Fundamental of Nursing PDF 2023/2024, Zagazig University

Zagazig University Faculty of Nursing Medical Surgical Department Credit Hours Fundamental of Nursing First year students 2023/2024...

Zagazig University Faculty of Nursing Medical Surgical Department Credit Hours Fundamental of Nursing First year students 2023/2024 1  Prepared by Academic staff of Medical-Surgical Nursing Department 2  Zagazig University Faculty of Nursing Medical Surgical Department ‫رؤية و رسالة كلية التمريض – جامعة الزقازيق‬ :‫رؤية القسم‬ ‫يتطلع قسم التمريض الباطني الجراحي كلية التمريض جامعة الزقازيق الي شغل مكان الصدارة بين‬ ‫كافة القسام العلمية المختلفة في الكلية والكليات المناظرة ويكون قادراا على منافسة كل مؤسسات‬.‫التعليم العالي والبحث العلمى للتمريض على المستوى القليمي والدولي‬ :‫رسالة القسم‬ ‫تكمن رسالة قسم التمريض الباطنى والجراحى فى إعداد طالب مؤهل معرفيا ومهاريا ومهنيا لتقديم‬ ‫رعاية تمريضية شامله ذات جوده عاليه للتمريض الباطنى والجراحى وللمرضى والصحاء‬ ‫بالمستشفيات والمراكز الصحية المختلفة والقيام بإجراء البحاث العلمية المتطورة لتلبية احتياجات‬.‫ومتطلبات سوق العمل محليا‬ Mission: The mission of Medical Surgical Nursing Department in the preparation of qualified student cognitive, skillfully and professionals to provide a comprehensive high-quality nursing care for Medical Surgical nursing, patients and healthy people in hospitals and different health centers and conduct evolving scientific research to meet the needs and requirements of the market locally. Vision: Medical Surgical Nursing Department, Faculty of Nursing, Zagazig University looks to take the lead among all the various scientific departments in the faculty and faculties counterpart and be able to compete with all higher educational institutions and scientific research for nursing at regional and international level. 3  Contents Content Page  Introduction of Nursing 5  Nursing process 8  Health, Wellness, and illness 23  Basic Human Needs 32  Recording and reporting (Documentation) 42  Infection Control 47  Vital Signs 54  Medication 75  Immobility 86  Oxygenation 100  First Aids 112 4  Introduction of Nursing Definition of nursing: Nursing is an art and science based on knowledge, skills and attitudes, aimed to assist individuals, family and community in health and illness, as promotion of health, prevention of illness, care and management of diseases , prevent complications and rehabilitation. Nursing practice: Nursing practice means assisting individuals or groups to maintain or attain optimal health throughout the life process by assessing their health status, establishing a diagnosis, planning and implanting starting of care to accomplish defined goals and evaluating responses care and treat treatment. Nursing Auxiliary: The person who assist in nursing practice under the standards and direct or indirect supervision of nurses are referred to in a general as auxiliaries or assistants. Definition of nurse: The nurse is a person who has completed a program of basic generalized nursing education and has authority to practice nursing in his or her country. The nurse is prepared and authorized to: 1- Engage in general scope of nursing practice (promotion of health, prevention of illness, and care of diseases, and disabled person in all health care settings. 2- Carry out health care teaching. 3- Participate fully, as a member of the health team. 4- Supervise and train nursing and health care auxiliaries. 5- Involved in research. Registered nurse (RN): means a person who practice professional caring out the practice of those function which, directly or indirectly in collaboration with a client and with other health workers, have as their effective objective, promotion of health, prevention of illness, alleviation of suffering, restoration of health and maximum development of health potential and without restricting. The generality of the foregoing includes:  Assessment (collecting data relating to the health status of an individual or groups) 5   Setting the nursing goals and establishing nursing diagnosis  Determining nursing approaches and activities  Implementing the nursing care plan supportive or restorative of life, will being  Implementing care relevant to medical treatment  Evaluating the consequences of nursing care provided  Reevaluation on care plan  Authorizing nursing intervention that may be performed by others  Maintaining safe and effective nursing care  Teaching the theory and practice of nursing  Managing the practice of nursing  Collaborating with other health professionals in the management of health care Specific Roles: The professional nurse fulfills the entire following Role: 1- Specialist 2- Care giver 3- Teacher 4- Counselor 5- Leader 6- Manager 7- Collaborator 8- Consultant 9- Change agent 10- Advocate 11- Culture broker 12- Registered 1- Specialist: The nurse prepared beyond to level of a nurse generalist and authorized to practice as specialist with advanced expertise in a branch of nursing field as (clinical, teaching, administration, search and consultant roles). 2- Care giver: Caring, administering and implementing Nursing strategies. 3- Teacher: The nurse can teaches both theory and practice in updated to meet the advances in sciences technology and education. 4- Counselor: Helping a client to cope with stress or social problems and provide psychologic support. Counseling requires therapeutic communication skills nurse 6 5- Leader: Nurse is leader for families, groups of client's, society and professional colleagues. Leadership requires many skills especially good communication. 6- Manger: Coordination integration of resources through planning, organizing, directing and controlling as specific institutional goals and objectives 7- Collaborator: The nurse works with another health professional team illustrates the overlapping responsibilities of health personal and reflects the relationship between health team. 8- Consultant: Referring or transferring clients to another person. Responsibility of clients care remains with the nurse who seeks the consultations 9- Change agent: The nurse can change the status in system so that who involved must relearn how to perform their role and promote change in client's knowledge, skill and attitudes. 10- Advocate: An advocate has two basic functions to allow clients to make their own decisions and to support clients in their decisions. 11- Culture Broker: Nurse acting as a culture broker mediates between client and health professional team. 12- Registered: Nurse collect data about health status of patient, setting nursing goals and establishing nursing diagnosis, implementing the nursing care plan and evaluating the consequences of nursing care provided Factors influencing nursing practice: 1- Consumer Demands 2- Family structure 3- Economics 4- Science and technology 5- Legislation 6- Demography 7- Women's movement 8- Collective bargaining 9- Nursing profession Trends in Nursing: 1- Scientific basis 2- Broadening focus 7 3- Technology 4- Education 5- Collaboration 6- Home health care nursing a self-care 7- Health policy making 8- Collective bargaining 9- High touch 10-Autonomy Nursing process At the end of this lecture, the learner will be able to: Describe the components of the Nursing Process (NP). List the benefit & characteristics of NP Describe the five phases of the nursing process. Identify methods of data collection. Differentiate between objective and subjective data Distinguish between primary and secondary data. Describe the characteristics and formulations nursing diagnosis Identify factors that the nurse must consider in planning, implementing, and evaluating patient care. Outline critical pathways and concept maps are used to create a nursing care plan. Formulate client health outcome evaluation criteria Explain how evaluation relates to various phases of the nursing process. Nursing process: is a systemic step that professional nurses use to apply the best available evidence to deliver nursing care. Purposes of nursing process: 1- Identify client strengths and potential or actual health problems or needs. 2- Develop specific nursing interventions to achieve outcomes. 3- Provide individualized, holistic, effective client care efficiently. 4- Providing professional, quality nursing care. 5-Provides the basis for critical thinking in nursing. Characteristics: Systematic—part of an ordered sequence of activities 8  Cyclical & Dynamic—great interaction and overlapping among the five steps Interpersonal—human being is always at the heart of nursing Outcome oriented—nurses and patients work together to identify outcomes Universally applicable—a framework for all nursing activities Client-centeredness—the nurse organizes the plan of care according to identified client problems. Focus on problem solving— the nursing process uses both problem- solving and systems theory to organize care Focus on decision making— Decision making is involved in every phase of the nursing process. Interpersonal and collaborative style— Nurses communicate directly and consistently with clients to meet their needs. Also collaborate, as members of the health care team, to provide quality client care. Use of critical thinking— Nurses must use a variety of critical thinking skills to carry out the nursing process Phases of the nursing process: 1. Assessment 2. Diagnosis 3. Planning 4. Implementation 5. Evaluation 9 Steps (Phases) of nursing process: 1. Assessment: Is the first step in the nursing process and includes systematic collection of data to determine the patient’s health status and any actual or potential health problems Nursing assessment involves two steps: 1. Collection of information from a primary source (a patient) and secondary sources (e.g., family caregiver, family members or friends, health professionals, medical record). 2. The interpretation and validation of data to determine whether more data are needed or the database is complete. Dimensions for gathering data for a health history: Past Health: Past health events are important because they may have residual effects on the current health state. 