Fundamental of Nursing Theory PDF

First Year FUNDAMENTAL OF NURSING THEORITCAL BOOK  Prepared By Dr. Mai El-Sayed Mohsen Medical- Surgical Nursing Dr. Mayada Soliman Rashed MSc. Abdullah Shokrey Ismail Obstetrics and Gynecology Nu...

First Year FUNDAMENTAL OF NURSING THEORITCAL BOOK  Prepared By Dr. Mai El-Sayed Mohsen Medical- Surgical Nursing Dr. Mayada Soliman Rashed MSc. Abdullah Shokrey Ismail Obstetrics and Gynecology Nursing Critical Care and Emergency Nursing MSc. Muhammad Said Seif Dr. Hanaa El-sayed Mohamed Medical- Surgical Nursing Pediatric Nursing  List of content Content Page Chapter one foundation of Nursing Practice 1. Definition of Nursing. 3 2. The Nursing Profession and Its Characteristics 4 3. The Role of The Nurse and Its Functions. 6 4. Ethics in Nursing Profession. 8 5. Patient’s Safety 11 6. Health and Illness Concept 15 Chapter two Communication 1. Components of the communication process 22 2. Mods (forms) of communication 24 3. Levels of communication 26 4. Factors influencing the communication process 27 5. Therapeutic communication technique 29 Chapter three Critical Thinking in Nursing Practice 1. Critical thinking 34 2. Nursing process 36 3. Health assessment and physical examination 43 Chapter four A Physiological Basis for Nursing Practice 1. Maslow hierarchy of basic human need 58 2. Physiological needs: 61 62 a. Fluids, electrolyte and acid base 69 b. Oxygen 74 c. Nutrition 77 d. Elimination 82 e. Rest and sleep 85 f. Sex concept 87 g. Activity 90 99 Chapter five Admission Transfer and Discharge 1. Patient admission 104 2. Patients transfer and referral 109 3. Patient discharge 111 Chapter six First Aid 1. Medical emergencies 117 2. injury emergencies 128 3. environment emergencies 135  List of abbreviation Abbreviation Meaning ANA American Nursing Association RN Registered nurse ICN International Council of Nurses CDC Centers for Disease Control and Prevention WHO World Health Organization NANDA North American Nursing Diagnosis Association ECF Extracellular fluid I&O Intake & Output ABG Arterial Blood Gases STD Sexual Transmitted Disease GI Gastro intestinal ADL Activity of Daily Living RTA Road Traffic Accident ER Emergency OPD Outpatient Department ICU Intensive Care Unit AED Automated External Defibrillator CPR Cardiopulmonary Resuscitation PPE Personal Protective Equipment 1|Page  Chapter one (Foundation of Nursing Practice) Learning objectives: At the end of the chapter the students will be able to: 1. Describe the historic background of nursing, definitions of nursing, and the status of nursing as a profession and as a discipline. 2. Discuss the development of professional nursing roles. 3. Explain the aims of nursing as they interrelate to facilitate maximal health and quality of life for patients. 4. Identify purpose of patient safety 5. List factors influencing patient safety 6. Illustrate international patient safety goal 2|Page  Introduction Nursing is an art and a science. As a professional nurse you will learn to deliver care artfully with compassion, caring, and respect for each patient’s dignity and personhood. As a science, nursing practice is based on a body of knowledge that is continually changing with new discoveries and innovations. 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 responses; and advocacy in health care for individuals, families, communities, and populations. (ANA, 2018). Definition of a Nurse. The nurse is a person who has completed a program of basic, generalized nursing education and is authorized by the appropriate regulatory authority to practice nursing in his/her country. Aim of nursing: Four broad aims of nursing practice can be identified in the definitions of nursing: 1. To promote health 2. To prevent illness 3. To restore health 4. To facilitate coping with disability or death To meet these aims, the nurse uses knowledge, skills, and critical thinking to give care in a variety of traditional and expanding nursing roles. 3|Page The nursing profession and its characteristics: A variety of career opportunities are available in nursing, including clinical practice, education, research, management, administration, and even entrepreneurship. As a student it is important for you to understand the scope of professional nursing practice and how nursing influences the lives of your patients, their families, and their communities. The patient is the center of your practice. Types of standards for nursing » Standards of Practice. The nursing process is the foundation of clinical decision making and includes all significant actions taken by nurses in providing care to patients. ▪ Assessment: The registered nurse collects comprehensive data pertinent to the patient’s health and/or the situation. ▪ Diagnosis: The registered nurse analyzes the assessment data to determine the diagnoses or issues. ▪ Outcomes Identification: The registered nurse identifies expected outcomes for a plan individualized to the patient or the situation. ▪ Planning: The registered nurse develops a plan that prescribes strategies and alternatives to attain expected outcomes. ▪ Implementation: The registered nurse (RN) implements the identified plan. ▪ Evaluation: The nurse evaluates progress toward attainment of outcomes. 4|Page » Standards of Professional Performance: The American Nurses Association ANA Standards of Professional Performance describes a competent level of behavior in the professional role (ANA,2010). The standards provide a method to assure patients that they are receiving high-quality care. 1. Ethics: The registered nurse practices ethically. 2. Education: The registered nurse attains knowledge and competency that reflects current nursing practice. 3. Evidence-Based Practice and Research: The registered nurse integrates evidence and research findings into practice. 4. Quality of Practice: The registered nurse contributes to quality nursing practice. 5. Communication: The registered nurse communicates effectively in all areas of practice. 6. Leadership: The registered nurse demonstrates leadership in the professional practice setting and the profession. 7. Collaboration: The registered nurse collaborates with health care consumer, family, and others in the conduct of nursing practice. 8. Professional Practice Evaluation: The registered nurse evaluates her or his own nursing practice in relation to professional practice standards and guidelines, relevant statutes, rules, and regulations. 9. Resources: The registered nurse uses appropriate resources to plan and provide nursing services that are safe, effective, and financially responsible. 10. Environmental Health: The registered nurse practices in an environmentally safe and healthy manner. 5|Page The role of the nurse and its functions: Nurses provide care and comfort for patients in all health care settings and concern for meeting their patient’s needs. These roles are described as the following: - 1- Direct care provider/ caregiver: As a caregiver, the nurse integrates the roles of communicator, teacher, counselor, leader, researcher, advocate, and collaborator to meet physical, emotional, intellectual, sociocultural, and spiritual needs for all patients. 2- Communicator: The use of effective interpersonal and therapeutic communication skills to establish and maintain helping relationships with patients of all ages in a wide variety of healthcare settings. 3- Teacher/Educator: The use of communication skills to assess, implement, and evaluate individualized teaching plans to meet learning needs of patients and their families. 4- Counselor: The use of therapeutic interpersonal communication skills to provide information, make appropriate referrals, and facilitate the patient’s problem-solving and decision-making skills. 5- Leader: The assertive, self-confident practice of nursing when providing care, effecting change, and functioning with groups. 6- Researcher: The participation in or conduct of research to increase knowledge in nursing and improve patient care. 7- Advocate: The protection of human or legal rights and the securing of care for all patients based on the belief that patients have the right to make informed decisions about their own health and lives. 6|Page 8- Collaborator: The effective use of skills in organization, communication, and advocacy to facilitate the functions of all members of the healthcare team as they provide patient care. The nurse carries out these roles in many different settings, with care increasingly provided in the home and in the community. Examples for providing patients are the following: Hospitals Ambulatory surgery centers Emergency helicopter services Clinics Homes Educational programs Public health offices Doctors’ offices Industry Long-term care facilities Mobile healthcare units Schools Offices Hospice Mental health facilities State health programs Skilled-care facilities Churches Prisons 7|Page  Ethics in nursing profession Introduction Ethical values are essential for any healthcare provider. Ethical values are universal rules of conduct that provide a practical basis for identifying what kinds of actions, intentions, and motives are valued. Definition of ethics: Ethics are moral principles that govern how the person or a group will behave or conduct themselves. Definition of nursing ethics: systematic rules or principles governing right conduct. Each nurse, is practiced with the responsibility to adhere to the standards of ethical practice and conduct set by the profession. Ethical principles: Ethical principles are the basis of all nursing practice and provide a framework to help the nurse in ethical decision making. The primary ethical principles include: ▪ Beneficence: Acting for the good and welfare of others and including such attributes as kindness and charity. ▪ Nonmaleficence: Acting in such a way as to prevent harm to others or to inflict the minimal harm possible. ▪ Autonomy: Recognizing the individual’s right to self-determination and decision-making. ▪ Justice: Acting in fairness to all individuals, treating others equally and showing all individuals the same degree of respect and concern. 