Fundamental of Nursing - Soojeede.comsoojeede.com/wp-content/uploads/2016/12/Soojeedes-Fundamental...

Macalin Soojeede [Pick the date]

Fundamental

of Nursing First Edition

Author: Dr. M. I. A. Soojeede”

Bsc. Veterinary Medicine & Animal Husbandary

Bsc. Public Health

Master of HSM at KU

Year -2014

LECTURE NOTE

M. I. A. SOOJEEDE

II

Dr-Mohamed Ibrahim Abdi “Soojeede”

Master of Health service management at KU

III

Dr-Mohamed Ibrahim Abdi “Soojeede”

Master of Health service management at KU

FUNDAMENTAL OF NURSING (TEXTBOOK OF INTRODUCTION TO FUNDAMENTAL OF NURSING)

TO MY DEAR MOM;

FATIMO DAHIR ALASOW

WITH LOVE AND APPRECIATION FOR HER PATIENCE

TO GREW UP AND SUPPORT OVER THE ALL MY LIFE

Dr-Mohamed Ibrahim Abdi (Soojeede)

- Master of HSM at KU

- Batch Public Health

- Batch Veterinary Medicine & Animal Husbandry

Hope University _ Midwifery

Mogadishu - campus

Hope-University. Faculty of Clinical Midwifery, Subject: Fundamental of Nurse

IV

PERFACE

This is a lecture note which contains the latest evidence-based

Knowledge to help you to prepare for success in today's competitive

nursing field. Learn this fundamental of Nursing With practical, fully

integrated study support, this edition makes it easier and builds the

understanding and clinical reasoning of the individual nurses.


V

TABLE OF CONTENTS

PERFACE ................................................................................................................. IV

CHAPTER ONE ......................................................................................................... 1

CONCEPT OF NURSING AND ITS PROFESSIONS ................................................ 1

CHAPTER TWO ....................................................................................................... 11

HEALTH AND ILLNESS ......................................................................................... 11

CHAPTER THREE .................................................................................................. 16

NURSING PROCESS ............................................................................................... 16

CHAPTER FOUR .................................................................................................... 30

COMMUNICATION SKILLS ON NURSING TO PATIENT RELATIONSHIPS... 30

CHAPTER FIVE ....................................................................................................... 41

BASIC NURSING SKILLS ....................................................................................... 41


1

CHAPTER ONE

CONCEPT OF NURSING AND ITS

PROFESSIONS

Introduction: Definition

Nursing originated from Latin word nutrix-meaning “to nourish”. Therefore the

definition of nurse and nursing are based on this word.

Nurse is an art and science where knowledge and skills are applied to provide

health)

“Nursing is the protection, promotion of health and ability, prevention of illness

and injury. But the work of the nurse is beyond patient care today

Nurse is a care

Nurse is a person who assists (care, helping) a sick people.

Nurse is a person meeting a patient immediate needs.

Nurse is a science

Science is the:

Observation

Identification

Description

Experimental investigations, and

Explanation of phenomena.


2

Nurse is an art.

Art is the application of knowledge and skills to bring about desired results. Art

therefore is an individualized action.

Nursing was an art at the beginning. It evolved from the familial roles of

development and care taking.

History of Nurse

The history of nurse follows three different generations which are.

1. Colonization time

i. physician not required to license

2. Industrialization time

i. risk factors increased

b. School of nursing started, opened by Dr-joseph in 1836.

3. influence of world war

Criminal war occurred.

Florance Nightingate

Florace Nightingate she is an England woman, she was born in 1820. She stared

nursing school in London in 1860, she opened this school in Italy in 1873, she died

in 1910.

The First World War 1914 up to 1918 the school participate to dimension the

soldier death; it was estimated 42.7% of soldier mortality rate.


3

She played a big role in the Crimean war, she restored health through provision of

good ventilation, sanitation and nutrition thus minimizing infection causing agents,

gangrene and lowered mortality rate

In 1903 Nursing is recognized professional

Goals of nurse

1. Maintenance of health

Nurse work in many settings (hospitals, nursing home and clinics and etc.)

where the goal of health care is the maintenance of health.

2. Promotion of wellness/health

Wellness is state of human functioning that may defined as the achievement of

one’s maximum attainable possible.

3. Restoration of health e.g. “mental illness

Nurse who work in hospitals and clinics spends most of their time working to

restore the health of patient

4. Prevention of illness

The objectives of illness prevention activities are to reduce the risk of illness to

promote good health ways.

5. Facilitate coping

The nurse also facilitate client and family managing with changed functions life

disaster and death.


4

6. Care of dying

To provide care for dying patient because care and the restoration of health are

always not possible

Major factors for evolution of Nursing

1. Industrial revolution

2. War

3. Nursing shortage

4. Increasing costs of health care

5. Emerging new knowledge

Nurse related words

Health: WHO defined as “a state of complete physical, mental, and social well

being and not the mere absence of disease or infirmity.”

