end of this lecture each student will be able to provide nursing care for immobilized patient according to the patient's needs Objectives: By the end of this lecture each students should be able to:  Recognize Anatomy of musculoskeletal system  Define mobility, bed rest, immobility  List the predisposing factors and causes of immobilization.  Explain the Pathophysiology of immobilization and discus the effect of immobilization on body system.  Explain the nursing care for immobilized patient according to ABC, Hs.  Apply the general nursing care for immobilized patient on the clinical area. 44 Outlines: 1- Introduction 2- Anatomy of musculoskeletal system 3- Function of musculoskeletal system 4- Definitions : ( Mobility, Immobility, Bed rest ) 5- Purpose of mobility 6- Predisposing factors and causes of immobility 7- Pathophysiology of immobilization : A. Respiratory system changes B. Cardiovascular system changes C. Gastrointestinal system changes D. Urinary system changes E. Metabolic system changes F. Musculoskeletal system changes G. Integument system changes H. Psychosocial changes I. Developmental changes 8- Nursing care for immobilized person. 45 Anatomy of Musculoskeletal System The musculoskeletal system consists of bones of the skeleton, the joints and the skeletal muscles. The skeleton is subdivided into two major divisions the axial and appendicular. It provides form, support, stability, and movement to the body. The musculoskeletal system’s functions include supporting the body, allowing motion, and protecting vital organs. The skeletal also acts as the main storage system for calcium and phosphorus. Further, it contains important components of the hematopoietic system. Axial and Appendicular Skeleton 46 Introduction: A decline in a person’s mobility status may result from many types of health problems e.g. stroke, fracture. And may produce hazardous effect on the person and there is no body system is immune to this hazardous. Definitions: Mobility: It is a person ability to move freely in his or her environment. Immobility : Immobility occurs when a person is unable to independently move or change position, or movement is restricted for medical reasons. Bed rest : Is an intervention in which the client is restricted to bed for therapeutic reasons. Purpose of mobility: 1. Expressing emotion 2. Self-defense. 3. Attaining basic needs. 4. Performing recreational activities. 5. Completing activities of daily living (ADLs). 6. Maintaining the body's normal physiological activities. 7. Maintain normal physical motility, the nervous muscular and skeletal systems of the body must be intact, functioning and used regularly. 47 Predisposing factors and causes of immobility: 1- Physical: e.g. sever pain, sensory changes reducing the physical stimulus to move, paralysis 2- Social: e.g. Insecurity 3- Emotional: e.g. Sadness, depression, isolation 4- Mental: e.g. phobia 5- Environmental: e.g. Bed, chair, cast, splint N.B: Immobility = Stagnation Pathophysiology of immobilization: Each body system is at risk for impairments resulting from immobility. 1- Respiratory changes :- Shifts of lung position + intra-abdominal pressure which preventing the descent of the diaphragm + resistance of bed or chair decrease lung expansion + generalized respiratory muscle weakness lead to  Oxygen  Stasis of secretion  Infection  Hypostatic pneumonia  Bronchitis  Dyspnea  Hypoxia  Atelectasis 2- Cardiovascular changes :- A. circulating fluid volume + pooling of blood in the lower extremities + generalized muscle weakness lead to 48  Orthostatic hypotension (15 mmHg or more in systolic B.P.)  Venus return.  Systolic B.P. and stroke volume.  Cardiac workload.  Oxygen consumption. B. Venous stasis + external pressure which resulting in obstruction of blood vessels and damage the nerves causing loss of sensation + fluid intake + alteration in blood clotting factors + loss of pumping action of the skeletal muscles lead to Thrombus formation. Pulmonary emboli. Thrombus formation in a vessel 3- Gastrointestinal changes: Immobility + hypercalcemia + muscle weakness + change defecation habits and position lead to  Prolonged retention of fecal material in colon  Colon absorbs the water from fecal material  constipation 49  Rectal ulcers and fissures  Hemorrhoids  Abdominal distension  Heart burn  Anorexia 4- Urinary changes: A. In recumbent position + muscle weakness urinary stasis leads to infection and renal calculi. B. Muscle activities lactic acid execration urine become alkaline Ca precipitate renal stones and infection Stasis of urine Renal calculi 5- Metabolic changes: A. Immobility + energy requirements of body cells + oxygen demand lead to basal metabolic rate (BMR). B. Pancreatic activity insulin production Glucose level in blood fat in the body wt. 50 6- Musculoskeletal change: A. Muscle inactive muscle strength. B. Metabolic changes body mass muscle mass muscle atrophy + shortening of the muscles. C. Disuse + atrophy + shortening of the muscles and surrounding joint tissues lead to  Contracture ( Flexion and Fixation of joint)  Rom  Foot drop  Pain D. Immobility stress on the bone bones become weak bone resorption Osteoporosis and may be at risk for pathological fracture. 7. Integument changes: Pressure on the skin + poor circulation Ischemia skin breakdown (Pressure ulcer) N.B: The pressure sores can develop over bony prominence pressing against any surface (e.g. bed or chair). 51 8. Psychological changes  Depression.  Behavioral changes (e.g. irritability, anger ).  Sleep-wake disturbances.  Impaired coping (e.g. withdrawal and passiveness).  Changes in self-concept.  Hopelessness.  Dependency.  Social isolation.  Helplessness  Frustration.  Nursing care for immobilized person:- The nursing care and client education are directed toward minimizing all these hazards because it is easier to prevent the complications than to treat or cure them. 1- Respiratory system Assessment : 1- Inspect chest wall movement 2- Assess respiration characteristics 3- Auscultate the lung for chest sounds for presence of secretions 4- Observe the skin color to identify O2and CO2 changes 5- Assess type of cough if present and assess sputum (color, odor, consistency) 52 6- dentify the respiratory function by spirometer test 7- Observe blood gases to identify exchange of gases Nursing interventions: 1. Increase warm fluid intake minimum to 2000 ml / day if not restricted 2. Put client in semi sitting position to facilitate breathing. 