10 Childhood Illnesses: Measles, mumps, rubella, chickenpox, pertussis, and strep throat, Rheumatic fever, scarlet fever, poliomyelitis Accidents or Injuries: Serious or Chronic Illnesses: Asthma, depression, diabetes, hypertension, heart disease, human immunodeficiency virus (HIV), hepatitis, cancer and seizure disorder Hospitalizations: Operations: Type of surgery Obstetric History: Number of pregnancies, number of deliveries, preterm, number of incomplete pregnancies (miscarriages or abortions), and number of children living (living) Immunizations: Last Examination Date: Physical, dental, vision, hearing, electrocardiogram (ECG), chest x-ray film, mammogram, Pap test, stool occult blood, serum cholesterol. Allergies: Note both the allergen (medication, food, or environmental agent). Current Medications: General Overall Health State:  Present weight (gain or loss), fatigue, weakness or malaise, fever, chills, sweats or night sweats. Skin: History of skin disease (eczema, psoriasis, hives), pigment or color change, excessive dryness or moisture, pruritus, excessive bruising, rash or lesion. Hair: Recent loss, change in texture. Nails: change in shape, color, or brittleness. Head: Any unusually frequent or severe headache; any head injury, dizziness (syncope), or vertigo. Eyes: Difficulty with vision (decreased acuity, blurring, blind spots), eye pain, diplopia (double vision), redness or swelling, watering or discharge, glaucoma or cataracts. Wear glasses or contacts 11 Ears: Earaches, infections, discharge and its characteristics, tinnitus or vertigo. Hearing loss, hearing aid use, how loss affects daily life, any exposure to environmental noise, and method of cleaning ears. Nose and Sinuses: Discharge and its characteristics, any unusually frequent or severe colds, sinus pain, nasal obstruction, nosebleeds (epistaxis), allergies, or change in sense of smell. Mouth and Throat: Mouth pain, frequent sore throat, bleeding gums, toothache, lesion in mouth or tongue, dysphagia, hoarseness or voice change, tonsillectomy, altered taste. Pattern of daily dental care, use of dentures, bridge, and last dental checkup. Neck:  Pain, limitation of motion, lumps or swelling, enlarged or tender nodes, goiter. Breast: Pain, lump, nipple discharge, rash, history of breast disease, any surgery on breasts. Performs breast self-examination, including its frequency and method used; last mammogram. Axilla: Tenderness, lump or swelling, rash. Respiratory System:  History of lung diseases (asthma, emphysema, bronchitis, pneumonia, TB), chest pain with breathing, wheezing or noisy breathing, shortness of breath, cough, sputum (color, amount), hemoptysis, toxin or pollution exposure.  Last chest x-ray study, TB skin test. Cardiovascular: o Chest pain, pressure, tightness or fullness, palpitation, cyanosis, dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, nocturia, edema, history of heart murmur, hypertension, coronary heart disease, anemia. o Date of last ECG or other heart tests, cholesterol screening. 12 Peripheral Vascular:  Coldness, numbness and tingling, swelling of legs (time of day, activity), discoloration in hands or feet (bluish red, pallor, mottling, associated with position, especially around feet and ankles), varicose veins, thrombophlebitis, ulcers. Gastrointestinal: Appetite, food intolerance, dysphagia, heartburn, indigestion, pain (associated with eating), other abdominal pain, nausea and vomiting, vomiting blood, history of abdominal disease (liver or gallbladder, ulcer, jaundice, appendicitis, colitis), flatulence, frequency of bowel movement, any recent change, stool characteristics, constipation or diarrhea, black stools, rectal bleeding, rectal conditions (hemorrhoids, fistula). Use of antacids or laxatives. Urinary System: Frequency, urgency, nocturia (the number of times the person awakens at night to urinate, recent change); dysuria; polyuria or oliguria; hesitancy or straining, narrowed stream; urine color (cloudy or presence of hematuria); incontinence; history of urinary disease (kidney disease, kidney stones, urinary tract infections, prostate); pain in flank, groin, suprapubic region, or low back. Musculoskeletal System:  History of arthritis or gout.  In the joints: Pain stiffness, swelling (location, migratory nature), deformity, limitation of motion, friction with joint motion  In the muscles: muscle pain, cramps, weakness, gait problems, or problems with coordinated activities?  In the back: pain (location and radiation to extremities), stiffness, limitation of motion, or history of back pain or disk disease?  How much walking per day?  What is the effect of limited range of motion on ADLs such as grooming, feeding, toileting, and dressing? Are any mobility aids used? Neurologic System: History of seizure disorder, stroke, fainting, blackouts. Motor function: Weakness, tremor, paralysis, or coordination problems? 13  Sensory function: Numbness, tingling (paresthesia)? Cognitive function: Memory disorder (recent or distant, disorientation)? Mental status: nervousness, mood change, depression, or history of mental health dysfunction or hallucinations? Interpersonal relationships and coping patterns. Hematologic System:  Bleeding tendency of skin or mucous membranes, excessive bruising, lymph node swelling, exposure to toxic agents or radiation, blood transfusion and reactions. Endocrine System: o History of diabetes or diabetic symptoms (polyuria, polydipsia, polyphagia), history of thyroid disease, intolerance to heat and cold, change in skin pigmentation or texture, excessive sweating, relationship between appetite and weight, abnormal hair distribution, nervousness, tremors, and need for hormone therapy. Functional Assessment (Including Activities of Daily Living) Characteristics of data Purposeful Complete Factual and accurate Relevant Sources Patient (primary source) by using both interview and physical examination. Family/significant other Patient record Other healthcare professionals Nursing and other healthcare literature Purpose of assessment: 1. Organize a database regarding a client's health. 2. Identified of actual or potential health problems. 3. The nurse can ascertains of the clients about: a. Functional abilities b. Absence or the presence of dysfunction 14  c. Normal activities of daily living, and d. Lifestyle pattern. 4. Identifying the client strengths gives the nurse information about the abilities, behavior, and skills the client can use during the treatment and recovery process. 5. Provides an opportunity to form a therapeutic relationship with clients. 6. The client can discuss health care concerns and goals with the nurse. Type of assessment: Three types of assessment include: 1. Comprehensive assessment: a. Provide baseline of client data including a complete health history and current needs assessment. b. Usually completed upon admission to health care agency. c. Changes in the clients' health status can be measured against this database. d. Includes of clients physical and psychological health, perception of health, presence of health risk factors, and coping patterns. 2. Focused assessment: a. Is limited to potential health care risks, a particular need, or health care concern. b. There are not as a detailed as comprehensive assessment. c. Often used when short stays are anticipated (e.g., outpatient surgery and emergency departments). d. Used in specialty areas such as mental health settings and delivery. e. Used in screening for specific problems or risk factors. 3. Ongoing assessment: a. Follow up, or monitoring of specific problems. b. Broadens the database and allow the nurse to confirm the validity of data obtained during the initial assessment. c. Systematic monitoring allows the nurse to determine the client's response to nursing interventions and to identify any other problems. 15 Types of Data collection: A. Subjective data (also called symptoms):  Information that is provided verbally by the patient  Information perceived only by the affected person  For example, pain experience, feeling dizzy, feeling anxious B. 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. The primary method of collecting objective information is the physical examination, which provides information about the function of body systems. Inspection, palpation, percussion, and auscultation techniques are used to collect objective data. For example, elevated temperature, skin moisture, and vomiting, flushed face. Methods of data Collection: 1- Observation whenever the nurse is in contact with the client or support persons. 2- Interviewing is used mainly while taking the nursing health history 3- Examining is the major method used in the physical health assessment 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 16  need only to be recorded at that time. Data that reflect a significant deviation from the normal (for example, rapid heart rate with irregular rhythm, severe difficulty in breathing, or high levels of anxiety) would need to be reported as well as recorded. Examples of data that need only to be recorded at the time include a report that prescribed medication has relieved a headache and a determination that an abdominal dressing is dry and intact. NOTE: Assessment is dynamic and continues with each nurse-client interaction. 2. Nursing Diagnosis phase: According to the North American Nursing Diagnosis Association (NANDA): 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 3 physician that identifies or determines a specific disease, condition, or pathological state. Nursing Diagnosis Medical Diagnosis  Focuses on clients responses to actual  Focuses on illness, injury, or disease or potential health problems process.  Changes as the client’s response and/or  Remains constant until a cure is the health problem changes. effected or client dies.  Recognizes situations that the nurse is  Recognizes conditions the physician is licensed and qualified to intervene. licensed and qualified to treat.  Example: (Nausea, Acute pain,  Example: (Lung cancer, Congestive Anxiety, Impaired physical mobility, heart failure, Brain tumor, Exploratory Ineffective breathing pattern, Risk for surgery, Appendectomy, Bronchial imbalanced fluid volume). asthma). Purpose of diagnosing step:  Identify how an individual, group, or community responds to actual or potential health and life processes.  Identify factors that contribute to, or cause, health problems (etiologies).  Identify resources or strengths upon which the individual, group, or community can draw to prevent or resolve problems 17   Provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable Types of Nursing Diagnoses/Problem Statements: 1. An actual nursing diagnosis: client problem that is already present at the time of the nursing assessment 2. A potential nursing diagnosis: is one in which evidence about a health problem is incomplete or unclear. A potential diagnosis requires more data either to support or to refute it. 3. A risk nursing diagnosis: is a clinical judgment that a problem does not yet exist, but the presence of risk factors indicates that a problem is likely to develop unless the nurse intervenes. For example, all people admitted to a hospital have some possibility of acquiring an infection 4. A wellness nursing diagnosis: “describes human responses to levels of wellness in an individual, family or community that have a readiness for enhancement”. Sometimes is referred to as health promotion diagnosis, which relates to clients’ preparedness to implement behaviors to improve their health condition Components of a NANDA Nursing Diagnosis Problem: Activity Intolerance a. Identifies what is unhealthy about patient b. Addresses the human response Etiology “related to” Related to Bed rest - identifies factors maintaining the unhealthy state Defining Characteristics / signs & symptoms “as evidenced by” - identifies the subjective and objective data that signal the existence of a problem As evidenced by Verbal report of fatigue Example ND: Acute pain r/t myocardial ischemia AEB C/O of radiating chest pain to neck and left jaw 3. Planning: Development of goals and outcomes, as well as a plan of care designed to assist the patient in resolving the diagnosed problems and achieving the identified goals and desired outcomes 18 The Planning Process I. Setting priorities based on Maslow's Hierarchy of Human Needs Steps to Setting Priorities 1. Assign high priority to first-level priority problems (immediate priorities): Remember the “ABCs plus V”: Airway problems Breathing problems Cardiac/circulation problems Vital sign concerns (e.g., high fever) Exception: With cardiopulmonary resuscitation (CPR) for cardiac arrest, begin chest compressions immediately. 