8|Page  ▪ Veracity: Being truthful, trustworthy, and accurate in all interactions with others. ▪ Fidelity: Being loyal and faithful to individuals who place trust in the nurse. ▪ Integrity: Acting consistently with honesty and basing actions of moral standards. International Council of Nurses Code of Ethics Preamble The ICN Code of Ethics for Nurses has four principal elements that outline the standards of ethical conduct Elements of the Code 1. Nurses and People 1. The nurse’s primary professional responsibility is to people requiring nursing care. 2. In providing care, the nurse promotes an environment in which the human rights, values, customs and spiritual beliefs of the individual, family and community are respected. 2. Nurses and Practice ▪ The nurse carries personal responsibility and accountability for nursing practice, and for maintaining competence by continual learning. ▪ The nurse maintains a standard of personal health such that the ability to provide care is not compromised 3. Nurses and the Profession ▪ The nurse assumes the major role in determining and implementing acceptable standards of clinical nursing practice, management, research and education. 9|Page  ▪ The nurse is active in developing a core of research-based professional knowledge. 4. Nurses and Co-workers ▪ The nurse sustains a co-operative and respectful relationship with co- workers in nursing and other fields. ▪ The nurse takes appropriate action to safeguard individuals, families and communities when their health is endangered by a co-worker or any other person. 10 | P a g e  Patient Safety Safety, often defined as freedom from psychological and physical injury, is a basic human need. Health care provided in a safe manner and a safe community environment is essential for a patient’s survival and well- being. Definition of patient safety: The world health organization (WHO) defined patient safety as the prevention of errors and adverse effects to patients associated with health care. Purpose of patient safety: It aims to prevent and reduce risks, errors and harm that occur to patients during provision of health care. A cornerstone of the discipline is continuous improvement based on learning from errors and adverse events. Factors influencing patient safety ▪ Age and Development ▪ Lifestyle factors that place individuals at risk for injury include unsafe environments. ▪ Mobility and Health Status Alterations in mobility related to paralysis, muscle weakness, diminished balance, and lack of coordination place clients at risk for injury. ▪ Sensory Perceptual Alterations Accurate sensory perception of environmental stimuli is vital to safety. ▪ Emotional State states can alter the ability to perceive environmental hazards. 11 | P a g e  ▪ Ability to Communicate Individuals with diminished ability to receive and convey information are at risk for injury. ▪ Environmental Factors Client safety is affected by the healthcare setting. ▪ Cognitive Awareness is the ability to perceive environmental stimuli and body reactions and to respond appropriately through thought and action. The Joint Commission National Patient Safety Goals Effective January 2023 for the Hospital Program Goal: Improve the accuracy of patient identification. ▪ Use at least two patient identifiers when administering medications, blood, or blood components; when collecting blood samples and other specimens for clinical testing; and when providing treatments or procedures. Goal: Improve the effectiveness of communication among caregivers. ▪ Report critical results of tests and diagnostic procedures on a timely basis. Goal: Improve the safety of using medications. ▪ Label all medications, medication containers, and other solutions on and off the sterile field in perioperative and other procedural settings. ▪ Reduce the likelihood of patient harm associated with the use of anticoagulant therapy. ▪ Maintain and communicate accurate patient medication information. 12 | P a g e Goal: Reduce patient harm associated with clinical alarm systems. ▪ Improve the safety of clinical alarm systems. Goal: Reduce the risk of health care-associated infections. ▪ Comply with either the current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines or the current World Health Organization (WHO) hand hygiene guidelines. ▪ Implement evidence-based practices to prevent healthcare associated infections due to multidrug-resistant organisms in acute care hospitals and in nursing care centers. ▪ Implement evidence-based practices to prevent central line–associated bloodstream infections (CLABSI). ▪ Implement evidence-based practices for preventing surgical site infections. ▪ Implement evidence-based practices to prevent indwelling catheter- associated urinary tract infections (CAUTI). Goal: Reduce the risk of patient harm resulting from falls. ▪ Reduce the risk of falls. Goal: Prevent health care-associated pressure ulcers (decubitus ulcers). ▪ Assess and periodically reassess each patient’s and resident’s risk for developing a pressure ulcer and take action to address any identified risks. 13 | P a g e Goal: The organization identifies safety risks inherent in its patient population. ▪ Reduce the risk for suicide. ▪ Identify risks associated with home oxygen therapy, such as home fires. Goal: Improve health care equity. ▪ Improving health care equity for the organization’s patients is a quality and safety priority. Goal: Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery ▪ Conduct a preprocedural verification process. ▪ Mark the procedure site. ▪ A time-out is performed before the procedure. 14 | P a g e  Health and Illness Concept Definition of Health Defining health is difficult. The World Health Organization (WHO) defines health as a “state of complete physical, mental, and social wellbeing, not merely the absence of disease or infirmity” (WHO, 1947). Definition of Illness o Illness is a state in which a person’s physical, emotional, intellectual, social, developmental, or spiritual functioning is diminished or impaired. o Cancer is a disease process, but one patient with leukemia who is responding to treatment may continue to function as usual, whereas another patient with breast cancer who is preparing for surgery may be affected in dimensions other than the physical. Acute and Chronic Illness Both acute and chronic illnesses have the potential to be life threatening. An acute illness is usually reversible, has a short duration, and is often severe. The symptoms appear abruptly, are intense, and often subside after a relatively short period. A chronic illness persists, usually longer than 6 months, is irreversible, and affects functioning in one or more systems. 15 | P a g e Characteristics of Acute and Chronic Illness Description Characteristics Acute Illness ▪ Usually, self-limiting Diseases that have a rapid onset and a short duration. ▪ Responds readily to treatment Examples: colds, influenza, acute ▪ Complications infrequent gastroenteritis ▪ After illness, return to previous level of functioning Chronic Illness ▪ Permanent impairments or deviations Diseases that are prolonged, do from normal. not resolve spontaneously, and are ▪ Irreversible pathologic changes rarely cured completely. ▪ Residual disability Examples: Alzheimer’s disease, ▪ Special rehabilitation required Arthritis, Cancer ▪ Need for long-term medical and/or nursing management Variables Influencing Health and Illness 1. Internal Variables ▪ Developmental Stage. A person’s thought and behavior patterns change throughout life. ▪ Intellectual Background. A person’s beliefs, knowledge, or incorrect information about body functions and illnesses, educational background, traditions, and past experiences. ▪ Perception of Functioning. The way people perceive their physical functioning affects health beliefs and practices. ▪ Emotional Factors. The patient’s degree of stress, depression, or fear can influence health beliefs and practices. ▪ Spiritual Factors. Spirituality including the values and beliefs exercised, the relationships established with family and friends, and the ability to find hope and meaning in life. 16 | P a g e 2. External Variables ▪ Family Practices. The way that patients’ families use health care services generally affects their health practices. Their perceptions of the seriousness of diseases and their history of preventive care behaviors. ▪ Psychosocial and Socioeconomic Factors. Socioeconomic and psychosocial factors increase the risk for illness and influence the way that a person defines and reacts to illness. ▪ Cultural Background. Cultural background influences beliefs, values, and customs. Health Promotion, Wellness, and Illness Prevention ▪ Health promotion activities such as routine exercise and good nutrition help patients maintain or enhance their present levels of health. ▪ Wellness education teaches people how to care for themselves in a healthy way and includes topics such as physical awareness, stress management, and self-responsibility. ▪ Illness prevention activities such as immunization programs protect patients from actual or potential threats to health. Levels of Preventive Care 1. Primary Prevention. Primary prevention is true prevention; it precedes disease or dysfunction and is applied to patients considered physically and emotionally healthy. Primary prevention aimed at health promotion includes health education programs, immunizations, nutritional programs, and physical fitness activities. 17 | P a g e 2. Secondary Prevention Secondary prevention focuses on individuals who are experiencing health problems or illnesses and are at risk for developing complications or worsening conditions. Activities are directed at diagnosis and prompt intervention, thereby reducing severity and enabling the patient to return to a normal level of health as early as possible. 3. Tertiary Prevention Occurs when a defect or disability is permanent and irreversible. It involves minimizing the effects of a long-term disease or a disability by interventions directed at preventing complications and deterioration. Activities are directed at rehabilitation rather than diagnosis and treatment. ▪ For example, a patient with a spinal cord injury undergoes rehabilitation to learn how to use a wheelchair and perform activities of daily living independently. Care at this level helps patients achieve as high a level of functioning as possible, despite the limitations caused by illness or impairment. 