Disease is the existence of some pathology or abnormality of the body, which is

capable of detection using, accepted investigation methods.

Sickness is a state of social dysfunction: a role that an individual assumes when ill

Vital signs: Signs of life (e.g., temperature, pulse rate, respiration rate, blood

pressure).

Specimen: A small amount of body excretion or body fluid that is sent to a

laboratory for examination.

Standard precaution: precautions designed for the care of all clients regardless of

diagnosis or infection status.


5

Purposes of Nursing Care

Nurses provide care to achieve the Purpose of the nurses such as.

Health promotion

Illness prevention

Health restoration

Ends of life care

Roles and functions of Nurses

Traditionally, the role of the nurse was to provide care and comfort as they carried

out specific nursing functions on patients.

Due to advancements in technology and modernization, the roles of the nurse have

expanded to include importance on health promotion, illness prevention, as well as

concern for the client as a whole. Today, Nurses’ roles and functions include:

Care giver

Communicator

Teacher

Counselor

Decision making

Leader/ manage

Comforter

Rehabilitator:

Protection/advocacy


6

Care giving

This remains the primary role of nurses in most agencies. The provision of care to

clients combines both the art and science of nursing in meeting the physical,

emotional, intellectual and nonphysical needs of the patient.

As care givers nurses help the client to restore health through the healing process.

Communication

The role of communication is central to other nursing roles. The quality of

communication is a critical factor in meeting the needs of the client, without

effective communication, nursing care is ineffective. You need effective communication skills to deliver good therapeutic information

and for interpersonal/professional relations.

Teaching/Education

As an educator, a nurse explains to client’s concepts and facts about their health,

demonstrates procedures such as self care activities and determines that the client

understands, reinforces learning or client behavior and evaluates progress in

learning.

Teaching may be unplanned and informal (e.g. responding to questions during

casual conversations)

May be planned or simple formal ( .e.g. teaching diet plan for diabetic client, or

scholars in the profession and relevant disciplines).


7

Counseling

This concerns the use of therapeutic interpersonal communication skills to provide

information, make appropriate referrals and facilitate the client problem solving

and decision making.

Decision making

To provide effective care, the nurse uses decision making skills, throughout the

nursing process

Before undertaking any nursing intervention, she / he plan the action by deciding

the best approach for each client using decision making skills.

Leadership/management

Nurse Managers coordinate the activities of other members of the team, such as

fellow nurses, physicians, or physiotherapists, etc. when managing clients’ needs.

Nurse’s managers also direct their subordinates in performance of quality nursing

care.

As managers, nurses coordinate and delegate care responsibilities and supervise

other healthcare workers.

Comforting

The role of comforting, caring for the client as a person, is a traditional and

historical one in nursing and has continued to be important as nurses have assumed

new roles.

Because nursing care must be directed to the whole person rather than simply the

body, comfort and emotional support often help give the client strength to recover.


8

Rehabilitation

This is the process by which the individual returns to maximum levels of

functioning after illness, accidents or other disabling events.

The nurse helps them to adapt as fully as possible by using knowledge and skills in

many concepts they have learnt.

Protection/advocacy

The protection of human or legal rights and securing of care for all clients based on

the belief that clients have RIGHTS to make informed decisions about their own

health and lives is usually done by Nurses.

As a protector the nurse helps to maintain safe environment for clients and takes

steps to prevent injury and protect the client from possible adverse effect of

diagnostic or treatment measures, e.g. confirming that a client does not have an

allergy to medication

As an advocator, the nurse protects the patients human and legal rights and

provides assistance in asserting those rights of the needs that arise e.g. providing

additional information to accept treatment.

Career of nurse’s professions

Clinical Nurse Practitioner (CNP)


9

Clinical Nurse practitioner is a nurse who working different healthy care setting.

A clinical Nurse has advanced degree of expertise and is considered the pillar in a

specialized area of nursing.

Carries direct client care, consultation, prescription, teaching clients, families and

staff and conducts research.

Nurse Midwife

Nurse Midwife is a nurse provides prenatal and postnatal care. This nurse qualifies

to serve in maternal and child health and is well informed in issues of obstetrics

and gynecology.

Nurse Researcher

Nurse Researcher is a nurse who carries out research in nurse field. The nurse

here carries out research in many areas and can teach other nurses research or is

consulted to do so.

Nurse anesthetist

Nurse anesthetist is nurse who participate operation by providing anasethesia

evaluate and monitoring. Carries out preoperative visits/ assessments, administers

and monitors anesthesia during surgery and evaluates post operative clients.

Nurse Educator

Nurse Educator is a nurse who is qualified to teach nurse knowledge and clinical

skills. May have a degree or diploma and teaches in educational or clinical

settings-theoretical knowledge and practical skills.