2. Next attend to second-level priority problems: Mental status change (e.g., confusion, decreased alertness) Untreated medical problems requiring immediate attention (e.g., a person with diabetes who has not had insulin) Acute pain Acute urinary elimination problems Abnormal laboratory values Risks of infection, safety, or security (for the patient or for others) 3. Address third-level priority problems (later priorities): Health problems that do not fit into the previous categories (e.g., problems with lack of knowledge, activity, rest, family coping) 19  II. Establishing client goals/desired outcomes:  After establishing priorities, the nurse and client set goals for each Nursing diagnosis Eg; Goal (broad): Improved nutritional status.  Desired outcome (specific): Gain 5 KG by April 25. Expected Outcomes must be (SMART):  Specific : reflect a specific patient behavior or response  Measurable: able to measure or observe whether a change takes place in a patient’s status.  Attainable /achievable: patient agree on the direction and time limits of care  Realistic: relevant for patients  Timed : Set a time for each goal and outcome to be met Purpose of Goals/Desired Outcomes  Provide direction for planning nursing interventions  Serve as criteria for evaluating client progress.  Enable the client and nurse to determine when the problem has been resolved.  Help motivate the client and nurse by providing a sense of achievement Types of goals: Short-term goals: - Outcomes achievable in a few days or 1 week Long-term goals Desirable outcomes that take weeks or months to accomplish for client’s with chronic health problems 4. Implementation phase: It consists of performing nursing activities that have been planned to meet the goals set with the client. The implementation phase of the nursing process requires cognitive (intellectual), psychomotor (technical), and interpersonal skills. The nurse must continue to assess the client’s condition before, during, and after the nursing intervention. a) In the nursing process, implementing is the action phase in which the nurse performs the nursing interventions. b) Implementing consists of doing and documenting the activities that are the specific nursing actions needed to carry out the interventions 20  c) Documenting nursing activities after carrying out the nursing activities, the nurse completes the implementing phase by recording the interventions and client responses in the nursing progress notes Types of Nursing Interventions: Nurse-initiated: - Actions performed by a nurse without a physician’s order Independent actions: - Those activities that nurse are licensed to initiate on the basis of their knowledge and skills. They include physical care, ongoing assessment, emotional support and comfort, teaching, counseling, environmental management, and making referrals to other health care professionals. Physician-initiated—actions initiated by a physician in response to a medical diagnosis but carried out by a nurse under doctor’s orders Dependent actions - Activities carried out under the orders or supervision physician or other health care provider authorized to write orders to nurses - Nurse is depending on Dr. (to write order for medication) for intervention Collaborative - Actions the nurse carries out in collaboration with other health team members, such as physical therapists, social workers, dietitians, and primary care providers. - Working with other members of team for intervention Actions performed in Nurse Initiated Interventions  Monitor health status.  Reduce risks.  If drug can make patient drowsy then put side rails up and monitor near patient  If patient is in respiratory difficulty then put patient in higher position and put oxygen then later on call physician and report. Physician can adjust level of oxygen as needed  Resolve, prevent, or manage a problem.  Facilitate independence or assist with ADLs (activities of daily living). 21   Promote optimum sense of physical, psychological, and spiritual well-being. III. Writing individualized nursing interventions on care plans  After choosing the appropriate nursing interventions, the nurse writes them on the care plan. The specific interventions chosen should focus on eliminating or reducing the etiology of the nursing Diagnosis. Type of nursing care plan: Initial Developed by the nurse who performs the nursing history and physical assessment Addresses each problem listed in the prioritized nursing diagnoses Identifies appropriate patient goals and related nursing care Ongoing Carried out by any nurse who interacts with patient Keeps the plan up to date States nursing diagnoses more clearly Develops new diagnoses Makes outcomes more realistic and develops new outcomes as needed Identifies nursing interventions to accomplish patient goals Be sure to check on patient frequently as that is an independent nursing action Discharge Carried out by the nurse who worked most closely with the patient Discharge teaching begins when the patient is admitted for treatment Uses teaching and counseling skills effectively to ensure home care behaviors are performed competently Can only be done by RN 5. Evaluation phase: Determination of the patient’s responses to the nursing interventions and the extent to which the outcomes have been achieved Determining whether the goals have been met, partially met, or not met. 22 1. If the goal has been met, the nurse must then decide whether nursing activities will stop or continue in order for status to be maintained. 2. If the goal has been partially met or not been met, the nurse must reassess the situation and change the plan of care accordingly. New problems may be identified at this stage, and thus the process will start all over again. There are a number of possible reasons that goals are not met or are only partially met, including: a. The initial assessment data were incomplete. b. The goals and expected outcomes were not realistic. c. The time frame was too optimistic. d. The goals and/or the nursing interventions planned were not appropriate for the client. Health, Wellness, and Illness Learning Outcomes: After completing this chapter, you will be able to: 1. Identify definitions of health, wellness, and well-being. 2. Describe five components of wellness. 3. Compare the various models of health. 4. Identify variables affecting health status, beliefs, and practices. 5. Differentiate illness from disease and acute illness from chronic illness. 6. Explain stages of illness. 7. Describe the effects of illness on individuals’ and family members’ roles and functions. Outline  Introduction  Definition of health  Definition of wellness  Models of health and wellness  Variables influencing health status, beliefs and practice  Definition of illness and disease 23   Classifications of illness and disease Health, wellness, and illness 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. Traditionally health was defined in terms of the presence or absence of disease. Florence Nightingale defined health as a state of being well and using every power. The World Health Organization (WHO) takes a more holistic view of health. It defines health as “a state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity.” This definition reflects concern for the individual as a total person functioning physically, psychologically, and socially. Disease: is a change in the structure or function of the body tissues, biological systems or the human mind. Illness: is the response to disease that involves a change in function. Illness is a state in which a person's physical, emotional, intellectual, social, developmental or spiritual functioning is diminished or impaired compares with previous experience. Personal definition of Health: Many people define and describe health as the following: Being free from symptoms of disease and pain as much as possible Being able to be active and to do what they want or must Being in good spirits most of the time Wellness and Well-Being: Wellness: is a state of well-being; has been described as the ongoing and dynamic process of striving to achieve optimum health. Basic aspects of wellness include:  Environmental: The ability to promote health measures, which improve the standard of living and quality of life in the community.  Social: The ability to interact successfully with people and within the environment.  Emotional: The ability to manage stress and to express emotions appropriately. 24   Emotional wellness: involves the ability to recognize, accept, and express feelings and to accept one’s limitations.  Physical: The ability to carry out daily tasks, achieve fitness (e.g., pulmonary, cardiovascular, gastrointestinal), maintain adequate nutrition and proper body fat, avoid abusing drugs and or using tobacco.  Spiritual: The belief in some force (religion, or a higher power) that serves to unite human beings and provide meaning and purpose to life. It includes a person’s own morals, values, and ethics.  Intellectual: The ability to learn and use information effectively for personal, family, and career development.  Occupational: The ability to achieve a balance between work and leisure time. Models of Health: Because health is such a complex concept, various researchers have developed models or paradigms to explain health and in some instance its relationship to illness or injury. Models can be helpful in assisting health professionals to meet the health and wellness needs of individuals. 25  1-Clinical Model: The narrowest interpretation of health occurs in the clinical model. People are viewed as physiological systems with related functions, and health is identified by the absence of signs and symptoms of disease or injury. It is considered the state of not being (sick) in this model, the opposite of health is disease or injury. 2-Role Performance Model: Health is defined in terms of an individual’s ability to fulfill societal roles, that is, to perform his or her work. People usually fulfill several roles (e.g., mother, daughter, friend). According to this model, people who can fulfill their roles are healthy even if they have clinical illness. 3-Adaptive Model: In the adaptive model, health is a creative process; disease is a failure in adaptation.The aim of treatment is to restore the ability of the person to adapt. 4-Health–Illness Continua: Health–illness continua (grids or graduated scales) can be used to measure a person’s perceived level of wellness. Health and illness or disease can be viewed as the opposite ends of a health continuum from a high level of health a person’s condition can move through good health, normal health, poor health, and extremely poor health, eventually to death. Variables influence health status, beliefs, and practices:  Health status: A report of health status may include anxiety, depression, or acute illness and thus describe the individual’s problem in general. Health status can also describe such specifics as pulse rate and body temperature. 