18 | P a g e  Students’ self-assessment Circle the letter that corresponds to the best answer for each question. Immunizing children against measles is an example of which of the following levels of preventive care? a. Primary b. Secondary c. Tertiary Referring an HIV-positive patient to a local support group is an example of which of the following levels of preventive care? a. Primary b. Secondary c. Tertiary Which of the following guidelines was developed by the American Hospital Association to enumerate the rights and responsibilities of patients while receiving hospital care? a. Code of Ethics b. Patient Bill of Rights c. Biomedical ethics d. Hospital patient advocacy 1. Mention Factors influencing patient safety 2. Enumerate The role of the nurse and its functions. 3. differentiate between Characteristics of Acute and Chronic Illness 19 | P a g e  References 1. American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). Silver Spring, MD: Author. 2. Chaet, D. (2016). The AMA Code of Medical Ethics’ opinions on ethics committees and consultations. AMA Journal of Ethics, 18, 499–500. doi:10.1001/journal of ethics. 3. Joint Commission. (2023). Hospital national patient safety goals. Hospital National Patient Safety Goals 2023. Available at: http://www.jointcommission.org. 4. Kozier, B. (2022). Fundamentals of nursing: concepts, process and practice. Eleventh edition. Pearson education. 5. Perry, A. G., & Potter, P. A. (2021). Fundamentals of nursing. tenth edition St. Louis, Elsevier Inc. [ 20 | P a g e  Chapter Two (Communication) ) Learning objective At the end student will be able to: Identify the communication Describe the components of the communication process Discuss the mods (forms) of communication Categories the levels of communication Describe factors influencing the communication process Discuss therapeutic communication technique 21 | P a g e  Introduction Communication is a critical skill for nursing. It is the process by which humans meet their survival needs, build relationships, and experience emotions. In nursing, communication is a dynamic process used to gather assessment data, to teach and persuade, and to express caring and comfort. It is an integral part of the helping relationship. Definition of communication Communication is the process of exchanging information and generating and transmitting meanings between two or more people. It is the foundation of society and the most primary aspect of a nurse patient interaction. Basic components of the communication process The communication process is initiated based on a stimulus; in this case a patient need that must be addressed. The need might be due to a patient’s discomfort or desire for information or to address any uncertainty the patient might be experiencing. 1. The sender or source (encoder) of the message is a person or group who initiates or begins the communication process. 2. The message is the actual communication product from the source It might be a speech, interview, conversation, chart, gesture memorandum, or nursing note. 3. The channel of communication is the medium the sender has selected to send the message. The channel might target any of the receiver’s senses. The message can be sent to the receiver through the following channels: ▪ Auditory—spoken words and cues ▪ Visual—sight, observations, and perception 22 | P a g e  ▪ Kinesthetic—touch Nurses use all three of these channels to communicate with patients and other health care providers. 4. The receiver (decoder) must translate and interpret the message sent and received. To be an effective communicator, the nurse needs to be considerate of the receiver, and select a message that appeals to the patient’s interests and that requires minimal effort and time to decode. 5. Confirmation of the message provides feedback (i.e., evidence) that the receiver has understood the intended message. Communication is a reciprocal process in which both the sender and the receiver of messages participate simultaneously. 23 | P a g e  The Mods (Forms) Of Communication The sending and receiving of messages is accomplished through verbal and nonverbal communication techniques. These can occur separately or simultaneously. 1. Verbal Communication - Verbal communication is an exchange of information using words including both the spoken and written word. Verbal communication depends on language, or a prescribed way of using words so that people can share information effectively. - Nurses use verbal communication extensively when providing patient care, including verbal interactions with patients and family giving oral reports to other nurses and health care providers developing nursing care plans, and evaluating patient progress. 2. Nonverbal Communication Nonverbal communication is the transmission of information without the use of words, also known as body language. It often helps nurses to understand subtle and hidden meanings in what the patient is saying verbally. The various forms of nonverbal communication follow. Touch Tactile sense has been studied seriously as a form of nonverbal communication only since the 1960s. Touch is a personal behavior and means different things to different people. Familial, regional, class, and cultural influences largely shape tactile experiences. 24 | P a g e  Eye Contact Communication often begins with eye contact. A glance, for example is often an attention-getting method to open conversation. In many cultures, eye contact suggests respect and a willingness to listen and to keep communication open. Facial Expressions The face is the most expressive part of the body. Examples of the various messages facial expressions convey are anger, joy, suspicion sadness, fear, and contempt. Posture The way a person holds the body carries nonverbal messages. People in good health and with a positive attitude usually hold their bodies in good alignment. Depressed or tired people are more likely to slouch Posture also often provides nonverbal clues concerning pain and physical limitations. General Physical Appearance Many illnesses cause at least some alterations in general physical appearance. Observing for changes in appearance is an important nursing responsibility for detecting illness or evaluating the effectiveness of care and therapy. Sounds. Sounds such as sighs, moans, groans, or sobs also communicate feelings and thoughts. They have several interpretations: moaning conveys pleasure or suffering, and crying communicates happiness, sadness, or anger. Validate nonverbal messages with the patient to interpret them accurately. 25 | P a g e 3. Electronic Communication - The Internet and a variety of social websites provide new and challenging opportunities for nurses to communicate and collaborate with other health care providers. - The challenges of using social media include protecting patient privacy and confidentiality and preventing unintended consequences for the employer or the nurse. Social Media Social media are web-based technologies that allow users to create share, and participate in dialogue in virtual communities and networks The availability of social media sites has dramatically changed communications among people, communities, and organizations social media networks allow nurses to share ideas, develop professional connections, access educational offerings and forums receive support, and investigate evidence-based practices. E-Mail and Text Messages E-mail and text messages are efficient means to communicate with staff members and, in some cases, patients. The risk for violating patient privacy and confidentiality exists any time a message is sent electronically. levels of communication Throughout our lives and the lives of our patients, communication occurs at varying levels. Nurses engage in four levels of communication during practice: ▪ intrapersonal communication ▪ interpersonal communication, ▪ small-group communication, ▪ Public communication 26 | P a g e  Intrapersonal communication is a powerful form of communication that occurs within an individual. This level of communication is also called self-talk self- verbalization or inner thought People's thoughts strongly influence perceptions, feelings, behavior, and self-concept. Interpersonal communication is one-on-one interaction between a nurse and another person that often occurs face to face. It is the level most frequently used (in nursing situations and lies at the heart of nursing practice.) Small-group communication is an interaction that occurs when a small number of people meet. This type of communication is usually goal-directed and requires an understanding of group dynamics. Public communication is interaction with an audience. Nurses have opportunities to speak with groups of consumers about health-related topics, present scholarly work to colleagues at conferences, or lead classroom discussions with peers or students. Factors influencing the communication process Many factors influence the communication process. Some of these are development, gender, values and perceptions, personal space, territoriality, roles and relationships, environment, congruence, interpersonal attitudes, and boundaries. 27 | P a g e  Development Language, psychosocial, and intellectual development move through stages across the lifespan. Knowledge of patient’s developmental stage will allow the nurse to modify the message accordingly. Gender From an early age, females and males communicate differently. Girls tend to use language to seek confirmation, minimize differences, and establish intimacy. Boys use language to establish independence and negotiate status within a group. Values and Perceptions Values are the standards that influence behavior, and perceptions are the personal view of an event. Because each individual has unique personality traits, values, and life experiences, each will perceive and interpret messages and experiences differently. Personal Space Personal space is the distance people prefer in interactions with others 1. Intimate: 0 to 1 12 feet 2. Personal: 1 12 to 4 feet 3. Social: 4 to 12 feet 4. Public: 12 feet and beyond 28 | P a g e  Environment People usually communicate most effectively in a comfortable environment. Temperature extremes, excessive noise, and a poorly ventilated environment can all interfere with communication. Interpersonal Attitudes Attitudes convey beliefs, thoughts, and feelings about people and events. Attitudes are communicated convincingly and rapidly to others. Therapeutic communication technique Therapeutic Communication Techniques are specific responses that encourage the expression of feelings and ideas and convey acceptance and respect. 