10

Nurse recoder

Nurse Educator is a nurse who record documents and files used by nurse,

Others:

General Nurse, Nurse administrator/ manager, etc

Nursing cadres (groups)

Enrolled (certificate holder)

Registered Nurse/Midwife/comprehensive (Diploma holder)

Nurses with first degree- comprehensive

Nurses with masters

Nurses with PhD

NB: Nursing aids do not fall in the above categories as they are not professionals.


11

CHAPTER TWO

HEALTH AND ILLNESS

DEFINITIONS OF HEALTH STATES

• Health: a state of complete physical, mental, and social well being, not

merely the absence of disease

• Illness: the unique response of a person to a disease

• Wellness: an active state, oriented toward maximizing the potential of

the individual

• Disease: a pathological change in structure and function of the body

Human Dimensions of Health

Physical

Intellectual

Emotional

Sociocultural

Spiritual

Environmental aspects

The Human Dimensions Composing the Whole Person

Acute Illness

• Generally has a rapid onset of symptoms and lasts only a relatively short

time, Examples: appendicitis, pneumonia, diarrhea, common cold

Chronic Illness

• A broad term that encompasses many different physical and mental

alterations. Examples: diabetes mellitus, lung disease, arthritis, lupus


12

Characteristics of a Chronic Illness

It is a permanent change

It causes, or is caused by, irreversible alterations in normal anatomy and

physiology

It requires special patient education for rehabilitation

It requires a long period of care or support

Stages of Illness Behavior

• Experiencing symptoms

• Assuming the sick role

• Assuming a dependent role

• Achieving recovery and rehabilitation

Models of Health and Illness

• The agent-host-environment model

• The health–illness continuum

• The high-level wellness model

• The health belief model

• The health promotion model

Agent-Host-Environment Model (Leavell and Clark)

• Examines the causes of disease in an individual

• Agent, host, and environment interact in ways that create risk factors

• Understanding the risk factors is important for the promotion and

maintenance of health

• The host reaction is influenced by family history, age, and health habits

• The environment includes physical, social, biologic, and cultural factors

• Each of the agent-host-environment factors affects and is affected by the

others

• The Agent-Host-Environment Triangle


13

The Health–Illness Continuum

• Measures a person’s level of health

• Views health as a constantly changing state with high-level wellness and

death on opposite sides of a continuum

• Illustrates the dynamic (ever-changing) state of health

• The Health–Illness Continuum

The High-Level Wellness Model (Dunn)

• Encourages the nurse to care for the total person

• Involves functioning to one’s maximum potential while maintaining

balance and a purposeful direction

• Regards wellness as an active state, oriented toward maximizing the

potential of the individual, regardless of his or her state of health

• Incorporates the processes of being, belonging, becoming, and befitting

The Health Belief Model (Rosenstock)

• Concerned with what people perceive to be true about themselves in

relation to their health

• Modifying factors for health include demographic, sociopsychological,

and structural variables

• Based on three components of individual perceptions of threat of a

disease

– Perceived susceptibility to a disease

– Perceived seriousness of a disease

– Perceived benefits of action

The Health Promotion Model (Pender)

• Illustrates the “multidimensional nature of persons interacting with their

environment as they pursue health”


14

• Joins individual characteristics and experiences and behavior-specific

knowledge and beliefs, to motivate health-promoting behavior

• Personal, biologic, psychological, and sociocultural factors are

predicative of a certain health-related habit

• Health-related behavior is the outcome of the model and is directed

toward attaining positive health outcomes and experiences throughout the

lifespan

Factors Affecting Health Status, Beliefs, and Practices

• Risk factors for illness

• Factors in the human dimensions that influence health–illness status

• Beliefs and practice

• Basic human needs

• Self-concept

The Human Dimensions

• Physical dimension—genetic inheritance, age, developmental level, race,

and gender

• Emotional dimension—how the mind affects body function and responds

to body conditions

• Intellectual dimension—cognitive abilities, educational background, and

past experiences

• Environmental dimension—housing, sanitation, climate, pollution of air,

food, and water

• Sociocultural dimension—economic level, lifestyle, family, and culture

• Spiritual dimension—spiritual beliefs and values

Basic Human Needs

• Physiological needs

• Safety and security needs


15

• Love and belonging needs

• Self-esteem needs

• Self-actualization needs

Factors That Influence a Person’s Self-Concept

• Past experiences

• Interpersonal interactions

• Physical and cultural influences

• Education

Levels of Preventive Care

Primary prevention—e.g., diet, exercise, immunizations

Secondary prevention—e.g., screenings, mammograms, family counseling

Tertiary prevention—e.g., medications, surgical treatment, rehabilitation


16

CHAPTER THREE

NURSING PROCESS

WHAT IS THE “NURSING PROCESS”?