26   Health beliefs: Concepts about health that an individual believes are true. Such beliefs may or may not be founded on fact.  Health behaviors: The actions people take to understand their health state, maintain an optimal state of health, prevent illness and injury, and reach their maximum physical and mental potential.  Internal Variables: include Biologic, psychological, and cognitive dimensions. They are often described as no modifiable variables because, for the most part, they cannot be changed. I- Biologic dimensions: Genetic, sex, age, and developmental level all significantly influence a person’s health. Genetic influences biologic characteristics It has been related to susceptibility to specific disease, such as diabetes and breast cancer. Sex: Certain acquired and genetic diseases are more common in one sex than in the other. Disorders more common among females include osteoporosis and rheumatoid arthritis. Those more common among males are stomach ulcers, abdominal hernias, and respiratory diseases. Age: is also a significant factor. The distribution of disease varies with age. For example, arteriosclerotic heart disease is common in middle-aged males, and measles are common in children but rare in older. Developmental level has a major impact on health status. For examples: Infants lack physiological and psychological maturity so their defenses against disease are lower during the first years of life. Toddlers who are learning to walk are more prone to falls and injury than are older children. II- Psychological dimensions: Psychological (emotional) factors influencing health include mind– body interactions and self-concept. Mind–body interactions can affect health status positively or negatively. Emotional responses to stress affect body function. For example, a student who is extremely anxious before a test may experience urinary frequency and diarrhea. 27  Emotional distress may influence the immune system through central nervous system and endocrine alterations. Self-concept: is how a person feels about self (self-esteem) and perceives the physical self (body image) III- Cognitive dimensions: Cognitive or intellectual factors influencing health include lifestyle choices and spiritual beliefs. Lifestyle refers to a person’s general way of living, including living conditions and individual patterns of behavior that are influenced by sociocultural factors and personal characteristics. Practices that have potentially negative effects on health are often referred to as risk factors. Examples of healthy lifestyle choices: Regular exercise Weight control Avoidance of saturated fats Avoidance use of tobacco products Immunization updates Regular dental checkups Regular health maintenance visits for screening examinations External Variables: External variables affecting health include the physical environment, standards of living, family and cultural beliefs, and social support networks. Environment: People are becoming increasingly aware of their environment and how it affects their health and level of wellness. Pollution of the water, air, and soil affects the health of cells. Standards of living: An individual’s standard of living (reflecting occupation, income, and education) is related to health, morbidity, and mortality. Family and cultural beliefs: The family passes on patterns of daily living and lifestyles. Culture and social interactions also influence how a person perceives, experiences, and copes with health and illness. Social support networks: 28 Having a support network (family, friends) and job satisfaction helps people avoid illness. Support people also provide the motivation for an ill person to become well again. Illness and disease: Illness is a highly personal state in which the person’s physical, emotional, intellectual, social, developmental, or spiritual functioning is diminished. There are many ways to classify illness and disease; one of the most common is as acute or chronic. Acute illness is typically characterized by symptoms of relatively short duration. The symptoms often appear suddenly and subside quickly and, depending on the cause, may or may not require intervention by health care professionals. Some acute illnesses are serious (for example, appendicitis may require surgical intervention), but many acute illnesses, such as colds, subside without medical intervention or with the help of over-the counter medications. Following an acute illness, most people return to their normal level of wellness. A chronic illness is one that lasts for an extended period, usually 6 months or longer, and often for the person’s life. Chronic illnesses usually have a slow onset and often have period of remission, examples of chronic illnesses are arthritis, heart and lung diseases, and diabetes mellitus. Nurses are involved in caring for chronically ill individuals of all ages in all types of settings homes, hospitals, clinics, and other institutions. Care needs to be focused on promoting the highest level possible of independence, sense of control, and wellness. Illness Behaviors: Illness behavior, a coping mechanism, involves ways individuals describe, monitor, and interpret their symptoms, take remedial actions, and use the health care system. How people behave when they are ill is highly individualized and affected by many variables, such as: age, sex, occupation, socioeconomic status, religion, ethnic origin, psychological stability, personality, education, and modes of coping. Stage 1: Symptoms experiences: At this stage the person comes to believe something is wrong. Either someone significant mentions that the person looks unwell, or the person experiences some symptoms such as pain, rash, cough, fever, or bleeding. 29 Stage 1 has three aspects: The physical experience of symptoms The cognitive aspect (the interpretation of the symptoms in terms that have some meaning to the person) The emotional response (e.g., fear or anxiety). During this stage, the person usually consults others about the symptoms or feelings, validating with support people that the symptoms are real. At this stage the sick person may try home remedies. If self-management is ineffective, the individual enters the next stage Stage 2: Assumption of the sick role: The individual now accepts the sick role and seeks confirmation from family and friends. Often people continue with self-treatment and delay contact with health care professionals as long as possible. During this stage people may be excused from normal duties and role expectations. Emotional responses such as withdrawal, anxiety, fear, and depression are not uncommon depending on the severity of the illness. When symptoms of illness persist or increase, the person is motivated to seek professional help. Stage 3: Medical care Contact: Sick people seek the advice of a health professional. When people seek professional advice, they are really asking for three types of information: - Validation of real illness - Explanation of the symptoms in understandable terms - Reassurance that they will be all right or prediction of what the outcome will be. The health professional may determine that the client does not have an illness or that an illness is present and may even be life threatening. The client may accept or deny the diagnosis. If the diagnosis is accepted, the client usually follows the prescribed treatment plan. If the diagnosis is not accepted, the client may seek the advice of other health care professionals. Stage 4: Dependent Client role: After accepting the illness and seeking treatment, the client becomes dependent on the professional for help. People vary greatly in the degree of ease with which they can give up their independence, particularly in relation to life and death. Most people have minimal dependence needs and do everything possible to 30 return to independent functioning. A few may even try to maintain independence to the detriment of their recovery. Stage 5: Recovery or rehabilitation: During this stage the client is expected to give up the dependent role and resume responsibilities. People who have long-term illnesses and must adjust their lifestyles may find recovery more difficult. For clients with permanent disability, this final stage may require therapy to learn how to make major adjustments in functioning. Effects of Illness The changes vary depending on the nature, severity, and duration of the illness, Attitudes associated with the illness by the client and others, the financial demands, the lifestyle changes incurred, adjustments to usual roles. Impact on the client: Ill person may experience behavioral and emotional changes, changes in self-concept, body image, and lifestyle changes. Behavioral and emotional changes associated with short-term illness are generally mild and short lived, may become irritable and lack the energy or desire to interact in the with family members or friends. More acute responses are likely with severe, life-threatening, chronic, or disabling illness. Anxiety, fear, anger, withdrawal, denial, a sense of hopelessness, and feelings of powerlessness Certain illnesses can also change the client’s body image or physical appearance, especially if there is severe scarring or loss of a limb or sense organ. The client’s self-esteem and self-concept may also be affected. Many factors can play a part in low self-esteem and disturbance in self-concept: loss of body parts and function, pain, disfigurement, dependence on others, unemployment, financial problems, inability to participate in social functions, strained relationships with others, and spiritual distress. Family interactions may change so that clients are no longer involved in making family decisions or even decisions about their own health care. Nurses need to support clients’ right to self-determination and autonomy as much as possible by providing them with sufficient information to participate in decision-making processes and to maintain a feeling of being in control. 