3. Changing the client position /2 hrs to allow the lung to expand. 4. Back rub to help movement of secretion. 5. Postural drainage to reduce the stagnation of secretion. 6. Teach the client coughing exercise. 7. ROM exercises. 8. Reporting any abnormality e.g. productive cough and it's criteria, cyanosis, chest wheezing …) 2- Cardiovascular system Assessment: 1- Assess base line vital signs during admission. 2- Monitoring B.P. in laying and sitting or standing position. 3- Check edema which indicates some time heart failure. 4- Check temperature and color of the skin to assess the circulation. 5- Assess lower limps for redness, warmth, and tenderness to assess occurrence of DVT. 53 Nursing intervention: 1- Get the client out of bed as soon as the physical condition allows it, even if the move is only to a chair (to maintain muscle tone and increase venous return). 2- Move the client gradually from a supine position into a sitting position. 3- Teach client to avoid crossing the legs, sitting for prolonged period of time wearing tight clothing that constricts the legs or waist, putting pillows under the knees, and massaging the legs to prevent thrombus formation. 4- Increase fluid intake minimum to 2000 ml/day if not restricted to prevent increase viscosity of the blood. 5- ROM exercises reduce thrombi formation and improve circulation. 6- Ask client to share is ADLs which exerts pressure on the veins to promote venous return and reducing venous stasis. 7- Elastic stocking also aid in maintaining external pressure on the muscle and venous. 3- Metabolic system Assessment : 1- Assess base line Ht. and Wt. and skin folds and then periodically 2-4 weeks to evaluate muscle atrophy. 2- Measuring intake and output / 24 hrs. 3- Observing laboratory data electrolytes. 4- Observe the appetite to assess nutritional status. 5- Assess environment for odor or noise that may interfere with appetite. 6- Assess the content of diet for the client to assess the nutritional intake for the client 54 Nursing intervention : 1- Make a dietary plan for the client depending on needs and prefers 2- Ca intake to satisfy the client's need and a cording the electrolyte results. 3- Ask client to share in ADLs to BMR 4- Fat intake preventing further breakdown of nutritional stores 5- Fluid intake to minimum 2000 ml / d to prevent hypercalcemia. 4- Gastrointestinal system Assessment : 1. Assess the dietary habits of the client. 2. Auscultate the peristaltic movement. 3. Assess the elimination habits and material ( time, consistency, content, color, …). 4. Observe stool analysis if necessary. Nursing intervention : 1- Introduce the diet on suitable time and attractive way. 2- Provide small frequent meal. 3- fiber in diet to prevent constipation 4- Fluid intake if not restricted. 5- Physical exercise to promote muscle activity and peristaltic movement. 6- Frequent mouth care to prevent unpleasant odor. 7- Try to maintain regular elimination time. 8- Give enema if recommended. 9- Frequent prenial care 5. Urinary system Assessment : 1- Measuring total intake and output / 24 hrs 55 2- Assess the usual urination patterns 3- Observe results of urine analysis and kidney functions 4- Assess kidneys by palpation for enlargement and for pain 5- Observe urine output for (color, content, odor, …) Nursing intervention: 1. Fluid intake minimum to 2000 ml/day. 2. Recording and reporting the fluid balance /24 hrs. 3. Monitor the frequency and amount of urinary output to prevent bladder distention. 4. Provide perineal care to prevent infection. 5. If the client connected with catheter, provide frequent catheter care. 6. Keep urinary bag hanging under the client's level of bed but don't touch the floor. 7. Recording and reporting any abnormalities of urine. 6- Musculoskeletal system Assessment : 1. Observe client's gait and ability to carry out ADLs 2. Observe ROM of affected joint 3. Inspect joints for redness or swelling indicating potential inflammatory process 4. Observe for signs of fatigue 5. Frequent observing Ca level in blood and urine 6. Assess dietary intake ( content, amount, frequency, … ) Nursing intervention: 1. Assist client to carry ADLs according physical condition. 56 2. Maintain regular physical exercises and ROM exercise (may be for 2 hr. scheduled in a 24 hrs to prevent physical disuse). 3. Teach client breathing skills to help reduce anxiety and to fully oxygenate tissues and expand lungs during exercise. 4. Stop exercise if the client has pain, shortness of breath, or a change in vital signs. 5. Be aware of any medical limitations e.g. untreated fracture or cardiovascular disease. 6. Increase protein, Ca, and vit. D intake. 7- Integument system Assessment : 1. Continually assess the skin for signs of pressure ulcer formation (skin breakdown, color changes, …) at least once daily 2. Continually assess client who at risk for pressure ulcer formation e.g. chronically ill client in long term care, the incontinent client, the orthopedic client …. 3. Assess pressure ulcer if present ( site, stage, size, odor, … ) 4. Assess for fluid intake and output to assess hydration status of the skin Nursing intervention : 1. Change position every 2 hrs and use written repositioning schedule. 2. Maintain an adequate fluid intake. 3. Good hygiene care to maintain skin clean, and dry. 4. Use air matters if available. 5. Use moisturizers for dry skin. 6. Do not massage over bony prominences. 7. Increase protein intake and maintain balanced diet. 8. Good bed making (no particles, stretched linen, dry clean linen) 57 8- Psychological changes : Assessment : 1. Observe for changes in emotional status ( e.g. depression ) and behavioral changes. 2. Observe for changes in the client's sleep-wake cycle such as difficulty falling asleep or frequent a wakening. Nursing intervention : 1. Encourage client to carry ADLs 2. Nursing care should be scheduled to minimize sleep interruptions. 3. Focus on abilities and not disabilities 4. Maintain regular contact with people 5. Give the client express his / her feelings freely 58 59 Communication and Documentation Objectives At the end of this lecture, the student will be able to:  Discuss factors influencing communication process.  Explain purposes of documentation in health care.  Identify elements of effective documentation.  Describe various methods of documentation.  