It is a systematic method that directs the nurse and patient in planning patient

care, and enables you to organize and deliver nursing care

It involves assessment (data collection), nursing diagnosis, planning,

implementation, and evaluation, The steps are interrelated and dependent on

the each by the preceding steps

It is used to identify, diagnose, and treat human responses to health and

illness. The process as a whole is cyclical, the steps being interrelated.

The Nursing Process


17

Five Steps of the Nursing Process

Assessment – collection of patient data

Diagnosis – identifies patients strengths and potential problems

Planning – develop the specific holistic desired goals and nursing

interventions to assist the patient

Implementation – carry out the plan of care

Evaluation – determine the effectiveness of the plan of care

Nursing Assessment

The first phase of the nursing process that involve collecting,

organizing and analyzing information and data relating patient problem

called nursing assessment,

The problem of the patient can either

I. Actual problem means “what happing now”

II. Potential problem means “what could happen”

Assessment Activities

The types of data in assessing that make up the assessment are the following:

1. Source of data

2. Data collection

3. Data analysis


18

Sources of data

It can be primary or secondary. The client is the primary source of data.

• Primary Source - Client or patient

• Secondary Source - Family members or other support persons, other

health professionals, records and reports, laboratory and diagnostic

analyses,

Data collection

Data collection is the process of compiling information about the client,

begins with the first client contact.

There are method of data collected which divided into three stages.

Observation,

Interviewing,

Physical examination.

Observation

Observation is the processing Gathering data using the senses

• Used to obtain vital signs of data:

• Temperature (37.8)

• Pulse rate (72)

• Respiration rate (18-20)


19

• Blood pressure (120/80)

Interview

Interviewing is the process Planned for the communication or a conversation

with the patient with a purpose

• Used to:

• Identify problems of mutual concern

• Evaluate change

• Teach

• Provide support

• Provide counseling or therapy

Physical examination

Physical examination is a Systematic data-collection method Uses physical

examination methods

• Inspection,

• Auscultation,

• Palpation, and

• Percussion

Heart and lungs sounds

Skin temperature and moisture


20

Muscle strength

Inspection

Inspection: Is visual examination of the client that is done in a methodical

and deliberate manner.

The client is observed first from a general point of view and then with

specific attention to detail.

Effective inspection requires adequate lighting and exposure of the body

parts being observed.

Palpation

Uses the sense of touch to assess texture, temperature, moisture, organ

location and size, vibrations and pulsations, swelling, masses, and tenderness.

Palpation requires a calm, gentle approach and is used systematically, with

light palpation preceding deep palpation and palpation of caring areas

performed last.

Percussion

Uses short, tapping strokes (plessor) or fingers on the surface of the skin to

create vibrations of underlying organs.

It is used for assessing the density of structures or determining the location

and the size of organs in the body.


21

Auscultation

Involves listening to sounds in the body that are created by movement of air

or fluid. Using equipment which known as stethoscope

Areas most often auscultated include the lungs, heart, abdomen, and blood

vessels.

Data analysis

Data analysis: is to analyze and make intuition for their data collected the

patient.

Intuition: means Intuition plays a role in the nurse’s ability to analyze signs

rapidly, make clinical decisions, and implement nursing actions even though

assessment data may be incomplete or complete.

a) Data review “checking are data accurate and complete”.

b) Data interpretation “ what the actual and potential problems of the

patient are?

Types of data

- Subjective data also known as symptoms or covert cues include the client's

feeling and statement about his or her health problems

- Objective data also known as signs or overt cues, are observable and

measurable (quantitative) data that are obtained through observation, standard

assessment techniques performed during the physical examination, and

laboratory and diagnostic testing.


22

Types of Assessments

a. Initial

b. Problem-Focused

c. Emergency

d. Time-lapsed

Types of assessments

Initial assessment: is performed within a specified time after admission to a

health care agency for the purpose of establishing a complete database for

problem identification, reference, and future comparison.

Problem-focused assessment : is an ongoing process integrated with nursing

care to determine the status of a specific problem identified in an earlier

assessment.

Emergency assessment: occurs during any physiologic or psychologic crisis

of the client to identify the life-threatening problems and to identify new or

overlooked problems.

Time-lapsed (expired) reassessment: occurs several months after the initial

assessment to compare the client’s current status to baseline data previously

obtained.

Assessment Activities

Collecting data


23

Organizing data

Validating data

Documenting data

Collecting data is the process of gathering information about a client’s

health status.

Organizing data is categorizing data systematically using a specified format.

Validating data is the act of “double-checking” or verifying data to confirm

that it is accurate and factual.

Documenting is accurately and factually recording data.

Diagnosis

The second step in the nursing process where we describe the actual and

potential problems of the patient when diagnosing a patient there is format to

be followed which is PE

P=problem E= etiology

The goal of a nursing diagnosis is to identify actual and potential responses

NURSING DIAGNOSIS VS MEDICAL DIAGNOSIS

A medical diagnosis deals with disease or medical condition.