1. Active Listening. Active listening means being attentive to what a patient is saying both verbally and nonverbally. Active listening facilitates patient communication. 29 | P a g e 2. Sharing Observations. Nurses make observations by commenting on how the other person looks, sounds, or acts. 3. Sharing Empathy. Empathy is the ability to understand and accept another person's reality, accurately perceive feelings, and communicate this understanding to the other. 4. Sharing Hope. Nurses recognize that hope is essential for healing and learn to communicate a "sense of possibility" to others. 5. Sharing Humor. Humor is an important but often underused resource in nursing interactions. 6. Sharing Feelings. Emotions are subjective feelings that result from one's thoughts and perceptions. If individuals do not express feelings, stress and illness may worsen. 7. Using Touch. Touch is one of the most potent forms of communication. Historically physical touch played a central role in healing. 8. Using Silence. Silence prompts some people to talk. It allows a patient to think and gain insight. 9. Providing Information, providing relevant information tells other people what they need or want to know so they are able to make decisions, experience less anxiety, and feel safe and secure. 10.Clarifying. To check whether understanding is accurate, restate an unclear message to clarify the sender's meaning. 11.Focusing. Focusing centers on key elements or concepts of a message. If the conversation is vague or patients begin to repeat themselves, focusing is a useful technique. 30 | P a g e 12.Paraphrasing. Paraphrasing is restating another's message more briefly using one's own words. 13.Asking Relevant Questions. Nurses ask relevant questions to seek information needed for decision-making. Ask only one question at a time and fully explore one topic before moving to another area. 14.Summarizing. Summarizing is a concise review of key aspects of an interaction. It brings a sense of satisfaction and closure to an individual conversation and is especially helpful during the termination phase of a nurse-patient relationship. 31 | P a g e  Students’ self-assessment An old woman was brought for evaluation due to increasing forgetfulness and limitations in daily function. She says to the nurse who offers her breakfast, “Oh no, I will wait for my husband. We will eat together” The therapeutic response by the nurse is: a. “Your husband is dead. Let me serve you your breakfast.” b. “I’ve told you several times that he is dead. It’s time to eat.” c. “You’re going to have to wait a long time.” d. “What made you say that your husband is alive? Which of the following are considered nonverbal cues? Select all that apply. a. Tone and rate of voice b. Eye contact and physical appearance c. Soft voice d. Use of touch A subtle therapeutic technique that communicates to the patient that you are interested and want to hear more. It indicates your acceptance of the patient as a person. It usually involves nonverbal cues such as eye contact and nodding. a. Therapeutic relationship b. Moral support c. Minimal encouragement d. Act of kindness When talking to a patient from another culture and with another language, the most effective way to communicate is: a. Using picture. b. Using gestures c. Using a translator d. Using an interpreter 32 | P a g e  Chapter Three (Critical thinking in nursing practice) Learning objectives: At the end of this chapter the student will be able to: 1. Critical thinking ▪ Define critical thinking ▪ Discuss critical thinking skills in nursing 2. Nursing process ▪ Define the Nursing Process. ▪ Identify the characteristics of Nursing Process ▪ List the purpose of Nursing Process ▪ Explain Phases of Nursing Process ▪ Develop nursing care process. 3. Health assessment ▪ Define health assessment. ▪ List types of assessment. ▪ Discuss phases of health assessment. 4. Physical examination ▪ Define physical examination. ▪ Mention purpose of physical examination. ▪ Describe the types used in physical examination. ▪ Discuss the components of physical examination. 33 | P a g e Introduction: Critical thinking is an essential skill for nursing students to have, because it helps them make decisions based on the available information and their past experiences and knowledge of the field. It also allows nurses to plan before making any intervention to be most effective as possible. The nurse uses critical thinking and problem-solving skills to determine the underlying cause of the patient’s symptoms. Critical thinking abilities compel nurses to challenge assumptions, question the context, look for new ways of doing and thinking, and consider, filter, and evaluate ideas or solutions. Critical Thinking Skills in Nursing Definition: Critical thinking is an active form of thinking that is used within the healthcare setting by nurses. It involves taking data from situations and analyzing the information to help formulate the best course of action objectively. Critical thinking skills: Critical thinking skills that will be utilized in nursing are based on the following cognitive skills: 1. Recognition - when a nurse understands that there is a problem 2. Questioning - when a nurse decides whether safety is a concern 3. Information gathering - when a nurse gathers data through observations 4. Evaluation - when the nurse evaluates the decisions to understand which should be applied 34 | P a g e  5. Communication - when the decision is communicated to other healthcare professionals if needed 6. Observation - a nurse's assessment that forms the basis for all decisions 7. Analysis - when the nurse examines the observations 8. Interpretation - when the nurse takes raw data and analyzes the results 9. Reflection - when the nurse looks back on the decisions and data to understand if the choice was sound 10. Inference - when the nurse draws a conclusion based on the information gathered 11. Problem-solving - when the nurse applies critical thinking skills to the issue at hand 12. Decision-making - when the nurse makes a concrete choice based on best practice Uses of critical thinking in nursing: critical thinking is applied by nurses through the nursing process for solving problems of patients and decision-making process with creativity to enhance the effect of the care provide to the patient. 35 | P a g e  Nursing process Definition: A process is a series of steps or acts that lead to accomplishment of some goal or purpose. Nursing process: American Nurses Association defined as an organized systematic method of problem-solving steps used to identify and to manage the health problems of patients. Figure (1) The Nursing Process in action 36 | P a g e Purpose of nursing process: To identify a client’s health status and actual or potential health care problems or needs. To establish plans to meet the identified needs. To deliver specific nursing interventions to meet those needs. Characteristics of Nursing Process Continuous & Dynamic nature patient centered Focus on problem solving and decision making Interpersonal and collaborative style Universal applicability Use of critical thinking and clinical reasoning. Components of nursing process It involves: Assessment (data collection). Nursing diagnosis. Planning. Implementation. Evaluation. Figure (2) Components of the Nursing Process 1. ASSESSMENT Definition: Assessment is the systematic and continuous collection, organization, validation, and documentation of data. 37 | P a g e During this step, the nurse gathers information about the patient’s health status, including physical, psychological, and social factors using different assessment techniques such as head-to-toe physical assessment. This data is used to form an accurate diagnosis and develop a care plan. 2. Diagnosis Diagnosis is the second phase of the nursing process. In this phase, nurses use critical thinking skills to interpret assessment data to identify client problems. A. North American Nursing Diagnosis Association (NANDA) define or refine nursing diagnosis is: “a clinical judgment concerning a human response to health conditions/life processes, or a vulnerability for that response, by an individual, family, group, or community.” 38 | P a g e  Purposes of the Nursing Diagnosis B. Identifies nursing priorities C. Directs nursing interventions to meet the client’s high-priority needs D. Provides a common language and forms a basis for communication and understanding between nursing professionals and the healthcare team. Difference between medical and nursing diagnosis A nursing diagnosis: Is a clinical judgment about individual, family, or community responses to actual or potential health problems. A medical diagnosis: Is a clinical judgment by the physician that identifies or determines a specific disease, condition, or pathological state. Medical Diagnosis Nursing Diagnosis Focuses on illness, injury, or Focuses on client’s responses to actual or disease process. potential health problems or life processes. Remains constant until a cure Changes as the client’s response and/or the health is affected or client dies. problem changes. Example:(Lung cancer, heart Example: (Nausea, Acute pain, Anxiety, Impaired failure, Brain tumor, physical mobility, Ineffective breathing pattern, Bronchial asthma). Risk for imbalanced fluid volume). Types of nursing diagnosis: 1. An Actual Diagnosis is a client problem that is present at the time of the nursing assessment. Examples are ineffective breathing pattern and anxiety. 2. Risk (Potential)Nursing Diagnosis is a clinical judgement that a problem does not exist, but the presence of risk factors indicates that a problem may develop if adequate care is not given. 39 | P a g e  For example, all people admitted to hospital have some possibility of acquiring an infection; however, a client with diabetes or a compromised immune system is at higher risk than others. 3.Wellness Nursing Diagnosis “Describes human responses to levels of wellness in an individual, family or community that have a readiness for enhancement”. Examples of wellness diagnoses would be readiness for enhanced spiritual well-being or readiness for enhance family coping. 