Describe various types of documentation records.  Describe the importance of computerized documentation.  Discuss various types of reporting. 60 Outlines  Introduction  Definition of Communication process.  Types of Communication.  Factors influencing communication process.  Communication barriers.  General Documentation Guidelines.  Elements of Effective Documentation.  Methods of documentation.  Definition of Reporting  Forms of reporting 61 Introduction: Reporting and recording are the major communication techniques used by health care providers to direct client-based decision making and continuity of care. The medical record serves as a legal document for recording all client activities assessed and initiated by health care practitioners. Communication: It's an interaction between two persons or between an individual and a group of people to exchange information knowledge and attitudes. Types of communication:-  Verbal communication: Exchange of information using words.  Nonverbal communication: through body language Nonverbal messages are messages without words or silent messages. These are the messages (other than spoken or written words). Research indicates that our nonverbal messages have much more impact than verbal messages. 1. Eye contact: Eyes transmit more information than any other part of the body. Because eye contact is so revealing, people generally observe some unwritten rules about looking at others. 2. Facial expressions: Most of our observations are very accurate. If we are able to assess the inner emotions of the other person, we can be sure that person is doing the same to us, drawing conclusions based on our facial expressions. 3. Gestures: ex: placing hand over mouth, clenching hands together, crossing legs, or griping arms. These gestures send messages to people about how person react to them and to the situation. 4. ersonal space: It is possible to make others uncomfortable by standing too close to or too far away from them. A customer may feel uncomfortable if a salesperson stands too close. 62 Levels of communication:- 1- Intrapersonal communication: It’s occurring within an individual. It also called self-talk, the person speak to himself. Ex. When a nurse walks into the client’s room and thinks,” He looks uncomfortable; I’d better turn him on his side”. 2- Interpersonal communication: Is the interaction that occurs between two people or in a small group. Ex. Between the nurse and another person like patient. That often occurs face to face and is the type most frequently used innursing situations. 3- Public communication: Is interaction with large groups of people being a competent communicator with an audience requires the ability to envision oneself speaking to a group. Special platform skills such as use of posture, body movements, and tone of voice help a person express a point. Ex. Nurse gives lecture to patient about cardiac disease. Basic Elements of the Communication Process:- During communication the person may or may not be aware of each element of communication. During casual conversation participants do not bother to analyze the meaning of every gesture or word. For Example :- A person may become quite animated, using hands to express an idea without conscious thinking, ―I’ II wave my hand to stress this point‖. 63 The nurse, however, learns to be conscious of each element of the communication process in this way, the nurse can interact effectively with the clients and remain aware of communication’s effect on them. Basic elements of the communication process including :- Channel Message Sender Receiver Feed back Stimulus 64 1- Referent:- (stimulus) It is the stimulus, motives a person to communicate with others it may be an object, experience, emotion, idea or act individuals who consciously consider the referent during interpersonal interaction can carefully develop and organize messages. 2- Sender :- ( speaker or encoder ):- Sender is a person who initiates the interpersonal communication. The sender puts the referent into a form that can be transmitted and assumes responsibility for the accuracy of content and emotional tone of the message. The message is the information that is sent or expressed by the sender. The most effective message is clear, complete, concise, organize and expressed in a familiar manner to the person receiving it. For Example:- Teach the client to manage a colostomy when the client is not willing to look at the stoma. 3- Channels:- The message is sent through a channel of communication. Channels are means of conveying messages. Is the medium or carrier of the message such as Television, the voice or written world touch communication rarely taken place over only one channel you may use two, three, or four different channels. For Example :- When a nurse use booklets, posters and hand out to explain health education for patient with diabetes 4- Receiver:- Is the person to whom the message is sent for communication to be effective, the receiver must perceive or become aware of the message. The message from the sender then acts as one of the receiver’s referents. It prompts the receiver to decode and respond to the sender’s message. 5- Feed back:- Communication is an ongoing process. the receiver returns a message to the sender. It indicates whether the meaning of the sender’s messages was understood. e.g. when the teacher ask students to answer quiz exam after the lecture 65 Factors influencing communication process:- These factors should be considered by nurses:  Ability to listen.  Sensory losses-visual or hearing.  Emotional factors  Developmental stage  Gender  Values  Socio cultural differences.  Distance at which an interaction take pace.  Environment. Therapeutic relationship between nurse and client: The most common problems that can arise in nursing care are failure to establish a helping relationship with patient. It is a relationship between nurse and client that help the client to meet his needs and overcome his problems. Characteristics of therapeutic relationship:  It focuses on patient concerns and needs at first then nurse needs.  Have specific purposes.  Time limited interaction.  It is professional communication not friendship.  Mutual trust and respect between nurse and client.  May develop over weeks or minutes.  Planned communication goals to be met.  Client feel he or she the primary focus of nurse. 66 Common goals of therapeutic communication.  