A nursing diagnosis deals with human response to actual or potential health

problems and life processes.


24

Components of a nursing diagnosis:-

The components of a nursing diagnosis typically consist of three parts.

• Problem

• Etiology

• Defining characteristics

The first component is a problem statement or diagnostic label.

The second component of a two-part nursing diagnosis is the etiology. The

etiology is the related cause or contributor to the problem.

The third component consists of defining characteristics (collected data that

are also known as signs and symptoms, subjective and objective data, or

clinical manifestations).

Nursing Diagnosis

Types of Nursing Diagnosis

a. Actual

b. Risk

c. Wellness

d. Possible

Actual Diagnosis


25

Problem present at the time of the assessment, it Describe a human response

to a health problem that is being manifested.

• Presence of associated signs and symptoms

• (ineffective breathing pattern)

Risk Diagnosis

Problem does not exist but Describes human responses to health conditions

that may develop in a vulnerable individual to disease.

Presence of risk factors

• (High risk for complication)

Wellness Diagnosis

Readiness for improvement, describes human responses to levels of wellness

in an individual, family, or community that have a readiness improvement.”

• (readiness for enhanced spiritual well-being or readiness for

enhanced family coping)

Possible Diagnosis

Is made when not enough evidence supports the presence of the problem but

the nurse thinks that is highly possible.

Requires more data to either support or to disprove it

• (possible social isolation)


26

Planning

Is the third nursing process step, where the nurse prioritize nursing care

activities though the patient goals and nursing orders.

Patient goals = patient nursing care

Nursing order = what the nurse will do.

The nursing process includes the formulation of guidelines that establish the

proposed course of nursing action in the resolution of nursing diagnoses and

the development of the client’s plan of care.

Planning of nursing care

The planning of nursing care occurs in three phases:

Initial planning,

Ongoing planning, and

Discharge planning.

Each type of planning contributes to the coordination of the client’s

Initial planning involves development of beginning of care by the nurse who

performs the admission assessment and gathers the comprehensive admission

assessment data.

Ongoing planning involves continuous updating of the client’s plan of care.

Every nurse who cares for the client is involved in ongoing planning.


27

Discharge planning involves critical anticipation and planning for the

client’s needs after discharge.

Critical elements of planning

There are four critical elements of planning which shown a below include:

I. Establishing priorities

II. Setting goals and developing expected outcomes (outcome

identification)

III. Planning nursing interventions (with collaboration and consultation as

needed)

IV. Documenting

Implementation “Doing”

This is the fourth step of nursing processes where the nurse carries out the set

of nursing care plan to achieve the goals or outcomes which can be in short

term care and long term care.

The implementing phase, provide the actual nursing activities and client

responses that are examined in the final phase, the evaluating phase.

To implement the care plan successfully, nurses need to have the following

skills.

i. Cognitive skills,


28

ii. Interpersonal skills, and

iii. Technical skills.

The cognitive skills (intellectual skills) include problem solving, decision

making, critical thinking, and creativity.

Interpersonal skills are all of the activities, verbal and nonverbal, people use

when interacting directly with one another, this depends on the ability of the

nurse to communicate effectively with others. It is necessary for all nursing

activities, caring, comforting, advocating, referring, counseling, and

supporting others.

Technical skills are hands-on skills such as manipulating equipments, giving

injections and bandaging, moving lifting, and repositioning clients. These are

called procedures, tasks, or psychomotor skills.

Five processes of the implementing

Five processes of the Implementing are,

a. Reassessing the client

b. Determining the nurse’s need for assistance

c. Implementing nursing interventions

d. Supervising delegated care

e. Documenting nursing activities


29

Evaluation

The evaluation is the fifth step of nursing processes where the nursing

evaluate and compares patient current status with the stated patient goals

where the goals achieved if not review the nursing.

It’s the judgment of the effectiveness of nursing care to meet client goals

based on the client’s behavioral responses.

Process of Evaluating Client Responses

Collecting data related to the desired outcomes

Comparing the data with outcomes

Relating nursing activities to outcomes

Drawing conclusions about problem status

Continuing, modifying, or terminating the nursing care plan.


30

CHAPTER FOUR

COMMUNICATION SKILLS ON

NURSING TO PATIENT RELATIONSHIPS

DEFINITION OF COMMUNICATION

Communication is “an interaction between two or more persons that

involves the exchange of information between a sender and a

receiver”.

Communication is a complex process of sending and receiving

verbal and nonverbal messages.

The process of creating common understanding

The process of sharing information

It involves the expression of emotions, ideas, and thoughts through

verbal and non-verbal signals.

Communication and the Nursing process

Communication is one of the instruments of data collection and

implementation in the nursing process.