4.Possible Nursing Diagnosis ▪ Is one in which evidence about a health problem is incomplete or unclear. ▪ Requires more data either to support or to refute it. For example, an elderly widow who lives alone is admitted to the hospital. The nurse notices that she has no visitors and is pleased with attention and conversation from the nursing staff. 5. Syndrome Nursing Diagnosis Is a diagnosis in which is associated with a cluster of other diagnoses. For example, Clusters of diagnoses associated with this syndrome include impaired physical mobility, risk for impaired tissue integrity, risk for activity intolerance, risk for constipation, risk for infection, risk for injury, risk for powerless, impaired gas exchanged, and so on. 40 | P a g e Components of a NANDA Nursing Diagnosis has three components: 1- Problem (P): statement of the client’s health problem (NANDA label) 2- The etiology component of a nursing diagnosis identifies causes of the health problem. 3- The defining characteristics (are the cluster of signs and symptoms that indicate the presence of health problem. Example: Acute pain related to tissue ischemia as evidenced by patient discomfort sever pain on my chest and pain scale. 3. Planning - Planning involves decision making and problem solving. - Establishing client goals/desired outcomes - Setting priorities - Selecting nursing interventions and activities - Writing individualized nursing interventions on care plans. 41 | P a g e 4. Implementation The process of implementation includes; Implementing the nursing interventions Documenting nursing activities 5. Evaluation The evaluation includes; Comparing the data with desired outcomes Continuing, modifying, or terminating the nursing care plan. Example: 42 | P a g e  Health Assessment& physical examination Introduction Assessment is a key component of nursing practice, required for planning and provision of patient and family centered care. Assessment can be called the “base or foundation” of the nursing process. Nursing assessments are critical to the job of being a nurse, and there are several different types of assessments that nurses need to be able to perform. Assessment definition is a process where a nurse gathers, sorts and analyzes a patient's health information using evidence informed tools to learn more about a patient's overall health, symptoms and concerns Purpose of assessments: Obtain baseline data and expand the data base from which subsequent phases of the nursing process can evolve To identify and manage a variety of patient problems (actual and potential) Evaluate the effectiveness of nursing care Enhance the nurse-patient relationship Make clinical judgments 43 | P a g e Types of assessment: 1. Initial comprehensive assessment: ▪ Provide baseline of client data including a complete health history and current needs assessment. general appearance, physical examination and vital signs. ▪ Usually completed upon admission to health care agency. Problem Focused or Ongoing assessment: Is limited to potential health care risks, or a particular need. Follow up, or monitoring of specific problems. Expands the database and allow the nurse to confirm the validity of data obtained during the initial assessment. Systematic monitoring allows the nurse to determine the clients’ response to nursing interventions and to identify any other problems. Emergency assessment: Primary assessment includes (Airway, Breathing, Circulation and Disability) for determining life threatening problems. Time-lapsed Reassessment Time lapsed reassessment, takes place after several months to the initial assessment to evaluate any changes in the clients' health status (e.g., periodic outpatient clinic visits, home health visits, health and development screenings) to compare the client ‘s current status to baseline data previously obtained. Steps OR phases of assessment: A. Data collection from a variety of sources. B. Data validation. 44 | P a g e  C. Organizing the data. D. Data interpretation (Data analysis). E. Making initial inferences or impressions. F. Recording or reporting data. 1. Sources of Data collection: ▪ Primary sources: the client should be considered the primary source of data. As much information as possible should be gathered from the client, using both interview techniques and physical examination skills. ▪ Secondary sources: data source from other than the client is considered secondary sources (family members, other health care providers, and medical records). Methods of data collection: Data are obtained through: ▪ Interviews- patient, nurses, support persons ▪ Physical examinations ▪ Observations ▪ Review of records and diagnostic reports ▪ Collaboration with colleagues Types of Data collection: Subjective data (also called symptoms): are data from the client’s point of view (provided verbally by the patient) and include feelings, perceptions, and concerns. Interview is the primarily method of collecting subjective information. 45 | P a g e Examples of subjective information: A. I have had pains in my legs for three days ago. B. I have had headache, nausea, vomiting, and dizziness for three hours ago. C. I have had anxiety from surgery. Objective data (also called signs): are observable and measurable data that are obtained through both physical examination and the result of laboratory and diagnostic tests. Examples of objective information include: ▪ Temperature (37.3°C), Pulse rate (100 b/m), Respiration (18 T/m), Blood pressure (130/76 mm/hg). ▪ Positive bowel sounds. ▪ Flushed face. 2- Validating the data: Objective information may add to or validate subjective information. Validation is a critical step in data collection to avoid omissions, prevent misunderstandings, and avoid incorrect inferences and conclusions. 3- Organizing the data: Data that are collected must be organized to be useful to the health care professional collecting the data as well as others involved with the client’s care. 4- Interpreting the data: when data are placed in clusters the nurse can: 1. Distinguish between relevant and irrelevant data. 2. Determine whether and where there are gaps in the data. 3. Identify patterns of cause and effect. 46 | P a g e 5- Documenting the data: Assessment data must be recorded and reported. The nurse must make a judgment about which data are to be reported immediately and which data need only to be recorded at that time. Definition of documentation: Any written or electronically generated information about a client that describes the care or service provided to that client as the administration of tests, procedures, treatments, and client education. Definition of report: A report is oral, written, or computer-based communication intended to convey information to others. For instance, nurses always report on clients at the end of a hospital work shift. Definition of record: A record, also called a chart or client record, is a formal, legal document that provides evidence of a client’s care and can be written or computer based. Purpose of health care documentation 1. Professional Responsibility and Accountability 2. To facilitate communication 3. To promote good nursing care 4. To meet professional and legal standards 5. Education 6. Research 7. Auditing and Monitoring 47 | P a g e Principles of documentation 1. Date & Time ▪ Document date and time of each recording. ▪ Record time in conventional manner (E.g. 9am, 6pm etc) ▪ Avoid recording in advance. 2. Legibility& Signature ▪ Entries must be legible and easy to read. ▪ Writing must be clear and sign. 3.Correcting spelling & Terminology ▪ Very important in recording numbers and medical terms 4.Completeness & appropriates Examples of records Form Information Admission (face) sheet Legal name, birth date, age, gender Social Security number Address / Marital status Date, time, and admitting Diagnosis Food or drug allergies Name of admitting primary care provider Insurance information. Initial nursing assessment Findings from the initial nursing history and physical health assessment Graphic record Body temperature, pulse rate, respiratory rate, blood pressure, daily weight, and special measurements such as fluid intake and output and oxygen saturation Daily care record Activity, diet, bathing, and elimination records 48 | P a g e Special flow sheets Examples: fluid balance record, skin assessment Name, dosage, route, time, date of regularly Medication record administered medications. Name or initials of individual administering the medication Nurse’s notes Pertinent assessment of client Specific nursing care including teaching and client’s responses Client’s complaints and how client is coping Medical history and Past and family medical history, present physical examination medical problems, differential or current diagnoses, findings of physical examination by the primary care provider Physician’s order form Medical orders for medications & treatments. Physician’s progress notes Medical observations, treatments &client progress. Consultation records Reports by medical and clinical specialists Diagnostic reports Examples: laboratory reports, x-ray reports, CT scan reports Consultation reports Physical therapy, respiratory therapy Client discharge plan and Started on admission and completed on referral summary discharge; includes nursing problems, general information, and referral data 49 | P a g e  Assessment Techniques: 1- Inspection – critical observation (always first) 1. Take time to “observe” with eyes, ears, nose. 2. Use good lighting 3. Look at color, shape, symmetry, position 4. Observe for odors from skin, breath, wound 5. Develop and use nursing instincts 6. Inspection is done alone and in combination with other assessment techniques. 2- Palpation – light and deep touch a. Back of hand (dorsal aspect) to assess skin temperature b. Fingers to assess texture, moisture, areas of tenderness c. Assess size, shape, and consistency of lesions and organs. 3- Percussion – sounds produced by striking body surface Produces different notes depending on underlying mass (dull, resonant, flat, tympanic) Used to determine size and shape of underlying structures by establishing their borders and indicates if tissue is air-filled, fluid-filled, or solid Action is performed in the wrist. 