Establish a constructive relationship between the nurses and client  Promotes understanding.  Increase independence for the patient.  Improve patient's health Communication barriers:- Nurse need to recognize and avoid these barriers:  Failure to listen.  Use of poor verbal and body language communication.  False interpretation of message.  Pacing the nurse needs above client needs.  Being defensive.  Denial.  Use of medical language.  Changing topics.  Inappropriate / false reassurance.  Telling the patient what to do.  Improper questioning.  Patient feeling that he has not the interest of others- nurse, doctors.  Patient fear, anxiety, stress.  Limited communication between patient and nurse.  Break confidence,  Environmental distracter Documentation is defined as written evidence of: 1. The interactions between health professionals, clients, their families, and health care organizations 2. The administration of tests, procedures, treatments, and client education 3.The results or client’s response to these diagnostic tests and interventions. Purposes of documentation: 67  Accurate data needed to plan client’s care and ensure continuity of care.  Written evidence of what was done for client, client’s response, and any revisions made in the plan of care  Compliance with professional practice standards.  Compliance with accreditation criteria.  A resource for review, audit, education, and research  A written legal record to protect the client, institution, and practitioner General Documentation Guidelines:  Ensure that you have the correct client record and that client’s name and identifying information are on every page of the record.  Document as soon as client meeting is finished to ensure accurate recall of data (follow institutional guidelines on frequency of charting).  Date and time each entry.  Sign each entry with full legal name.  Do not leave space between entries.  If an error is made while documenting, use a single line to cross out the error, then date, time, and sign the correction; avoid erasing, or using correction fluid.  Never change another person’s entry, even if it is incorrect.  Document in sequential order.  Write legibly.  Use a permanent-ink pen (black is preferable because of its ability to photocopy well).  Document in a complete but concise manner by using phrases and abbreviations as appropriate.  Document all telephone calls that you make or receive that are related to a client’s case. Elements of Effective Documentation  Use of a common vocabulary. 68  Legibility and simplicity.  Use of only authorized abbreviations and symbols.  Factual and time-sequenced organization.  Accurately including any errors that occurred. Use of Common Vocabulary Use of common vocabulary will enhance the quality of documentation and support the efforts of researchers. Also improve intrateam communication and lessen the chance of misunderstandings. Legibility Whatever is charted must be easily readable, without any chance of error. If handwriting is not readable, print. If you make a mistake, do not erase or obliterate it; draw one line through the erroneous entry and state the reason for the error, then sign and date the correction. Abbreviations and Symbols Facilities usually have a list of acceptable abbreviations and symbols to be used when documenting information in the client’s record. Always refer to the facility’s proved listing. Avoid abbreviations that can be misunderstood. Organization  Start every entry with the date and time.  Chart in a chronological order—assessment data, observation, intervention, and evaluation.  Chart medications immediately after administration to avoid errors.  Sign name after each entry. Accuracy  Accuracy and objective data are crucial.  Use correct spelling and grammar, and write complete sentences. 69  Differentiate who does what.  Read notes recorded by nurses on previous shifts and make furthercomments on their findings to maintain the continuity of care. Methods of documentation There are several types of forms used in record keeping: Kardex, flow sheets, nurses’ progress notes, and discharge summaries. All of these forms are designed to facilitate record keeping, reduce duplicate activity, and ensure quick and easy access to information. Kardex  A Kardex (client profile and client summary sheets): A Kardex is a summary worksheet reference of basic client information that is used as a reference throughout shift and during change of- shift reports. Kardexes come in various sizes, and types (may be computer-generated). Flow Sheets  Flow sheets have vertical or horizontal columns for recording dates and times to show assessment and interventions, making it easy to track changes in client’s condition. Use of special equipment and IV therapy are other aspects of flow sheet. Nurses’ Progress Notes  The nurses’ progress notes are used to document the client’s condition, problems, and complaints; interventions; response to interventions; and achievement of outcomes.  Progress notes include the following forms: nurses’ notes, medication administration record (MAR), personal care flow sheets, intake and output forms, vital sign records, and specialty forms (e.g., diabetic flow sheet and neurologic assessment form). 70 Discharge Summary Discharge summaries highlight client’s illness and course of care, it includes: Client’s status at admission and discharge. A brief summary of client’s care. Intervention and education outcomes. Resolved problems and continuing care needs for unresolved problems. Client instructions regarding medications, diet, and food drug interactions, activity, treatments, follow-up instructions, and other special needs. The form has a duplicate copy for client; the original is in medical record. Computerized nursing documentation requires the skills of technically competent nurses to improve client care and change the delivery of health care. In order to demonstrate the quality, effectiveness, and value of the services that nurses provide, standardized data bases have to be developed to ensure accuracy and precision in nursing information systems. 71 72 Assessment and Intervention Flow Sheet 73 REPORTING  Reporting is the verbal communication of data regarding the client’s health status, needs, treatments, outcomes, and responses.  