The steps of the nursing process can also be applied in the process of

communication.


31

Purposes of communication

Information

Education

Persuasion

Entertainment

Types of Communication

People Communicate in a variety of ways.

Verbal

Non verbal

1. Verbal Communication

Verbal Communication-is an exchange of information using words and

includes both the spoken and the written word. Verbal communication

depends on language. Language is a prescribed way of using words so

that people can share information effectively. Both spoken and written

communication reveal a great deal about a person.

2. Non verbal communication

Non verbal communication-is the exchange of information without the

use of words. It is communication through gestures, facial expressions,

posture, body movement, voice tone, rate of speech, eye contact.


32

It is generally accepted that non-verbal communication expresses more

of true meaning of a message than dose verbal communication.

Therefore nurses must be aware of both the verbal & non verbal

messages they send and receive from clients.

Non verbal is less conscious than verbal, requires systematic observation

and valid interpretation

A Communication Model

We have said that models add concreteness to a concept in addition to

having a form and utility of their own. The communication model

comprises six elements:

The source-encoder

The message

The channel

The receiver-decoder

Feedback

The sending and receiving of a message.

Sources

The thought, idea, or emotion conveyed. The source-encoder is a term

that describes one person who communicates with another. Our ability

to form, use and understand the messages we transmit is continually


33

influenced by numerous factors, it include our communication skills, our

attitudes, our levels of knowledge, and our sociocultural system.

Message

Message can be the vocal mechanisms used in speech, skill used in

writing, and the use of gestures and other nonverbal behaviors is an

encoding ability, these are the communication model which is labeled

the message.

Channel

we must route the message across a channel. Because the cannel in the

model involves the senses of hearing, seeing, touching, smelling and

tasting, the sensory channel selected must be appropriate to the message

we wish to convey.

Receiver

The receiver-decoder is one of the last links in our communication

model. Behind this label is the person to whom the message is directed,

that other individual who as been influenced by the same factors of

communication.


34

Feedback

Then the receiver provides some form of feedback, which allows us to

determine the success or failure of our communication efforts.

Influences on Communication

Age

Education

Emotions

Culture

Language

Attention

Surroundings

Communication Techniques in Nursing

A. Conversation skills

Control the tone of your voice so that you are conveying exactly what

you mean to say.

1. Be knowledgably about the topic of conversation and have

accurate information

2. Be flexible

3. Be clear and concise


35

4. Avoid words that may be interpreted differently

5. Be truthful

6. Keep an open mind

7. Take advantage of available opportunities

B. Listening Skills- is a skill that involves both

Listening Skills- is a skill that involves both hearing and interpreting

what is said. It requires attention and concentration to sort out, evaluate,

and validate clues so that one understands the true meanings in what is

being said. Listening requires concentrating on the client and what is

being said.

Techniques to improve listening skills

When ever possible sit when communicating with a client

Be attentive but relaxed and take sufficient time so that the client

feels at ease during the conversation

If culturally appropriate maintain eye contact with the client

Think before responding to the client

Listen for themes in the client's comments.

Use of silence

The nurse can use silence appropriately by taking the time to wait for the

client to initiate or continue speaking.


36

During period of silence, the nurse has the opportunity to observe the

clients verbal and non verbal messages simultaneously. Periods of

silence during communication

Listening and Observing

Listening and observing are two of the most valuable skills a nurse can

have. These two skills are used to gather the subjective and objective

data for the nursing assessment.

Active Listening

The process of hearing spoken words and noting nonverbal behavior,

active listening takes energy and concentration.

Factors that influence communication

1. Perceptions

2. Values

3. Background

4. Knowledge

5. Roles and relationships

6. Environmental setting


37

Interviewing Techniques

Interview is a major tool in nursing for the collection of data during the

assessment step of the nursing process.

Purpose: to obtain accurate and thorough information

Techniques of interview

1. Open-ended question

2. Closed question

3. Validation question

4. Clarifying question

5. Reflective question

6. Sequencing question

7. Directing question

Nurse-Client Communication

Almost every nurse-client interaction should involve therapeutic

communication. Nurse-client communication is influenced by both the

nurse and the client.

Three Phases of Nurse-Client Communication

Introduction “ orientation”: Fairly short; expectations clarified;

mutual goals set


38

Working: Major portion of the interaction; used to accomplish

goals outlined in introduction; feedback from client essential.

Termination: Nurse asks if client has questions; summarizing the

topic is another way to indicate closure.