50 | P a g e 4- Auscultation – listening to sounds produced by the body a. Direct auscultation – sounds are audible without stethoscope b. Indirect auscultation – uses stethoscope 5- Manipulation: It means moving with the body parts. It reveals rigidity, difficulty (or) discomfort in moving the body parts. 6- Reflex testing: Means automatic response to a given stimulus. It reveals reflex is present, or not present, strength and movements of hands and legs. 7- Olfaction: It means sense of smell (Odor). It reveals the nature of disease condition of the patient. NOTE: Assessment does not end with the initial interview and physical examination. Assessment is dynamic and continues with each nurse-client interaction. 51 | P a g e  Physical Examination Definition is the process of evaluating objective anatomic findings through the use of observation, palpation, percussion, and auscultation. Purpose: 1. check for possible diseases so they can be treated early 2. identify any issues that may become medical concerns in the future 3. update necessary immunizations 4. ensure that you are maintaining a healthy diet and exercise routine Types of physical examination Comprehensive initial assessment (e.g., when a client is admitted to a healthcare agency). Focused examination of a body system (e.g., the cardiovascular system) or body area (e.g., the lungs, when difficulty with breathing is observed). Functional assessment that examines one or more aspects of the client’s abilities (e.g., nutrition and metabolism, elimination, or sleep and rest). Component of The Physical Examination include: General appearance exam Vital signs Skin, hair and nail exam Head and Neck exam Neurologic exam Chest and Cardiovascular exam Abdominal exam Musculoskeletal exam Back and mobility Attachment and documentation 52 | P a g e Examples: Situation Physical Assessment Client complains of abdominal Inspect, auscultate, percuss, and palpate the pain. abdomen; assess vital signs. Assess level of consciousness using Glasgow Client is admitted with a head Coma Scale, assess pupils for reaction to light injury. and accommodation; assess vital signs. The client has just had a cast Assess peripheral perfusion of toes, capillary applied to the lower leg. blanch test, pedal pulse if able, and vital signs. The client’s fluid intake is Assess tissue turgor, fluid intake and output, minimal. and vital signs. 53 | P a g e  Student’ Self-Assessment Choose the correct answer: This step of the nursing process includes the systematic collection of all subjective and objective data about the client in which the nurse focuses on the client- physical, psychological, emotional, sociocultural, and spiritual. Name this step 1.Assessment 2. Planning 3- evaluation 4. Diagnosis Once a nurse assesses a client’s condition and identifies appropriate nursing diagnoses, a: 1. List of priorities is determined. 2. Review of the assessment is conducted with other team members. 3. Plan is developed for nursing care. 4. Physical assessment begins. Mr. Jones comes into the physicians’ office with his wife. During the initial interview with the nurse assessing the reason for the visit, the wife says that her husband has been feeling bad for three days. The nurse knows this is what type of data? 1. Secondary subjective data 2. Primary subjective data 3. Secondary objective data 4. Primary objective data 54 | P a g e Mrs. Johnson is a 62-year-old female who was admitted to the hospital with a complaint of severe headache and dizziness. Her skin is warm and dry. She has a past medical history of hypertension for the past 5 years, and she has been on antihypertensive medications. She reports occasional non-adherence to her medications due to forgetfulness. Upon admission, Mrs. Johnson's vital signs are as follows: blood pressure (BP) 180/100 mmHg, heart rate (HR) 88 beats per minute (BPM), respiratory rate (RR) 18 breaths per minute, and temperature 38.6°C. 1. What are the subjective and objective data of Mrs. Johnson? 2. Develop a plan of care based on patient needs and priorities 3. What patient education should the nurse provide to Mrs. Johnson regarding hypertension management? 55 | P a g e  References 1. Ackley, B. J., Ladwig, G. B., Makic, M. B. F., Martinez-Kratz, M. R., & Zanotti, M. (2019). Nursing diagnosis handbook E-book: An evidence- based guide to planning care. Elsevier Health Sciences. 2. Astle, B. J., Duggleby, W., Potter, P. A., Perry, A. G. G., Stockert, P. A., & Hall, A. (2023). Potter and Perry's Canadian Fundamentals of Nursing- E-Book. Elsevier Health Sciences. 3. Conroy, T., Feo, R., Alderman, J., & Kitson, A. (2021). Building nursing practice: The fundamentals of care framework. In Potter & Perry’s Fundamentals of Nursing: Australia and New Zealand 6th Edition (pp. 19- 33). Elsevier Australia. 4. Haugen, N., & Galura, S. J. (2019). Ulrich & Canale's Nursing Care Planning Guides E-Book: Prioritization, Delegation, and Clinical Reasoning. Elsevier Health Sciences. 5. Kozier, B. (2022). Fundamentals of nursing: concepts, process and practice. Eleventh edition. Pearson education. 6. Potter, P. A., Perry, A. G., Stockert, P. A., & Hall, A. (2021). Fundamentals of nursing-e-book. Elsevier health sciences. 7. Sharma, S. (Ed.). (2021). Potter and Perry's Fundamentals of Nursing: Third South Asia Edition EBook. Elsevier Health Sciences. 8. Yoost, B. L., & Crawford, L. R. (2021). Fundamentals of nursing E-book: Active learning for collaborative practice. Elsevier Health Sciences. 56 | P a g e  Chapter Four A physiological Basis for nursing practice Learning objectives: At the end of this chapter student will be able to: ▪ Define of the need& human need ▪ Discuss Maslow’s hierarchy theory ▪ Explain physiological needs 57 | P a g e  Introduction Physiological or Basic needs are common to all people; thus, basic needs are universal. Individuals of all cultures have basic needs; in other words, basic needs are transcultural— across all cultures. Needs can be satisfied or they can be blocked during times of illness. Nursing is concerned with helping clients meet their physiological, spiritual, and psychological needs. Illness or risk for illness occurs when people are unable to satisfy one or more of their basic needs independently. Nursing care will center on assisting people to meet these needs. Nursing also involves helping people to avoid risks or threats to their basic human needs. Terminology: Need: A need is something that is desirable, useful or necessary. Human needs: are physiologic and psychological conditions that an individual must meet to achieve a state of health or well-being. Common theory related to basic needs: Maslow’s hierarchy theory of Basic needs for Human Being Maslow’s hierarchy theory: Maslow’s hierarchy of needs is a five-tier list of human needs developed by Abraham Maslow, an American psychologist, often presented as a pyramid with the fundamental needs at the bottom and the higher-level needs at the top. 58 | P a g e ▪ Maslow defined the basic needs of all people as a progression from simple physical needs, or survival needs, to more complex ones, called aesthetic needs. Progression from physical needs to aesthetic needs: 1. Physiologic (physical) needs 1. Oxygen 2. Fluids 3. Nutrition 4. Activity 59 | P a g e  5. Elimination 6. Rest and sleep 7. Sex concept 2. Safety and Security 1. Physical safety 2. Psychological safety 3. The need for shelter and freedom from harm and danger 3. Love and belonging 1. The need to love and be loved 2. The need to care and to be cared for. 3. The need for affection: to associate or to belong 4. The need to establish fruitful and meaningful relationships with people, institution, or organization 4. Self-Esteem Needs 1. Self-worth 2. Self-identity 3. Self-respect 4. Body image 5. Self-Actualization Needs 1. The need to learn, create and understand or comprehend 2. The need for harmonious relationships 3. The need for beauty or aesthetics 4. The need for spiritual fulfillment 60 | P a g e  Physiological needs Learning objectives: At the end the students will be able to: ▪ Define physiological needs ▪ List of physiological needs ▪ Discuss fluid and electrolytes and acid base. ▪ Explain oxygenation in human body. ▪ Discuss nutrition as a basic physiological need. ▪ Discuss skin integrity to human body. ▪ Explain elimination in human body. ▪ Discuss rest & sleep needs for human body. ▪ Analyze activity as essential need for human body. Introduction Physiological needs - these are biological requirements for human survival, e.g., air, food, drink, shelter, clothing, warmth, sex, sleep. If these needs are not satisfied the human body cannot function optimally. Definition Physiological needs are the most basic things that everyone needs in order to survive such as food, water, sleep, medical care, and air. When these are not satisfied, human may feel sickness, irritation, pain, discomfort, etc. Physiologic (physical) needs 1. Fluids, electrolyte and acid base 5. Rest and sleep 2. Oxygen 6. Sex concept 3. Nutrition 7. Activity 4. Elimination 61 | P a g e  Fluid, Electrolyte and Acid base Body Fluids Total amount of fluid in the human body which is approximately 50%-60% of the total body weight. Body fluids compartments. Body fluids are divided into two main compartments: Intracellular fluid: Intracellular fluid functions as a stabilizing agent for the parts of the cell, helps maintain cell shape and assists with transport of nutrients across the cell membrane, in and out of the cell. Extracellular fluid. Extracellular fluid mostly appears as interstitial tissue fluid and intravascular fluid. Composition of body fluids: Water Dissolved solutes: Organic substances: Glucose, Amino acids, Fatty acids, Hormones & Enzymes. 62 | P a g e  Inorganic substances(electrolytes): Sodium, Potassium, Calcium, Magnesium, Chloride &Phosphate. Normal Intake and Output Daily intake. An adult human at rest takes appropriately 2,500 ml of fluid daily. Levels of intake. Approximate levels of intake include fluids 1, 200 ml, foods 1, 000 ml, and metabolic products 30 ml. Daily output. Daily output should be approximately equal in intake. Normal output. Normal output occurs as urine, breathing, perspiration, feces, and in minimal amounts of vaginal secretions. Electrolytes Definition: It is a substance that will disassociate into ions when dissolved in water. Origins. Electrolytes are found in the form of inorganic salts, acids, and bases. Active chemicals. Electrolyte concentrations are measured according to their chemical activity and expressed as milliequivalents. Ions. Each chemical element has an electrical charge, either positive or negative. Intracellular electrolytes. Important intracellular electrolytes are potassium, magnesium, sulfate, and phosphate, and the most dominant cation is potassium while the most dominant anion is phosphate. 