Summary reports, walking rounds, telephone reports and orders, and incident reports are all types of reporting. Summary Reports  Summary reports summarize pertinent client information that focuses on client’s needs for the new caregiver. Summary reports commonly occur at the change of shift and when the client is transferred to another area.  A summary, or end-of-shift, report should be presented as follows: Assessment of the functional health patterns Primary medical and nursing diagnoses and priority problems Identification of client's risk problems Recent changes in condition or in treatments (e.g., new medications, elevated temperature). Adjustments in the plan of care Walking Rounds  Walking rounds can be either nursing rounds, physician nurse rounds, or interdisciplinary rounds. Walking rounds is a reporting method used when the members of the care team walk to each client’s room and discuss care and progress with each other and with the client.  Rounds are more time-consuming than end-of-shift report but give nurses and client the opportunity to evaluate the effectiveness of care together. 74 Telephone Reports and Orders  Telephone communications are another way nurses report transfers, communicate referrals, obtain client data, solve problems, and inform a physician or client’s family members regarding change in client’s condition. Incident Reports  Incident reports, or occurrence reports, are used to document any unusual occurrence or accident in the delivery of client care, such as falls or medication errors.  Ethical practice requires that nurses file an incident report to protect the client not to punish the caregiver.  The incident report serves a function that it informs the facility’s administration of the incident, so risk management personnel can consider changes that might prevent similar occurrences in the future. 75 76 Health, wellness and illness Objectives: At the end of this lecture, the student will be able to:  Define Health, and illness.  List dimensions of Wellness  Discuss factors influencing health status, beliefs, and practices.  Classify illness and disease.  Identify impact of Illness on client and family.  identify models of health and illness.  Apply levels of prevention Outlines:  Introduction.  Definition of Health and illness.  Dimensions of Wellness.  Healthy life style.  Factors influencing health status, beliefs, and practices.  Classification and Stages of illness  Impact of Illness  Health and illness models 77 Health, wellness and illness Introduction:  Health, wellness, and well-being have many definitions and interpretations. The nurse should be familiar with the most common aspects of the concepts and consider how they may be individualized with specific clients. Definition of Health  Traditionally health has been defined in terms of the presence or absence of disease. Nightingale defined health as a state of being well and using every power the individual possesses to the fullest extent  The World Health Organization (WHO) defined health has a state of complete physical, mental, and social well-being, and not merely the absence of disease or disability.  Wellness is a dynamic process that is ever changing. The well person usually has some degree of illness and the ill person usually has some degree of wellness. 78 Dimensions 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, and generally to practice positive lifestyle habits. 2. Social  The ability to interact successfully with people and within the environment.  Social Wellness emphasizes the interdependence of others and encourages contributions to society 3. Emotional: The ability to manage stress and to express emotions appropriately, Emotional wellness involves ability to recognize, accept, & express feelings. 4. Intellectual: The ability to learn and use information effectively for personal, family, and career development. 5. Spiritual: The belief in some force (nature, religion, or a higher power) that serves to unite human beings and provide meaning and purpose of life 79 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 relationships with others. 7. Environmental: The ability to promote health measures that improve the standard of living and quality of life in the community. Healthy lifestyle What contributes to a healthy lifestyle?  Regular physical activity  Eating well  Managing stress  Avoiding destructive habits  Practicing safe sex  Adopting good safety habits  Adopting good personal health habits  Seeking and complying with medical advice  Protecting the environment Factors influencing health status, beliefs, and practices: 1) Internal factors:  Biologic dimension: sex, age, & developmental level all significantly influence a person's health. 80  Psychological: emotional factors influencing health as mind-body interactions & self-concept.  Cognitive dimension: include lifestyle choices and spiritual and religious beliefs. 2) External factors:  Socioeconomic factors: Social and psychological factors can increase the risk of illness and influence person's reaction to illness. Ex: life style habits and occupational environment. Economic variables affect client's level of health by increasing the risk of illness  Family practices: the way the client's family use health care services affect their health practices. Their perceptions about seriousness of disease and their history of preventive care behaviors can affect how client will think about health.  Cultural background: cultural beliefs and values can influence the personal health practices. nurses should focus on understanding client's traditions, values, and beliefs. Definition of Illness and disease  Is a personal state in which person's physical, emotional, intellectual, social, developmental, or spiritual functioning is thought to be diminished. Illness is associated with disease but may occur independently of it. Illness is a highly personal state in which the person feels unhealthy or ill. Classification of illness and disease:  Acute illness:  Characterized by symptoms of relatively short duration 81  Symptoms appear abruptly, subside quickly  May or may not require intervention by health care professionals  Most people return to normal level of wellness  A chronic illness: Physical and mental alterations in health with one or more of the following:  Lasts for an extended period, usually 6 months or longer, and often for person's life.  