Orientation Phase

Learn about the client and any concerns or needs

Roles are defined

Collect information

Establish goals

Clarify misunderstandings

Establish rapport

Working Phase

Client and nurse are ready to work toward reaching set goals

Client anxiety is reduced by the nurse’s nonjudgmental, supportive

approach

Client is able to respond and participate in plan of care

Termination Phase

Examine and evaluate relationship

Review goals and results

Say good-bye


39

Factors affect nurse’s and client Communication

A nurse’s communication is affected by:

Past Experience

State of Health

Home Situation

Workload

Staff Relations

A client’s communication is affected by:

a) Social Factors

b) Religion

c) Family Situation

d) Level of Consciousness

e) Stage of Illness

f) Visual, Hearing and Speech Ability

g) Language Proficiency

Therapeutic Communication

An application of the process of communication to promote the well-

being of the client, Sometimes called effective communication, it is

purposeful and goal-oriented, creating a beneficial outcome for the

client.


40

Therapeutic and social communication differ—therapeutic is client

centered and goal oriented; may share a personal experience to show

understanding for client’s situation

Goals of Therapeutic Communication

I. To obtain or provide information

II. To develop trust

III. To show caring

IV. To explore feelings


41

CHAPTER FIVE

BASIC NURSING SKILLS VITAL SIGNS

Vital signs reflect the body’s physiologic status and provide information critical to

evaluating homeostatic balance.

The term “vital” is used because the information gathered is the clearest indicator

of overall health status. Vital sign Includes:

a) T (temperature),

b) PR (Pulse Rate),

c) RR (Respiratory Rate),

d) and BP (Blood Pressure)

Purposes:

• To obtain base line data about the patient condition

• To aid in diagnosing patient condition (diagnostic purpose)

Times to Assess Vital Signs

1. On admission – to obtain baseline date

2. When a client has a change in health status or reports symptoms such as chest

pain or fainting

3. According to a nursing or medical order


42

4. Before and after the administration of certain medications that could affect RR

or BP

5. Before and after surgery to diagnostic the patient.

6. According to hospital /other health institution policy.

• Equipment's

Vital sign tray

Stethoscope

Sphygmomanometer

Thermometer (glasses, electronic a)

Second hand watch

Red and blue pen

Pencil;

Vital sign sheet

Cotton swab in bowel

Disposable gloves if available

Dirty pin dish


43

Temperature

• Body temperature is the measurement of heat inside a person’s body (core

temperature); it is the balance between heat produced and heat lost. Normal

Temperature Range For Adults.

• Oral - 97.6 - 99.6 F (Fahrenheit) or 36.5 -37.5 C (Celsius)

• Rectal - 98.6 - 100.6 F or 37.0 - 38.1 C

• Axillary(armpit)- 96.6- 98.6F or 36.0- 37.0C

There are Two Kinds of Body Temperature

1. Core Temperature

Is the Temperature of the deep tissues of the body, such as the cranium, thorax,

abdominal cavity, etc. Remains relatively constant. is the Temperature that we

measure with thermometer

2. Surface Temperature:

• The temperature of the skin, the subcutaneous tissue and fat.

Alterations in Body Temperature

Normal body temperature is 37 °C or 98.6°F (Average) the range is 36-38°c (96.8

– 100°F)

Pyrexia: a body temperature above the normal ranges 38°c – 41°c (100.4 – 105.8

F)

Hyper pyrexia: a very high fever, such as 41°C > 42°c leads to death.

Hypothermia: – body temperature between 34°c – 35°c, < 34°c is death.


44

Factors Affecting Temperature

Exercise

Age

Hormones

Medications

Infection

Emotions

Clothing

Environmental temperature/air movement

Measuring Body Temperature

Sites to Measure Temperature: Most common are:

• Oral

• Rectal

• Axillary

• Tympanic

Thermometer: is an instrument used to measure body temperature. Also divided

as mercury, digital and electronic types.

In developed countries, mercury type thermometers are no more use in hospital

setup but in our setting still very important.


45

Axillary

Procedure

I. Shake thermometer

II. Wash hands

III. Make sure that the client’s axilla is dry, If it is moist, dry it gently before

inserting the thermometer.

IV. After placing the bulb of the thermometer in to the axilla, bring the client’s

arm down against the body as tightly as possible.

V. Hold the glass thermometer in the place for 8 to 10 minutes. Hold the

electronic thermometer in place until the reading registers directly.

VI. Remove and read the thermometer. Dispose of the equipment properly.

Wash hands

VII. Record the reading

N.B. The axillary method is safest and most noninvasive.

Oral

Procedure

Explain the procedure to the patient

Wash hands and necessary equipment and bring to the patient bedside.

Position the person comfortably and request the patient to open the mouth;


46

Hold the thermometer firmly with the thumb and fore finger; shake it with

strong wrist movements until the mercury line falls to at least 35 oc .

Place the bulb of the thermometer well under the client’s tongue. Instruct the

client to close the lips (not the teeth) around the bulb. Ensure that the bulb

rests well under the tongue,

Remove the thermometer after 3 to 5 minutes, according to the agency

guidelines.