63 | P a g e  Extracellular electrolytes. Important extracellular electrolytes include sodium, chlorine, calcium, and bicarbonate, and the most essential cation is sodium while chlorine is the most important anion. Electrolytes in body fluids: Fluid and Electrolyte Transport Total electrolyte concentration affects the body’s fluid balance. The body cells. Nutrients and oxygen should enter body cells while waste products should exit the body. The cell membrane. The cell membrane separates the intracellular environment from the extracellular environment. Permeability. The ability of a membrane to allow molecules to pass through is known as permeability. Passive Transport Passive transport mechanisms include diffusion, osmosis, and filtration. 64 | P a g e  Diffusion. Diffusion, or the process of “being widely spread”, is the random movement of molecules from an area of higher concentration to an area of lower concentration. Osmosis. Osmosis is the diffusion of a pure solvent, such as water, across a semipermeable membrane in response to a concentration gradient in situations where the molecules of a higher concentration are non-diffusible. Filtration. Filtration is the transport of water and dissolved materials concentration already exists in the cell. Active Transport Mechanisms. Active transport mechanisms require specific enzymes and energy expenditure in the form of adenosine triphosphate (ATP). Different fluid volume disturbances that may affect an individual. Fluid volume deficit or hypovolemia occurs when the loss of ECF volume exceeds the intake of fluid. 65 | P a g e  Fluid volume excess or hypervolemia refers to an isotonic volume expansion of the ECF caused by the abnormal retention of water and sodium in approximately the same proportions in which they normally exist in the ECF. Disturbances in electrolyte balances are common in clinical practice and must be corrected. 66 | P a g e  Acid-Base Balance Acid. An acid is one type of compound that contains the hydrogen ion. Base. A base or alkali is a compound that contains the hydroxyl ion. Salt. Salt is a combination of a base and an acid and is created when the positive ions of a base replace the positive hydrogen ions of an acid. Important salts. The body contains several important salts like sodium chloride, potassium chloride, calcium chloride, calcium carbonate, calcium phosphate, and sodium phosphate. Potential of Hydrogen ▪ PH. The symbol of pH refers to the potential or power of hydrogen ion concentration within the solution. Buffers Buffers. A buffer is a chemical system set up to resist changes, particularly in hydrogen ion levels. Causes of fluid and electrolyte imbalances: Fluid retention. Retention of sodium is associated with fluid retention. Loss of sodium. Excessive loss of sodium is associated with decreased volume of body fluid. Trauma. Trauma causes release of intracellular potassium which is extremely dangerous. Loss of body fluids. FVD results from loss of body fluids and occurs more rapidly when coupled with decreased fluid intake. 67 | P a g e  Fluid overload. Fluid volume excess may be related to a simple fluid overload or diminished function of the homeostatic mechanisms responsible for regulating fluid balance. Low or high electrolyte intake. Diets low or excessive in electrolytes could also cause electrolyte imbalances. Medications. There are certain medications that could lead to electrolyte imbalances when taken against the physician’s orders. Nursing intervention: Intake &Output. The nurse should monitor for fluid I&O at least every 8 hours, or even hourly. Daily weight. Assess the patient’s weight daily to measure any gains or losses. Vital signs. Vital signs should be closely monitored. Physical exam. A physical exam is needed to reinforce other data about a fluid or electrolyte imbalance. Monitor turgor. Skin and tongue turgor are indicators of the fluid status of the patient. Urine concentration. Obtain urine sample of the patient to check for urine concentration. Oral and parenteral fluids. Administer oral or parenteral fluids as indicated to correct the deficit. Oral rehydration solutions. These solutions provide fluid, glucose, and electrolytes in concentrations that are easily absorbed. Central nervous system changes. The nurse must be alert for central nervous system changes such as lethargy, seizures, confusion, and muscle twitching. Diet. The nurse must encourage intake of electrolytes that are deficient or restrict intake if the electrolyte levels are excessive. 68 | P a g e  Oxygenation Introduction: The main function of our respiratory system is to provide the body with a constant supply of oxygen and to remove carbon dioxide. To achieve these functions, muscles and structures of the thorax create the mechanical movement of air into and out of the lungs called ventilation. Gas exchange occurs at the alveolar level where blood is oxygenated and carbon dioxide is removed. Several respiratory conditions can affect a patient’s ability to maintain adequate ventilation and respiration, and there are several medications used to enhance a patient’s oxygenation status. Definition: Oxygen: Is the most essential of all basic survival needs. Without oxygen circulating in the bloodstream, a person will die in a matter of minutes. Oxygen is provided to the cells by maintaining an open airway and adequate circulation. Oxygenation: It is process refers to how well the cells, tissues, and organs of the body are supplied with oxygen through the respiratory system functions. 69 | P a g e Respiration is the physiological process of taking in oxygen from the environment during inhalation, while getting rid of carbon dioxide during exhalation. It involves both ventilation and oxygenation. Physiology of respiration: While ventilation brings air into the lungs, it is oxygenation that helps ensure that the cells and body tissues receive enough oxygen molecules. The gaseous exchange occurs by diffusion in the alveoli. It depends on essentially three factors: o The integrity of the airway system to transport air to and from the lungs. o A properly functioning alveolar system in the lungs to oxygenate venous blood and to remove carbon dioxide from the blood. Mechanism of ventilation: 1. Inhalation (Inspiration) Expansion of the chest cavity and lungs creates negative pressure inside the lungs, causing air to be drawn in through the nose or mouth and airways. 2. Exhalation (Expiration)When the diaphragm and intercostal muscles relax, exhalation allows the chest and lungs to return to their normal resting size. 70 | P a g e Process of Oxygenation ▪ Ventilation: The process of moving gases into and out of the lungs. ▪ Perfusion: The ability of the cardiovascular system to pump oxygenated blood to the tissues and return deoxygenated blood to the lungs. ▪ Diffusion: Exchange of respiratory gases in the alveoli and capillaries. Exchange of respiratory gases: refers to, the oxygenation of blood and elimination of carbon dioxide in the lungs. 3. External Respiration Alveolar capillary gas exchange (or external respiration) occurs in the alveoli of the lungs. 4. Internal Respiration Capillary tissue gas exchange (or internal respiration) occurs in body organs and tissues. Factors Affecting Oxygenation Physiological factors (Increased metabolic rate). Disease process (Anemia, Hypovolemia, Fever, Obesity & Dehydration and hemorrhage). Decreased inspired oxygen concentration Environmental factors (High altitudes &occupational pollutants). Factors affecting chest wall movement (Trauma) Pregnancy Musculoskeletal abnormalities Medications Lifestyle Risk Factors (Activity and exercise, Stress, smoking & substance abuse). 71 | P a g e Common Respiratory Alterations ▪ Hyperventilation: ventilation in excess of that required; rate and depth of respirations increase. ▪ Hypoventilation: alveolar ventilation inadequate to meet the body’s oxygen demand; respiratory rate and depth is low ▪ Hypoxia: Inadequate tissue oxygenation at the cellular level, late sign cyanosis ▪ Hypoxemia: Inadequate blood oxygenation. ▪ Altered breathing patterns 1. Tachypnea (rapid rate) 2. Bradypnea (abnormally slow rate) 3. Apnea (cessation of breathing) 4. Dyspnea & Orthopnea ▪ Obstructed or partially obstructed airway: As a result of the presence of foreign body, or accumulation of mucus or inflammatory exudates. Nursing Interventions: Airway Management: ▪ Administer humidified air or oxygen immediately ▪ Regulate fluid intake ▪ Monitor respiratory and oxygenation status ▪ Administer drug therapy (bronchodilators, corticosteroids) ▪ Auscultate lung sounds before and after treatments Cough Enhancement ▪ Positioning for chest expansion ▪ Deep breathing, hold for 2 seconds, and cough 2-3 times. 72 | P a g e Respiratory Monitoring: Rate, rhythm, depth, and effort (overall patterns) Monitor for increased restlessness, anxiety, and air hunger Note changes in oxygen saturation (SaO2), arterial blood gases (ABG) values. Anxiety Reduction Calming & reassuring attitudes Stay with patient Encourage slow breathing (pursed lips) Teaching: ▪ Identify level of knowledge disease process & prescribed Medication ▪ Instruct on measure to prevent/minimize side effects of treatment Evaluate patient’s ability to self-administer medications ▪ Instruct patient on purpose, action, dosage, and duration of each medication ▪ Include family and significant others 73 | P a g e  Nutrition Introduction: Our bodies are built of and powered by solely what we eat and drink. Food is the source of all of the energy needed. Good nutrition is essential to wellness, and poor nutrition contributes to disease, so clients need accurate, current, and appropriate nutritional information. Definition: Nutrition: is a state of well-being achieved by eating the right food in every meal and the proper utilization of the nutrients by the body. Proper nutrition is important because: ▪ It helps in the development of the brain, especially during the first years of the child’s life. ▪ It speeds up the growth and development of the body including the formation of teeth and bones ▪ It helps fight infection and diseases ▪ It speeds up the recovery of a sick person ▪ It makes people happy and productive ▪ Proper nutrition is eating a balanced diet in every meal. Nutrients: It is the substances found in food which drive biological activity, and are essential for the human body. ▪ They are categorized as proteins, fats, carbohydrates (sugars, dietary fiber), vitamins, and minerals, and perform the following vital functions: ▪ Building all parts of the body such as muscle, bone, teeth, and blood ▪ Producing energy (power and heat) ▪ Keeping the body in good working order. 