31 In addition to participating in treatments and taking medications, the person may need to change diet, activity, and exercise, and rest, sleep patterns. Impact on the family: A person’s illness affects not only the person who is ill but also the family or significant others. The kind of effect and its extent depend chiefly on three factors: (1) the member of the family who is ill, (2) the seriousness and length of the illness (3) the cultural and social support. The changes that can occur in the family include the following: Role changes Task reassignments and increased demands on time Increased stress due to anxiety about the outcome of the illness for the client and conflict about unaccustomed responsibilities Financial problems Loneliness as a result of separation and pending loss Change in social customs Basic Human Needs Objectives: At the end of this unit, the student should be able to: State the basic human needs List at least five physiologic needs of all people Describe relationships among the different levels of needs Relate the achievement of basic human needs to health status Discuss the nurses’ role in assessing and meeting patient/client’s need Outlines:  Maslow's hierarchy of needs  The five levels of needs  Applying Maslow's hierarchy of needs Introduction: Health and human needs are interrelated. Humans need a number of essentials to survive. This unit therefore takes a detailed look at human needs with a view to enhancing nurses’ ability to help their clients meet these varied needs. Overview of Individual Needs Human needs are many, they encompass both physical and non-physical elements needed for human growth and 32 development, as well as all those things humans are innately driven to attain. Human needs, therefore can be broadly classified into two major groups: Primary needs and Secondary need. Primary needs otherwise known as Basic needs, are survival needs. They must be met to sustain life. Put differently, their absence or non-satisfaction portends great threat to human existence. Basic needs are physiological, such as oxygen, food, water, and sleep; as well as psychological, such as affection, security, and self-esteem. These basic needs are also called deficiency needs because if an individual does not meet them, then that person will strive to make up the deficiency and they are usually listed in hierarchical order. Secondary needs or Meta needs (growth needs): As they are sometimes referred to, additional higher needs that must be met to maintain the quality of life. They include justice, goodness, beauty, order, unity, etc. Basic needs normally take priority over growth needs. For example, a person who lacks food or water will not normally attend to justice or beauty needs. Unlike the basic needs, the Meta needs can be pursued in any order, depending upon a person's wants or circumstances, as long as the basic needs have all been met. The Basic Human Needs: Each individual has unique characteristics, but certain needs are common to all people. A need is something that is desirable, useful or necessary. Human needs are physiologic and psychologic conditions that an individual must meet to achieve a state of health or well-being. Characteristics of Basic Human Needs: 1. Needs are universal. 2. Needs may be met in different ways 3. Needs may be stimulated by external and internal factor 4. Priorities may be deferred 5. Needs are interrelated Maslow’s Hierarchy of Basic Human Needs Maslow's hierarchy of needs is often portrayed in the shape of a pyramid, with the largest, most fundamental needs at the bottom, and the need for self-actualization and transcendence at the top. In other words, the idea is that individuals' most basic needs must be met before they become motivated to achieve higher-level needs. The five levels of needs are as follows: 1- Physiologic needs. 2- Safety and security needs. 3- Love and belonging needs. 4- self-esteem needs. 33  5- Self- actualization needs. I - Physiologic 1. Oxygen 2. Fluids 3. Nutrition 4. Body temperature 5. Elimination 6. Physical activity 7. Rest and sleep 8. Sex II- Safety and Security 1. Physical safety 2. Psychological safety 3. The need for shelter and freedom from harm and danger III -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 V- Self-Esteem Needs 1. Self-worth 2. Self-identity 3. Self-respect 4. Body image IV- 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 34 4. The need for spiritual fulfillment Physiological needs Physiological needs are the base of the hierarchy. These needs are the biological component for human survival. According to Maslow's hierarchy of needs, (1) Oxygen: is the most essential of all needs because all body cells Require oxygen for survival. Nurse evaluates patients' oxygen needs by assessing skin color, vital signs, anxiety levels, responses to activity and mental responsiveness. (2)Water and fluid: water is necessary to sustain life. The nurse can assist in these conditions by: Measuring intake and output, Checking the condition of the skin and mucus membrane. Weighing the patient daily and observing intravenous infusion of fluids. (3)Food: Nutrients are necessary to maintain life, although the body can survive for several days or weeks without food. Poor nutritional habits, inability to chew or swallow nausea and vomiting, food allergies, refusal to eat and overweight pose threats to a patient's nutritional status. The nurse helps by: 1) feeding the patient, 2) monitoring caloric counts or maintaining alternative methods of nutrition such as tube feeding. Nutritional status is assessed with a variety of indicators, including weight, muscle mass, and laboratory investigations. (4)Elimination: elimination of the body waste products is essential for life and comfort. The body eliminates waste in several ways. The lungs eliminate carbon dioxide and water; the skin eliminates water and sodium; the kidneys eliminate fluids and electrolytes; the intestines discharge solid wastes and fluids. If the body inappropriately allows wastes to accumulate, many serious conditions can results. A bowel obstruction, bladder cancer, kidney diseases disrupt normal elimination. The nurse may help the patient eliminate waste by: giving medication to relieve diarrhea or constipation, an enema, urinary catheter or assisting with dialysis. (5)Temperature: the body has mechanism to assist in temporary regulation of body temperature. These mechanisms include shivering and perspiration. Several factors can threaten the body's need for temperature regulation, including excess external heat or cold or a high internal fever in response to an infection. Body temperature is assessed as vital signs by the nurse. (6)Physical activity: activity stimulates both the mind and body. Exercise helps maintain the body's structural integrity and health by enhancing circulation and respiration. The nurse can assist the patient to obtain needed 35 exercise in many ways. Examples include encouraging a person to walk after surgery, teaching the patient in a cast to do exercise, providing passive range of motion or turning the immobilized person to prevent lung problems, skin breakdown (bedsores) and other complications of immobility. (7)Sleep and rest: sleep and rest are important in maintaining health. The amount of sleep that people need varies; factors such as pregnancy, age and general health have an influence. The absence of sleep is not immediately life threatening but can cause various disorders if allowed to continue. For example, sleep deprivation aggravates some forms of mental illness. The nurse can assist patient to get enough sleep and rest by providing safe, comfortable and quiet environment. Various treatments such as back rub, warm bath, warm milk and certain medication can promote sleep. (8)Sexuality: sexuality is an integral part of each individual and may be affected by physical and emotional illnesses. The need for sex is not vital to the survival of the individual, but it is vital to the survival of the species. Once a nurse’s physiological needs are satisfied, the need for security and safety become silent. However, everyone wants to experience order and control in their lives. These needs can be fulfilled by family and society such as medical care, police, schools. II- Safety and Security Come next in priority and involve both physical and emotional components. Other examples of Safety needs are:  Emotional security  Financial security (employment social welfare)  Law and order  Freedom from fear  Social stability  Health and wellbeing (safety against accidents and injury) A. Physical safety and security means protected from potential or actual harm. Nurses roles to meet patient's physical safety needs as the following:  Using proper hand washing and sterile technique to prevent infection  Using electrical equipment properly  Administer medications knowledgably  Using skill when moving and ambulating patients  Teaching parents about household chemicals that are dangerous to children. 36 b. Emotional safety and security involves trusting others and being free of fear, anxiety and apprehension. Patients entering the healthcare system often fear the unknown and may have significant emotional security needs. Nurse can help meet such needs by encouraging spiritual practices that are source of strength and support, by allowing as independent decision making as possible and by carefully explaining new and unfamiliar procedures and treatments. III -Love and belonging Nurses should also feel empowered at work, knowing that their opinions and feelings are valued. They are the element of successful patient care. Nurses’ viewpoints and professional advice on processes, policies and goals should be looked out by healthcare staff. This level of nurses’ needs is social and involves feelings of belongingness. Belongingness refers to a nurse’s emotional need for social relationships, affiliating, connectedness and being part of a group in a healthcare environment. Examples of belongingness needs include:  Trust  Friendships  Acceptance  Receiving and giving affection Some nursing interventions to help meet this need are as follows:  Including family and friends in the care of the patient.  Establishing a nurse-patient relationship based on mutual understanding and trust by demonstrating caring, encouraging communication and respecting privacy.  Referring patient to specific support groups such as cancer group.  Encouraging visitors, cards and telephone calls V- Self-Esteem: People need to feel good about themselves, and that they are worthy of the respect of others. People who are in need of health care often feel that they are no longer important and that they cannot contribute in a meaningful way. The loss of ability and independence that may come with illness, injury or advanced age can affect a person’ s self-esteem. A loss of cognitive ability. Nursing interventions to promote or enhance a positive self-concept include helping a client to identify areas of strength. In addition, for clients who 37 have an altered self-concept, nurses should establish a therapeutic relationship and assist clients to evaluate themselves and make behavioral changes to enhance their self-esteem: Encourage clients to appraise the situation and express their feelings. Encourage clients to ask questions. Provide accurate information Explore clients’ positive qualities and strengths. Encourage clients to express positive self-evaluation more than negative self-evaluation. Avoid criticism IV - Self-actualization needs Self-actualization needs are the highest level in Maslow’s hierarchy. This is referred to the realization of a nurse’s potential, self- fulfilment, seeking personal growth and peak experiences. Maslow describes this level as the desire to accomplish everything that one can, to become the most a comfortable relationship with reality A nurse who wants to return to university that can achieve a higher degree, for example, may want to work only during the week. On the other hand, a nurse who needs to spend more time with her family may prefer to work only during the week. Nurses feel more supported and endurance that strengthens when hospitals provide a work environment that patients can trust and allows them to participate in problem solving decisions. Maslow lists the following qualities that indicate achievement of one's potentials:  Acceptance of self and self as they are.  