Permanent change  Causes or is caused by, irreversible alterations in normal anatomy and physiology  Requires special need for rehabilitation  Requires long period of care or support. Risk factors of illness 1) Genetic and physiologic factors: Hereditary and genetic predisposition to specific illness is a major physical risk factor. Ex: the person with a family history of diabetes is at risk for developing the disease later in life. 2) Age: Age increases or decreases susceptibility to certain diseases. Ex: infants born prematurely and all neonates are susceptible to infection. 3) Environment: Environment where we live (air, water, and soil) determine how we live, what we eat and diseases agents to which we are exposed. ex: some kinds of 82 cancer are more likely to develop when industrial workers are exposed to certain chemicals or toxic wastes. 2) Life style: Lifestyle practices and behaviors can have positive or negative effects on health. Practices with negative effects are risk factors as sedentary lifestyle, over eating or poor nutrition, smoking and alcohol or drug abuse. Stages of illness Suchman describes five stages of illness:  Stage 1 symptoms experiences: Believe something is wrong  Stage 2 assumption of the sick role: Accepts the sick role and seeks confirmation  Stage 3 medical care contact: Seeks advice of a health professional.  Stage 4 dependent client role: Becomes dependent on the professional for help  Stage 5 recovery or rehabilitation: Relinquish the dependent role Resume previous roles and responsibilities Impact of Illness On the Client:  Behavioral and emotional changes  Loss of autonomy  Self-concept and body image changes  Lifestyle changes On family:  Role changes 83  Task reassignments  Increased demands  Anxiety about outcomes  Financial problems  Loneliness as a result of separation  Change in social customs. Models of health and illness:- Model is a theoretical way of understanding a concept or idea. Because health and illness are complex concepts, models are used to understand the relationships between these concepts and the client's attitudes toward health and health behaviors. 1) Health belief model:  Health beliefs are a person's ideas, and attitudes about health and illness. Because health beliefs usually influence health behavior, they can positively or negatively affect a client's level of health.  Positive health behaviors are activities related to maintaining, attaining or regaining good health and preventing illness. Common positive health behaviors include immunization, proper sleep patterns, adequate exercise and nutrition.  Negative health behaviors include practices actually or potentially harmful to health such as smoking, drug or alcohol abuse, poor diet and refusal to take necessary medications.  The individual perception of susceptibility to an illness affects the health belief model. 84 Ex: a client needs to recognize the familial link for coronary artery disease. This link is recognized when one parent and two siblings have died in their fourth decade from myocardial infarction; the client may perceive the risk of heart disease.  A client's perception of susceptibility to disease and his or her perception of the seriousness of this disease helps him to take preventive measures include life style changes and search for medical advice or treatment. 2) Health promotion Model:  The health promotion model (HPM) proposed by Pender (1982, revised 1996). It defines health as a positive, dynamic state not merely the absence of disease.  Health promotion is directed at increasing a client's level of wellbeing.  The model focuses on three areas: 1- Individual characteristics & experiences. 2- Behavior specific knowledge and affect. 3- Behavioral outcomes.  The (HPM) notes that each person has unique personal characteristics and experiences that affect subsequent actions.  Health promotion activities such as routine exercise and good nutrition help clients to maintain health.  Illness prevention activities such as immunization programs protect clients from actual or potential threats to health. Levels of preventive care: Nursing care oriented to health promotion, wellness, and illness prevention can be understood in terms of health activities on primary, secondary and tertiary levels. 85  Primary prevention: is true prevention, it precedes disease or dysfunction and is applied to clients considered physically and emotionally healthy. Primary prevention includes health education programs, immunization and physical and nutritional fitness activities.  Secondary prevention: focuses on individuals who are experiencing health problems or illnesses and who are at risk for developing complications, activities are directed at diagnosis and prompt interventions to help the client to return to normal level of health.  Tertiary prevention: Occurs when a defect or disability is permanent and irreversible, activities are directed at rehabilitation rather than diagnosis and treatment. 3) Basic Human needs Model:  Basic human needs are elements that are necessary for human survival and health. Ex. Food, water, safety and love. All people share the basic human needs.  Maslow's hierarchy of needs is a model that nurses can use to understand the interrelationships of basic human needs. According to this model, certain human needs are more basic than others that are some needs must be met before other needs.  Ex. fulfilling the physiological needs before the needs of love and belonging. 4) Holistic Health Model:  ealth care has begun to take a more holistic view of health by considering emotional and spiritual wellbeing as well as other dimensions of an individual as important aspects of physical wellness.  Relaxation therapy and music therapy are examples of holistic strategies which can be used in all stages of health and illness. 86 Infection Control & Environmental Safety 87 Infection control and environmental safety 1. Definition of Infection. 2. Chain of infection. 3. Normal body defenses. 4. Prevention of infection. 5. Universal precautions. 6. Patient safety. 7. Restraints Learning objectives: At the end of lecture, the student will be able to: 1. Define Infection 2. List the elements of chain of infection 3. Describe normal body defenses. 