74 | P a g e  Protein: is the main constituent of the body, making up the muscles, internal organs, skin, and blood. they are essential for the growth, maintenance, and repair of body tissue. Fats/carbohydrates (sugars): the body's energy (power and heat) source Fats (lipids) are the most calorie-dense nutrient, providing (9kcal per gram). Fats are composed of triglycerides and fatty acids. Although consuming too much fat can lead to obesity, small amounts can provide a highly efficient energy source. Carbohydrates can be broken down further into the two categories of sugars and dietary fiber. Sugars are the carbohydrates which can be used as an energy source to move the body (such as during exercise) and are stored in the liver and muscles as glycogen. Sugars are also the main source of energy for the brain. Water. Water is critical because cell function depends on a fluid environment. Water makes up 60% to 70% of total body weight. 75 | P a g e  Vitamins/minerals: keeping the body in good working order Vitamins and minerals are not used as energy, but instead aid in breaking down and building up proteins, fats, and sugars, and are an essential nutrient for keeping the body healthy and in good working order. 76 | P a g e  Elimination After ingesting food and fluids, our body eliminates waste products through the urinary system and the gastrointestinal system. Elimination is the expulsion of waste products from the body through the skin, lungs, kidneys and rectum. Urinary elimination Definition: is the removal of waste products from the body through the urinary system(urine). Physiology of urine elimination ▪ When the urine is collected in the bladder, desire to void is experienced due to the stimulation of stretch receptors. ▪ This sensation occurs when the bladder is filled with 250-450 ml of urine in adults and 50-200 ml in children. ▪ The stretch receptors transmit the message to the voiding reflex center in the spinal cord. ▪ If the time is appropriate the brain seeds message through spinal cord causing stimulation so that the urine can be released from the bladder. ▪ If the time and place are appropriate the external sphincter and the urination process takes place. Normal Urinary Function ▪ Normal urine output is 60mL/hr. or 1500mL/day; should remain 30 mL/hr to ensure continued normal kidney function ▪ Urine normally consists of 96% water ▪ Solutes found in urine include: ▪ Organic solutes: urea, ammonia, uric acid and creatinine 77 | P a g e  ▪ Inorganic solutes: sodium, potassium, chloride, sulfate, magnesium & phosphorus. Factors Influencing Urinary Elimination ▪ Growth and Development ▪ Sociocultural Factors ▪ Psychological Factors ▪ Personal Habits ▪ Fluid Intake ▪ Pathological Conditions ▪ Surgical Procedures ▪ Medications ▪ Diagnostic Examinations Common Urinary Elimination Problems ▪ Anuria: 24-hour urine output is less than 50 mL; synonyms are complete kidney shutdown or renal failure. ▪ Dysuria: Painful or difficult urination ▪ Frequency: Increased incidence of voiding ▪ Glycosuria: Presence of sugar in the urine ▪ Nocturia: Awakening at night to urinate ▪ Oliguria: Scanty or greatly diminished amount of urine voided in a given time; 24-hour urine output is less than 400 mL ▪ Polyuria: Excessive output of urine (diuresis) ▪ Proteinuria: Protein in the urine; indication of kidney disease ▪ Pyuria: Pus in the urine; urine appears cloudy ▪ Suppression: Stoppage of urine production; normally the adult kidneys produce urine continuously at the rate of 60 to 120 mL/h ▪ Urgency: Strong desire to void ▪ Urinary incontinence: Involuntary loss of urine 78 | P a g e Bowel Elimination Regular elimination of bowel waste products is essential for normal body functioning. Alterations in bowel elimination are often early signs or symptoms of problems within either the gastrointestinal (GI) tract or other body systems. Because bowel function depends on the balance of several factors, elimination patterns and habits vary among individuals. The gastrointestinal tract, also known as the alimentary tract or canal, extends from the mouth to the anus. Definition: Bowel Elimination (Defecation) is a natural process by which the soiled waste products of digestion (feces or stool) are eliminated from the bowel. The Large Intestine Primary organ of bowel elimination Extends from the ileocecal valve to the anus Functions 1. Completion of absorption of H2O, Nutrients 2. Manufacture of some vitamins 3. Formation of feces 4. Expulsion of feces from the body The Small and Large Intestines Process of Peristalsis ▪ Peristalsis is under control of nervous system ▪ Contractions occur every 3 to 12 minutes ▪ Mass peristalsis sweeps occur 1 to 4 times each 24-hour period ▪ One-third to one-half of food waste is excreted in stool within 24 hours ▪ Peristaltic Movements in the Intestine – Colonic peristalsis is slow. 79 | P a g e  ▪ Mass peristalsis is strong, few waves per day, stimulated by food in small intestine. Factors that influence Bowel Elimination ▪ Age. ▪ Diet. ▪ Fluid Intake ▪ Physical Activity. ▪ Psychological Factors. ▪ Personal Habits. ▪ Position During Defecation. ▪ Pain. ▪ Pregnancy. ▪ Surgery and Anesthesia. ▪ Medications. ▪ Diagnostic Tests. Common Bowel Elimination Problems ▪ Constipation – abnormal frequency of defecation and abnormal hardening of stools ▪ Impaction – accumulated mass of dry feces that cannot be expelled ▪ Diarrhea – increased frequency of bowel movements (more than 3 times a day) as well as liquid consistency and increased amount; accompanied by urgency, discomfort and possibly incontinence ▪ Incontinence – involuntary elimination of feces ▪ Flatulence – expulsion of gas from the rectum ▪ Hemorrhoids – dilated portions of veins in the anal canal causing itching and pain and bright red bleeding upon defecation. 80 | P a g e Promoting Regular Bowel Habits: ▪ Timing -attend to urges promptly ▪ Positioning – have patient sit up, gravity aids in BM ▪ Privacy – close door & pull curtain ▪ Nutrition ▪ Exercise – abdominal muscles & thighs ▪ Abdominal settings ▪ Thigh strengthening 81 | P a g e  Rest & sleep Physical and emotional health depends on adequate sleep and rest. Without the proper amount of rest and sleep, the patient’s ability to concentrate, make judgments, promote healing, and participate in daily activity decreases. While caring for patients, you need to individualize an approach to sleep and rest based on the patient’s personal sleep habits and pattern of sleep to provide effective sleep therapies. Definition: Rest: is a condition in which the body is inactive or engaging in mild activity, after which the person feels refreshed. A person at rest is calm, at ease, relaxed, and free of anxiety and stress. Sleep: is a state of rest accompanied by dynamic and regulated set of behavioral and physiological states which during many processes vital to health and well-being take place. Sleep requirements and patterns: Eight hours of sleep a night has been the accepted standard. It varies according to age. Pattern of sleep periodicity appear to be learned. ▪ For example, most people learn to sleep at night and to be awake and work during the day. However, many night shift workers learn to sleep equally well during the day. 82 | P a g e  Physiology of Sleep Sleep is a cyclical physiological process that alternates with periods of wakefulness. Functions of Sleep 1. Cleaning the brain of toxins 2. Physical restoration 3. Information processing & memorization 4. Mood regulation 5. Strengthening immune system Factors affecting sleep ▪ Developmental considerations ▪ Physical activity ▪ Psychological stress ▪ Motivation ▪ Cultural implications ▪ Diet. ▪ Alcohol intake ▪ Caffeine-containing beverage 83 | P a g e  ▪ Smoking ▪ Environmental factors ▪ Lifestyle ▪ Exercise ▪ Illness ▪ Medications The more common sleep disorders are Dyssomnias that characterized by insomnia or excessive sleepiness. Parasomnias are patterns of waking behavior that appear during sleep such as somnambulism (sleepwalking), sleep talking, nocturnal enuresis (bedwetting during sleep). Narcolepsy is a condition characterized by uncontrollable desire to sleep. Insomnia is characterized by difficulty falling asleep, intermittent sleep, or early awakening from sleep. Sleep apnea refers to a period of no breathing between snoring intervals. Sleep deprivation refers to a decrease in the amount, quality of sleep. Nursing Care for Patient with Sleep Disorders: ▪ Assessment of sleep pattern and take sleep history ▪ Preparing restful environment ▪ Promoting bedtime rituals ▪ Offering appropriate bedtime snacks and beverages ▪ Promoting relaxation ▪ Respecting normal sleep wake pattern ▪ Scheduling nursing care to avoid unnecessary disturbances ▪ Using medication to produce sleep ▪ Teaching about rest and sleep 84 | P a g e  Skin integrity Introduction The integumentary system consists of the skin, hair, nails, sweat glands, and the subcutaneous tissue below the skin. The skin is the largest organ of the body. The major functions of the skin include protection of the internal organs, unique dentification of an individual, thermoregulation, metabolism of nutrients and metabolic waste products, and sensation. Functions of the Skin Protection (first line of defense) Body temperature regulation Psychosocial Sensation Vitamin D production Immunologic Absorption Elimination Factors Affecting Skin Integrity Basic principles related to