Focus of interest on problems outside oneself  Ability to be objective  Feeling of happiness and affection for others  Respect for all people  Creativity as a guideline for solving problems and pursuing interests. To help meet patient's self-actualization needs, the nurse focuses on: the person's strength and possibilities rather than on problems. Nursing intervention is aimed at providing a sense of direction and hope and providing teaching that is aimed at maximizing potentials. Applying Maslow's Theory: Nurses can apply Maslow's hierarchy of basic needs in the assessment, planning, implementation and evaluation of patient care. The hierarchy can 38 be used with patient at any age, in all settings where care is provided and in both health and illness. It is useful for: 1- It helps the nurse identify unmet needs as they become healthcare needs. Basic human needs are interrelated and may require nursing actions at more than one level at a given time. 2- Establishing priorities of care: show that certain needs are more basic than other needs and must be at least minimally met before other needs. 3- Understanding the relationship of basic human needs: basic human needs are interrelated and may require nursing actions at more than one level at a given time. For example, in caring for a person coming into the emergency department with a heart attack, the nurse's immediate concern is the patient's physiologic needs (oxygen, pain relief). At the same time, however, safety needs (following proper precautions with oxygen use and ensuring the person doesn't fall off the examining table) and love and belonging needs (letting a family member stay with the person, if possible) are still major consideration. Table 1: Hierarchy of Needs and Nursing Interventions Nursing actions and Maslow’s hierarchy can take many forms. This box gives examples of nursing interventions that can assist a client to meet basic and. The hierarchy begins at the bottom and works upward. Self-Actualization Needs ♦ Acknowledging the accomplishments of the individual Self-Esteem Needs ♦ Promoting positive self-image after surgery ♦ Encouraging an individual’s progress in rehabilitation ♦ Providing an opportunity for bonding with a new infant Love, Belonging Needs ♦ Allowing the client’s family to visit while in the hospital ♦ Encouraging the family to participate in the care of the client ♦ Allowing religious leaders and friends to visit and perform religious rites ♦ Being sensitive to a client’s particular needs as they relate to his or her role in society (e.g., financial provider ) 39  Security and Safety Needs ♦ Checking identification of client before administering medication ♦ Taking defective equipment from a client’s environment and reporting the defect ♦ Monitoring the client’s safety while in the shower, ambulating in the hall, or getting in or out of bed ♦ Performing a safety check in the home environment for a child or an elderly adult ♦ Reporting abuse to the proper authority Basic Physiologic Needs ♦ Administering oxygen ♦ Assisting with feeding a client ♦ Assisting with hygiene and elimination ♦ Maintaining warmth for a newborn  Remember the following  Human needs are thought of in progressive levels, known as a hierarchy.  Psychological needs are at a higher level than physiologic needs.  A person must meet lower-level needs before he or she can address higher-level needs.  Illness or injury can interfere with a person’s ability to meet basic needs.  Illness or injury can also cause a person to regress to a lower level of functioning.  Nursing can assist a person to meet needs or to eliminate potential threats to need satisfaction.  Many factors, such as loss of income, illness, homelessness, and personal crises threaten basic human needs. Nursing Documentation (Recording and reporting) Learning objectives: At the end of this lecture the student will be able to: 1. Define the Nursing Documentation. 2. List the purposes of Nursing Documentation. 40  3. Enumerate the uses of Nursing Documentation. 4. Identify the elements of effective Nursing Documentation. 5. Determine the characteristics of Nursing Documentation. 6. Discuss the principles of Nursing Documentation. 7. Define the records and reports. 8. Discuss the types of Hospital Records 9. Explain the types of reports. Outline: 1. Definition of the Nursing Documentation. 2. Purposes and uses Nursing Documentation. 3. Uses of Nursing Documentation. 4. Elements of effective Nursing Documentation. 5. Characteristics of Nursing Documentation. 6. Principles of Nursing Documentation 7. The Records and Reports. 8. Types of Hospital Records 9. Types of Hospital Reports. Introduction: Nursing Documentation is an accurate account of what occurred and when it occurred. Through documentation, nurses communicate their observations, decisions, actions and outcomes of these actions for clients. Quality nursing documentation plays a vital role in the delivery of quality nursing care services through supporting better communication between different care team members to facilitate continuity of care and safety of the clients. Definition of Nursing Documentation: Nursing documentation is the record of nursing care that is planned and delivered to patients by qualified nurses or other caregivers under the direction of a qualified nurse. Purposes of Nursing Documentation: 1. To ensure that services that were paid for that patient, are delivered 2. To provide a picture of the patients ’ condition 3. To detail how a patient is responding to treatment 4. Used as a guide for reimbursement of care costs. 5. Used as a legal record of care in a court of law 41  6. To show the use of the nursing process. It contains observations by the nurses about the patient's condition, care, and treatment delivered. Elements of Effective Documentation: To ensure effective documentation, nurses should:  Follow the elements of nursing process to be made evident documentation include (Assessment, Nursing Diagnosis, Planning, Implementation, and Evaluation).  Document accurately, completely, and objectively including any errors that occurred  Note date and time  Sign each entry  Identify the client  Use appropriate forms  Use standard abbreviations  Write in ink and on every line  Spell correctly and Write legibly  Correct errors properly  Chart Omissions  Documenting a Medication Error Characteristics of Effective Documentation 1. Factual – information about clients and their care must be factual. A record should contain descriptive, objective information about what a nurse sees, hears, feels and smells 2. Accurate – information must be accurate so that health team members have confidence in it as use of measurement ensures that a document is accurate. (The nurse descriptions such as intake, 360 ml of water rather than an adequate amount of fluid). 3. Complete and concise – the information within a record or a report should be complete, containing concise (easy to understand) and thorough information about a patient’s care. 4. Current – ongoing decisions about care must be based on currently reported information. 5. Organized – the nurse document in a logical format or order Principles of Nursing Documentation: 1. Nurses are responsible for documenting the care they personally provide to the patient and care provided by other staff members is best documented 42  by those staff members, except in certain circumstances such as an emergency (e.g. a cardiac arrest). 2. Nurses should use a logical process in documentation when caring for patients (e.g. assessment, nursing diagnosis, planning, implementation and evaluation). 3. Nurses document all relevant information about patients in chronological order on the patient’s health record and the documentation should be clear, concise, factual, objective, timely and legible (e.g. chart the time you gave a medication, administration route, and patient’s response). 4. Nurses document at the time they provide care or as soon as possible afterward because the delays may affect the continuity of care, affect the nurse’s ability to recall details about events and increase the possibility of errors, also the nurses should not document before giving care 5. The Nurses must correct any documentation errors in a timely, honest and forthright manner. 6. Nurses indicate their responsibility by adding their signature and title, or initials as appropriate, to each entry they make on the health record. 7. Nurses perform, more comprehensive, in depth and frequent documentation when patients are acutely ill, high risk or have complex health problems. 8. Nurses who have responsibility for patient records ensure that the records are retained for a minimum period of 16 years after the date of last entry.  Records: A record is a permanent written communication that documents information relevant to a patient's health care management. All records contains basically following information:-  Patient identification and demographic data.  Informed consent for treatment and procedures.  Admission history.  Nursing diagnosis or problem.  Nursing care plan  Medical history  Therapeutic orders  Reports of physician examinations  Reports of diagnostics studies. 43   Summary of operative procedures  Discharge plan and summary. Types of Hospital Records: The hospital records are broadly classified into four categories based on the area of usage. They are: 1. Patients clinical records It is the knowledge of events in the patient illness, progress in his or her recovery and the type of care given by the hospital personnel. 2. Individual staff records A separate set of record is needed for each staff, giving details of their sickness and absences, their carrier and development activities and a personnel note. 3. Ward records These are the records pertaining to a particular ward as circular record, round book, duty roaster, ward indent book, ward inventory book, staff patient assignment record, student attendance and patient assignment record. 4. Administrative records with educational value It includes treatment register, admission and discharge register, organization chart, job description and procedure manual.  Reports: Reports are oral or written exchanges of information shared between caregivers in a numbers of ways Types of Hospital reports made by nurses: 1.Change of shift reports At the end of each shift, nurses give report about their patients to the incoming nurse either face to face, written down, or on audiotapes. The purposes of the reports are to provide continuity of care among nurses who are caring for a client. 2. Telephone reports Nurses inform physicians of changes in client's condition and communicate information to nurses on other unites about client transfer. Persons involved with a telephone report need to provide clear, accurate and concise information. In many cases information in telephone report is documented when significant events or changes in client's condition have occurred. 44  3. Telephone orders Telephone orders involve a physician stating a prescribed therapy over the phone to a registered nurse. Telephone orders are frequently given at night or during an emergency and need to be used only when absolutely necessary. Telephone order guidelines:- 1. If physician sounds hurried over the phone, use clarification questions to avoid misunderstanding. 