4. Enumerate universal precautions 5. Explain what is patient safety 6. Give examples of restraints 88 Infection control and environmental safety Introduction  Microorganisms are naturally present in the environment, some are beneficial and other is not. Clients entering a variety of health care settings are at risk for infections. Furthermore, many clients have a lower resistance to microorganisms and develop disease or infection after increased exposure. Preventing the transmission of microorganisms is a concern of all health care personnel. It is one of the most important functions a nurse performs. Definition of Infection:  An invasion of pathogens or microorganisms into the body that are capable of producing disease. Infection Control:  Includes all of the practices used to prevent the spread of microorganisms that could cause disease in a person.  Infection control practices help to protect clients and healthcare providers from disease by reducing and/or eliminating sources of infection.  Contaminated – means dirty, soiled, and unclean.  Disinfection – cleaning so that germs (pathogens) are destroyed.  Mode of transmission – the way germs are passed from one person to another.  Mucous membranes – membranes that line body cavities that open to the outside of the body.  Communicable/ infectious disease – disease spread from one person to another. 89 The risk of infection is always present.  Patient may acquire infection before admission to the hospital = Community acquired infection.  Patient may get infected inside the hospital = Nosocomial infection or hospital acquired infection. Chain of Infection (Infection cycle): Infection develops if this chain stays intact. The nurse's efforts to control infection are directed at breaking this chain. 1) Pathogen/ Infectious agent: is a disease producing microorganisms (bacteria, viruses).  Resident – normally reside on the skin in stable numbers.  Transient – attach loosely to the skin by contact with another – easily removed by hand washing.  Fungi: are microorganisms that can grow in or on the body, causing infections of internal organs or of the skin, hair, and nails.  Viruses: are tiny infectious agents that can cause infectious diseases. A virus can only reproduce within the cells it infects.  Parasites: are organisms such as protozoa (one-celled animals), worms, or insects that must live on or inside a human or other organism to survive. An animal or plant harboring a parasite is called its host. Parasites live at the expense of the host and may cause illness. 90 2) Reservoir (or source of pathogen): Pathogen survives here but may or may not multiply.  Inanimate objects which include medications, air, food, water, soil (as gas gangrene and tetanus), or any other material on which organisms can find nourishment and survive.  Animals as rabies especially dogs  Human beings that include other clients, health care personnel, family members, visitors and clients themselves.  Carriers: are persons or animals who show no symptoms of illness but who have pathogens on or in their bodies that can be transferred to others. 3) Portal of Exit: Site where microorganism leaves the reservoir, exit through the skin, respiratory tract, blood. 4) Modes of transmission: through Body fluids – tears, saliva, sputum (mucus coughed up), urine, feces, semen, vaginal secretions, pus or other wound drainage, blood. Four main routes of transmission are:  Contact transmission: Direct: involves body surface to body surface contact causing the physical transfer of organisms between an infected person and a susceptible host as kissing and sexual intercourse. Indirect contact. Occurs when susceptible host is exposed to a contaminated object such as dressing, needle or surgical instrument.  Droplet transmission: that occurs when mucous membranes of the nose, mouth, or conjunctiva are exposed to secretions of an infected person who is coughing, sneezing or talking. 91  Vehicle transmission: that involves the transfer of microorganisms by way of vehicle (contaminated items) as food that can carry Salmonella, water, drugs and blood that can carry hepatitis and AIDs.  Airborne transmission: that occurs when fine particles are suspended in the air for a long time or when dust particles contain pathogens. These organisms can be inhaled by or deposited on the skin of a susceptible host. 5) Portals of entry: Anybody opening of an uninfected person which allows pathogens to enter. Nose, mouth, eyes, rectum, genitals and other mucous membranes. Cuts, abrasions or breaks in the skin. Organisms can enter the body through the same routes they use for exiting. 6) Susceptible host/ WHO IS AT RISK??  Susceptibility to an infectious agent depends on the individual's degree of resistance to pathogens.  Reasons for lowered resistance: age, nutritional status, existing illnesses, fatigue and stress.  The elderly have weaker immune systems and a lower resistance to pathogens.  Elderly are hospitalized more often, increasing the chance for hospital- acquired infections. Course of infection (stages of infection): An infection progress through the following phases: 1) Incubation Period: There is an interval between entrance of pathogen into the body and appearance of first symptoms. During this stage, the organisms are growing and multiplying. Its length may vary (e.g., common cold 1 to 2 days while tetanus is 2-21 days) 92 2) Prodromal Stage Of Illness: A person is most infectious during it.early signs and symptoms of disease are present but are vague and non specific ranging from fatigue, malaise to a low grade fever. It lasts from several hours to several days. 3) Full Stage of Illness: Client manifests signs and symptoms specific to type of infection (e.g., common cold manifested by sore throat, sinus congestion, rhinitis, and mumps manifested by earache, high fever, parotid and salivary gland swelling). 4) Convalescence: Acute symptoms of infection disappear and the person returns to a healthy state. Length of recovery depends on severity of infection and client's general state of health; recovery may take several days to months. Clinical signs and symptoms of infection: 1) Systemic (general) manifestations: Fever, fatigue, malaise, lymph node enlargement, loss of appetite, nausea, and vomiting may be found. 2) Localized manifestations: Redness, swelling, pain or tenderness, and restricted movement of a body part occur. There may be drainage from open lesions or wounds. 3) Laboratory data: Specific laboratory tests, including WBC count, cultures, erythrocyte sedimentation rate(ESR), differential count and presence of pathogen in urine, blood, sputum or other drainage culture add to the data base for assessing infection. 