2. Cleary determine the client’s name, room numbers, and diagnosis. 3. Repeat any prescribed orders back to the physician. 4. Write a telephone order to include date and time given, name of client, nurse, and physician, and the complete order. 5. Have the physician cosigns the order within the time frame required by the situation (usually 24 hours). 4. Transfer reports Give information about patient either by phone or in persons to other departments or nurses who will be caring for patients. For example, clients transfer from an intensive care unit or recovery room to general nursing care unit. 5. Incident reports. Document anything out of ordinary that has the potential to harm the patient. Example of incident includes client falls; Needle sticks injuries, a visitor having symptoms of illness, medication administration errors and accidental omission of ordered therapies. Infection control Objectives: At the end of this lecture the student should be able to:  Define of infection-related terms  Describe the signs and symptoms of infection  Discuss chain of infection  Define nosocomial infection  Identify predisposing factors in nosocomial infection  List types of nosocomial infection  Differentiate between medical and surgical asepsis  Discuss decontamination of medical equipment 45   Discuss standard precautions and transmission based precautions Outlines:  Definition of Infection-related terms  Stages of infection  Chain of infection  Definition of nosocomial infection  Predisposing factors in nosocomial infection  Types of nosocomial infection  Medical and surgical asepsis  Decontamination of medical equipment  Standard precaution and transmission based precaution Introduction: Infection is a major safety, and health hazard. Some infections are minor and cause short illnesses; others are serious and can cause death. Infections are serious for infants and older patients. Definition of infection: Infection is a disease state resulting from invasion, and growth of microbes and presence of pathogen in or on the body. A pathogen is a disease producing organism. Colonization is the usual presence of non-pathogenic and even potentially pathogenic microbes on the skin, in the nose, mouth, bowel, penile or vaginal mucosa, as a part of normal human flora, in the amount not harmful for the body – this is not an infection. Carrier state: is the non-usual presence of pathogenic microbes in the body, in the way not harmful for the carrier, but potentially dangerous for others, since the carrier is usually contagious. Signs and Symptoms:  Localized effect: Most common site of skin and mucous membrane breakdown as surgical and traumatic wounds and site of invasive device cause redness, swelling, drainage, pain, tenderness and restricted movement of part  Generalized effect: involves the entire body and cause fever, fatigue, malaise, mental changes & in all major lymph nodes become enlarged, swelling, and tender during palpation &loss of appetite, nausea, vomiting, decrease urine output, leucocytosis Types of infection: 46 (1) Endogenous infection (Self infection): Is caused by microorganisms which originate from patients themselves; Some parts of the body such as the lower respiratory tract, and bladder, which are normally free from organisms, are particularly prone to exposure to organisms which become pathogenic. Other areas, such as gut, have a wide and varied natural flora population of microbes. Normal flora is harmless in the area where they normally live, but migration may be result in infection elsewhere in the body. (2) Exogenous infection: Is caused by the transfer of a microorganism to an individual; this will have originated either from another patient or health care worker or from environment. Any hospitalized patient whose normal natural defense to infection is reduced will be particularly vulnerable to exogenous infections. More commonly, this may be from member of staff who has failed to wash his hand properly. Stages of infection:  Incubation period: the incubation period is the interval between pathogen's invasion of the body and presence of symptoms of infection. During this stage, the organisms are growing and multiplying  Prodromal stage: a person is most infectious during prodromal stage. Early signs and symptoms are present but they are vague and nonspecific.  Full stage of illness: the presence of specific signs and symptoms. The type of infection determines the length of the illness and severity of manifestations. Symptoms that are limited in one body area are referred to as "localized symptoms" whereas, symptoms manifested throughout the entire body are referred to as "systemic symptoms"  Convalescent period: Convalescent period is the recovery period from infection. The signs and symptoms disappear and person returns to a healthy state. Chain of infection: 47  The life cycle of pathogens frequently described as an uninterrupted chain of events. For organisms to spread disease, they must grow, reproduce and move from one source to another. Furthermore, in order for a client to acquire an infection, a series of elements needs to be present. Each element or link is necessary to result in infection. This process is known as the infection chain, and contains six links: (1) Microorganism (infectious agent), (2) Source or reservoir, (3) Portal of exit from reservoir, (4) Mode of transmission, (5) Portal of entry into host and (6) Susceptible host. (1) Infectious agent: Agents that produce infections can consists of bacteria, viruses, fungi, protozoa and rickettsia (2) Reservoir (source): Reservoir or source is a place for organism to live while awaiting a host. Inanimate objects, human being, and animals are sources. The human body is the most common reservoir. Inanimate objects include medications, air, food, water or any other material on which organism can find nourishment or lie dormant, and survive. Human sources include other clients, health care personnel, family members, visitors and clients themselves. In order to survive, the microbe needs food, oxygen (if aerobic), a viable temperature range (around 95˚F), water, a pH of 5-8 and lack of sunlight. (3) Portal of exit: The portal of exit is a mean for microorganism to leave the source. As Skin and Mucous Membranes, Respiratory Tract, Urinary Tract, Gastrointestinal tract, Reproductive Tract, and Blood; all permit microorganisms to exit the source. (4) Mode of transmission: Refers to the way in which the organism moves or is carried from the source's portal of exit. The five main routes of transmission are contact, droplet, vehicle, airborne and vector. 48 (A) Contact transmission: Contact transmission is the most frequent means of transmitting infections in health care facilities. Contact transmission is by direct or indirect contact. (1) Direct contact: Direct contact involves body surfaces to body surfaces contact causing the physical transfer of organism between an infected or colonized person and a susceptible host. Healthcare personnel can transfer organisms to client during care. Direct transfer also may be between two clients, with one acting as a source and the other as the host. (2) Indirect contact: Indirect contact occurs when a susceptible host is exposed to a contaminated object such as a dressing, needle or surgical instrument. (B) Droplet transmission: Droplet transmission occurs when mucous membrane of the nose, mouth or conjunctiva is exposed to secretions of an infected person who is coughing, sneezing or talking. (C) Vehicle transmission: Vehicle transmission involves the transfer of microorganisms by way of vehicles, or contaminated items that transmit pathogens. (D) Air-born transmission: Air-born transmission occurs when fine particles are suspended in the air for a long time or when dust particles contain pathogens. Air currents widely disperse organisms, which can be inhaled by or deposited on the skin of a susceptible host. (E) Vector transmission: vectors are living animals, such as rats or insects that carry pathogens. Vectors can be biological or mechanical. (5) Portal of entry: Portal of entry is the pathway by which infectious agents gain access to the body. The infectious agent often enters the body by the same way it left the source. For example, a break in the natural skin barrier allows infections to pass from the skin of the source directly to the skin host. A cough will allow infectious agent to exit the source via the respiratory tract, and then can enter the host through inhalation. (6) Susceptible host: Susceptible host is a person whose own body defense mechanism when exposed, are unable to withstand the invasion of pathogens. Breaking the chain of infection: 49 The nurse may prevent an infection from developing or spreading by minimizing the numbers and kinds of organisms transmitted to potential infection sites. 1. Eliminating reservoir of infection through:  Properly disposing of contaminated dressing or body fluids  Dispose of outdated IV solutions and medication;  Proper cleaning of spills;  Using disposable equipment;  Discarding any broken sterile packages;  Not wearing jewelry; colored nail polish or artificial fingernails;  Proper hand washing. 2. Portal of exit:  Keeping all wound covered;  Following isolation technique;  Proper hand washing. 3. Mode of transmission:  Correctly using of masks and gloves;  Properly disposing of wound drainage; urine, feces,  Carefully disposing of dressing, diapers or tubing,  Proper catheterization and injection technique  Correct handling of all body fluids,  Hand washing. 4. Portal of entry:  Following prescribed protective isolation protocol;  Using correct sterile technique for invasive procedures  Hand washing. 5. Susceptible host:  Promoting adequate nutrition, hydration, and rest,  Careful monitoring for skin integrity ,  Administering prescribed medication,  Careful history taking ( past related infection, diabetes)  Proper use of sterile supplies, barrier protection, and hand washing 6. The nurse must know the infectious organism and how it is transmitted, the actions needed to protect the client, and the steps to take to ensure protection from exposure to the microorganisms. Nosocomial infection: 50  Just by entering a hospital, patients exchange their secure home environment which may not have the same standard of cleanliness and in which many organisms have developed a resistance to antibiotics. Sharing facilities, equipment and staff with other patient further compound this risk. Definition of Nosocomial infection: Is infection acquired by an individual in a health care facility such as a hospital and not present or incubating on admission or by health care workers through their work in the hospital. Moreover, nosocomial infections are also known as hospital-acquired infections or, more recently, health-care associated infections. For a HAI, the infection must occur: 1. up to 48 hours after hospital admission 2. up to 3 days after discharge 3. up to 30 days after an operation Causative agents of nosocomial infection: Many different pathogens may cause nosocomial infections such as Bacteria, fungus, and viruses. Bacterial infections are the most common nosocomial pathogens (Bacteria alone cause about 90 percent of these cases). Predisposing factors in nosocomial infection: (1) Factors related to patient:  Trauma: can cause breaks in the skin, which leaves the body weakened against fighting infection. E.g. burns, compound fracture, or stab wound.  Pre –existing disease: generally poor health or frequent illness before entering the hospital, the patient may have an infection or condition that has lowered the body's defense e.g. autoimmune disease, diabetes or diminished lung disease.  Age: The very young and very old don't have a defense as do people of other age groups.  Inactivity: the person who is ill usually doesn't get much exercise, which leaves the body weakened against fighting infection.  Poor nutrition or inadequate hydration: lack of protein hinders the ability of the immune system to make antibodies and repair injured tissues  Stress or emotional shock: increased stress increases the body cortisone levels, reducing resistance to disease. 51  Fatigue: The person who is extremely tired can't effectively fight off disease. Those who are fighting illness or trauma or who have had surgery are often fatigue. Frequent or inappropriate use of broad- spectrum antibiotics: microorganisms that the person is harboring may develop resistance to antibiotic therapy after repeated exposure to the same antibiotic. The person may stop taking an antibiotic before the full course of therapy is completed or taken when they are not needed. (2) Factors related to Medical and surgical interventions:  Surgical incisions  Intravascular devices provide mean of entry for pathogens.  Immunosuppressive therapy allows even low-virulence organisms to assume a dangerously pathogenic role.  The medical therapy can facilitate infection include anesthesia and ventilation (may lead to nosocomial pneumonia) and antibiotics  Inadequately disinfected equipment e.g. endoscopes can transmit pathogens such as Mycobacterium tuberculosis, and as well as hepatitis viruses. (3) Factors related to hospital environment: Patients may become infected with new organisms, usually from other patients, or more rarely from staff or the environment.  Transient hand carriage by medical or nursing staff is thought to be the main route of spread.  Overcrowding, understaffing and poor hygiene, particularly hand washing, increase the risk of cross-infection.  Spread of hospital pathogens as antimicrobial-resistant pathogens  Inadequate procedures and policies of infection control in hospital. Types of nosocomial infections: There are various types of nosocomial infections affecting various different sites such as:  Urinary tract infections  Surgical site infections  Respiratory infections especially nosocomial pneumonia  Blood infections/bacteremia  Skin (especially burns),  Gastrointestinal tract infections, 52   Central nervous system infections Infection control: Definition of Infection control: Is the prevention of the spread of microorganisms from Patient to patient; Patient to Staff member and Staff member to patient. It is applied through standard precaution, transmission based precaution, and decontamination. A- Standard precautions Have replaced the term universal precautions with Standard precautions which are applied to blood, all body fluids, secretions, excretions, and contaminated items regardless of whether or not they contain visible blood and non- intact skin and mucous membrane. The elements of standard precautions: (1) Medical and surgical asepsis (2) Barrier techniques (3) Occupational health (4) Handling of linen (5) Handling of patient care equipment (6) Environmental control (7) Patient placement. (1) Medical and surgical asepsis:  To effectively limit the transfer of microorganisms, the nurse must understand the difference between commonly used terms as they apply medical and surgical asepsis.  Medical asepsis (clean technique): refers to the practice of reducing the number of microorganisms, to prevent re-infection of the client and to prevent or reduce the transmission from one person (or source) to another. It is used in care of all clients. For example - Hand washing - Barrier technique - Routine environmental cleaning Basic principles of medical asepsis in patient's care:  Practice good hand hygiene  Keep soiled linen and equipment from touching the clothing  Don't place soiled bed linen or any other items on the floor.  Avoid allowing patients to cough, sneeze or breathe directly on others 53  Don't shake linen  Clean the least soiled areas first then the more soiled ones  Dispose of soiled or used items directly into appropriate containers.  Use practices of personal grooming that help to prevent spreading microorganisms Surgical asepsis (sterile technique):  Refers to destruction of organisms before they enter the body.It is used only in certain for example; surgical incisions and suturing of wounds, insertion of intravascular devices, such as CVP lines, insertion of tracheostomy tubes or chest drains, and dressing change or wound care. Principles of surgical asepsis:  Only a sterile object can touch another sterile object.Unsterile touching means contamination has occurred.  Open sterile package so that the first edge or wrapper is directed away from the worker to avoid the possibility of sterile surface touching unsterile clothing.  A wet field is considered contaminated if surface immediately below it is not sterile or if a sterile item becomes wet it is considered unsterile.  Hold sterile object above the level of the waist.  Avoid talking, coughing, sneezing or reaching over sterile field or object.  Never walk away from or turn your back on a sterile field. Any opened sterile item is considered contaminated if it is left unattended.  All items brought into contact with broken skin or used to penetrate the skin in order to inject substances into the body or to enter normally sterile body cavities should be sterile.  These items include dressing used to cover wounds and incision, needles for injection and tubes (catheters) used to drain urine.  Use dry, sterile forceps when necessary, forceps soaked in disinfectant are not considered sterile.  Consider the edge (outer 1 inch) of a sterile field to be contaminated.  Consider an object contaminated if you have any doubts as to its sterility.  Any partially unwrapped sterile package is considered contaminated. 54   A commercially packaged sterile item is not considered sterile past its expiry date. (2) Barrier techniques: Include the use of personal protective equipment: gloves, eye protection, gowns and mask to keep organisms from entering or leaving the respiratory tracts, eyes or breaks in the skin. They protect the nurse from patient body fluids. (3) Occupational exposure: Health care workers are potentially exposed to blood in the course of their work and therefore are at risk of infection with blood borne pathogens, including Human immunodeficiency virus (HIV), hepatitis C and hepatitis B. Moreover, of all health care workers the nurses are at the most risk for needle stick incidents. Occupational exposures of health care workers occur because of inconsistent compliance with standard precautions. Safe handling of sharps:  Sharps such as needles, razor blades, or any broken glass must be carefully disposed into sharp container (puncture-resistant container).  Used needles and syringes are never placed in any waste basket, nurse' pocket, on patient's tray or on patient's bedside.  When container is 2/3 full is replaced with new one. Recapping, bending or breaking of contaminated needles is avoided.  Use one hand technique or mechanical device only when a sharp disposal box is unavailable  Never recap used needles, manipulate them using both hands, or use any other technique that involves directing the point of a needle toward any part of the body.  Do not remove used needles from disposable syringes by hand, and do not bend, break. B-Transmission-based precautions: include air-borne precautions, droplet precautions and contact precautions. (1) Air borne precautions: air-borne precautions are used for diseases transmitted by small droplet nuclei such as measles, pulmonary tuberculosis (TB). The barrier protection is private room, negative airflow respirator or mask. Doors are kept closed 55 (2) Droplet precautions: Droplet precautions are used for diseases transmitted by large droplets such as, pneumonia and meningococcal meningitis. Transmission can occur through sneezing, coughing, talking or during suction. The barrier protections are private room or cohort client, The room's door mat remain open, Mask when closer than 3 feet from patient, Have the patient wear a mask if you transport him or her to an area outside the room. (3) Contact precautions: Contact precautions are used for diseases transmitted by direct patient or environmental contact, such as colonization or infection with multi drug resistant organisms, major wound infections, and scabies. The barrier protection includes private room or cohort patient, the door may remain open, gloves and gowns. Decontamination of Medical Equipment: Medical equipment and surgical instruments are examples of devices that are essential to the care of patients; however, because they typically are designed for reuse, they also can transmit pathogens if any of the steps involved in reprocessing, cleaning, disinfection, or sterilization are inadequate or experience failures. Decontamination Is the process by which microorganisms are removed or destroyed in order to render an object safe. It includes Cleaning, Disinfection, Sterilization. The goals of safe reprocessing of medical equipment/devices include: a) Preventing transmission of microorganisms to personnel and patients b) Minimizing damage to medical equipment/devices from foreign material (e.g., blood, body fluids, saline and medications) or inappropriate handling. The Decontamination Steps: There are two steps to processing items that are used during clinical and surgical procedures. Cleaning is the first and the most important step. Cleaning is followed by either sterilization or disinfection and by immediate use or proper storage of the item. Decontamination of equipment is the responsibility of the user. Cleaning is always essential prior to disinfection or sterilization. An item that has not been cleaned cannot be adequately disinfected or sterilized. 56 1. Cleaning: is the removal of all foreign material (dirt and organic matter) from the object being reprocessed. 2. Disinfection: is a procedure which achieves the removal or destruction of vegetative microorganisms to safe or relatively safe levels, but not necessarily the spores.  Antiseptics: Are disinfectants which can be applied to the skin or other living tissue  Disinfectants: A disinfectant is a chemical agent that destroys most pathogens but may not kill bacterial spores. Disinfectants are used on inanimate objects only and not on living tissue.  High-level disinfectants: are chemicals that can act as a sterilant if an increased exposure time is utilized.  Sterilant: A chemical used on medical equipment/devices which results in sterilization of the equipment/device Methods of Disinfection: Disinfection can