93 Antibiotic Resistant Microorganisms:  Normal flora gone bad! Problem exists because of overuse and inappropriate use.  Resistant to multiple antibiotics.  Reduced options for treatment and required isolation precautions. Examples: MRSA, Solutions: more appropriate antibiotic use, better infection control and prevention. MRSA: Methicillin Resistant Staphylococcus Aureus. Common nosocomial infection in hospitals & long term care facilities. This staph aureus is resistant to methicillin. MRSA is easily transmitted by health care workers VERY IMPORTANT TO WASH YOUR HANDS…. Normal body defenses: Physical Barriers: 1) The skin: prevents invasion by microorganisms unless it is damaged—for example, by an injury, insect bite, or burn. 2) Mucus membrane: Mucous membranes are coated with secretions that fight microorganisms. For example, the mucous membranes of the eyes are bathed in tears, which contain an enzyme called lysozyme that attacks bacteria and helps protect the eyes from infection. The airways filter out particles that are present in the air that is inhaled. The walls of the passages in the nose and airways are coated with mucus. Microorganisms in the air become stuck to the mucus, which is coughed up or blown out of the nose. 94 3) Stomach Acid:  The digestive tract has a series of effective barriers, including stomach acid, pancreatic enzymes, bile, and intestinal secretions. The contractions of the intestine (peristalsis) and the normal shedding of cells lining the intestine help remove harmful microorganisms.  The bladder is protected by the urethra, the tube that drains urine from the body. When the bladder empties, it flushes out any bacteria that reach it. 4) The Blood:  The body also defends against infection by increasing the number of certain types of white blood cells (neutrophils and monocytes), which engulf and destroy invading microorganisms. 5) Inflammation: The inflammatory response occurs as a result of any bodily injury. This response can be caused by pathogens, trauma, or other events causing injury to tissues. Infection may or may not be present.  Vascular Response The first step of the inflammatory process is local vasodilation, which increases blood flow to the injured area. Increased blood flow creates redness and heat at the injury. Pathogenic organisms can trigger the first step of the inflammatory process.  Inflammatory Exudate Next, increased permeability of the blood vessels allows plasma to move out of the capillaries and into the tissues. Swelling occurs resulting in pain from pressure on nearby nerve endings. 95  Phagocytosis and Purulent Exudate The final step of the inflammatory process is the destruction of pathogenic organisms and their toxins by leukocytes. During this process, a purulent exudate (pus) may form that contains protein, cellular debris, and dead leukocytes. Immune Response:  When an infection develops, the immune system responds by producing several substances and agents that are designed to attack the specific invading microorganisms.For example, the immune system may produce killer T cells (a type of white blood cell) that can recognize and kill the invading microorganism. Fever: Body temperature increases as a protective response to infection and injury. An elevated body temperature (fever) enhances the body's defense mechanisms, although it can cause discomfort. A part of the brain called the hypothalamus controls body temperature. Impacts of Health Care-Associated Infections (Nosocomial infection): 1- Increase patients’ suffering. 2- Lead to permanent disability. 3- Lead to death. 4- Prolong hospital stay. 5- Increase need for a higher level of care. 6- Increase the costs to patients and hospitals. 96 Key Points for Personal Hygiene a) Bathe daily and wear a clean uniform/clothing every day. b) Keep your fingernails short, and do not wear artificial nails. c) Avoid wearing rings that harbor organisms. d) Cleanse your stethoscope at least daily and in between patient use with alcohol. e) Wash your hands between each patient contact. If you are unable to use soap and water, use a nondrying alcohol hand gel. f) Follow prescribed isolation precautions for your protection, as well as that of the patient. g) Remove your uniform and bathe/shower when you come home from work. h) Keep your nursing shoes clean and put away from the rest of the family. ASEPSIS Means the absence of disease-producing microorganisms or any activities that prevent infection or break the chain of infection The two types of aseptic technique that the nurse practices are medical asepsis and surgical asepsis. 1- Medical Asepsis : Clean technique; procedures used to reduce & prevent spread of microorganisms (Hand washing) 2- Surgical Asepsis: Sterile technique; procedures used to kill microorganisms (Sterilization). 97 Cleaning: It is the process of removing foreign materials (e.g., organic material such as blood or inorganic material such as soil) from objects. Generally, this is accomplished by the use of water, a detergent, and proper mechanical scrubbing action. Cleaning must occur before disinfection and sterilization procedures.  Disinfection: It is a process that eliminates almost all pathogen organisms on objects, with the exception of bacterial spores.  Sterilization: It is a process by which all forms of microorganisms including spores are destroyed. Universal precautions: Universal precautions are infection control guidelines designed to protect workers from exposure to diseases spread by blood and certain body fluids. Universal precautions guidelines:  Wear gloves if you may come in contact with blood, body fluids, secretions and excretions, broken or open skin.  Bag all disposable contaminated supplies.  Clean all surfaces that may be contaminated with infectious waste, such as beds, wheelchairs and shower chairs.  Do not touch clean objects with contaminated gloves.  Good hand washing is the most effective method to prevent the spread of infection. Personal Protective Equipment (PPE):  Gloves, aprons, gowns, eye protection, and face masks.  Health care workers should wear a face mask, eye protection and a gown if there is the potential for blood or other bodily fluids to splash.  Masks should be worn: 98  If an airborne infection is suspected or confirmed to protect an immune compromised patient. Gloves must be worn for:  All invasive procedures.  Contact with sterile sites.  Contact with non-intact sk

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