Remove the thermometer, wipe it using it once a firm twisting motion

Hold the thermometer at eye level. Read the point

Dispose the tissue. Wash the thermometer in soapy water. Dry and replace

the thermometer in a container. Wash your hands.

Record temperature on paper or flow sheet. Report an abnormal reading to

the appropriate person.

Contraindication

Child below 7 yrs

If the patient is delirious, mentally ill

Unconscious

Surgery of the mouth

Nasal obstruction

If patient has nasal or gastric tubs in place


47

II. Pulse

It is a wave of blood created by contraction of the left ventricle of the heart. i.e. the

pulse reflects the heart beat or is the same as the rate of ventricular contractions of

the heart – in a healthy person.

Factors Affecting Pulse

Age, as age increase the PR gradually decreases.

Sex, the average males PR is slightly lower than female

Drugs, digitalis preparation decreases PR, Epinephrin

Illness

Emotions, increases the sympathetic nerve.

Activity level

Temperature.

Physical training

Sites For Taking Pulse

Radial – base of thumb

Temporal – side of forehead

Carotid – side of neck

Brachial – inner aspect of elbow

Femoral – inner aspect of upper thigh

Popliteal - behind knee


48

Dorsalis pedis – top of foot

Apical pulse – over apex of heart

– taken with stethoscope

– left side of chest

Method of pulse

Pulse: is commonly assessed by palpation (feeling) or auscultation (hearing).

The middle 3 fingertips are used with moderate pressure for palpation of all pulses

except apical.

Pulse Rate

Normal 60-100 b/min (80/min)

Tachycardia – excessively fast heart rate (>100/min)

Bradycardia – decrease of heart rate (< 60/min).

Documenting pulse rate

– Noted as number of beats per minute

– Rhythm - regular or irregular

– Volume - strong, weak, thready, bounding

Procedure for measuring radial pulse (the most common)

Wash hands

Explain the procedure to the client


49

Position the client’s fore arm comfortably with the wrist extended.

Place the tips of your first, second, and third fingers over the client’s radial

artery on the inside of the wrist on the thumb side.

Press gently against the client’s radial artery to the point where pulsation can

be felt.

Using a watch, count the pulse beats for 30 seconds and multiply by two to

get the rate per minute

Count the pulse for full minute if it is abnormal in any way or take an apical

pulse

Record the rate (PR) on paper or the flow sheet. Report any irregular

findings to appropriate person

Wash your hands

III Respiration

Respiration is the act of breathing (includes intake of o2 removal of co2).

Ventilation is another word, which refer to the movement of air in and out of the

lungs.

Hyperventilation: very deep, rapid respiration

Hypoventilation: very shallow respiration


50

Two Types of Breathing

1. Costal (thoracic), Involves the external muscles and other accessory muscles.

Observed by the movement of the chest up ward and down ward. Commonly used

for adults

2. Diaphragmatic (abdominal), Involves the contraction and relaxation of the

diaphragm, observed by the movement of abdomen. Commonly used for children.

Healthy adult RR = 15- 20/ min. As the age decreases the respiratory rate

increases. Qualities of normal respirations

– 15-20 respirations per minute

– Quiet

– Effortless

– Regular

Term used respiration are.

1. Eupnea- normal breathing rate and depth

2. Bradypnea- slow respiration

3. Tachypnea - fast breathing

5. Apnea - temporary cessation of breathing


51

IV Blood Pressure

Blood pressure is the pressure exerted by blood against the wall of blood vessels. It

includes arterial, venous and capillary pressures.

Arterial BP: it is a measure of a pressure exerted by the blood as it flows through

the arteries. Arterial blood pressure (BP) = cardiac output (CO) x total peripheral

resistance (TPR).

There are two types of blood pressure.

1. Systolic pressure: is the pressure of the blood as a result of contraction of the

ventricle (is the pressure of the blood at the height of the blood wave);

2. Diastolic blood pressure: is the pressure when the ventricles are at rest.

• Normal blood pressure range

– Systolic: 90-140 millimeters of mercury

– Diastolic: 60-90 millimeters of mercury

Sites for Measuring Blood Pressure

1. Upper arm using brachial artery (commonest)

2. Thigh around popliteal artery

3. Fore -arm using radial artery

4. Leg using posterior tibial or dorsal pedis

Factors Influencing Blood Pressure


52

• Weight - increase

• Fever - increase

• Age

• Emotions

• Sex

• Hemorrhage – decrease

• Viscosity of blood

• Illness/Disease

Methods of Measuring Blood Pressure

Blood pressure can be assessed directly or indirectly

1. Direct (invasive monitoring) measurement involves the insertion of catheter in

to the brachial, radial, or femoral artery. With use of correct placement, it is highly

accurate.

2. Indirect (non invasive methods)

A. The auscultatory

B. The palpatory, and


53

The auscultatory method is the commonest method used in health activities,

• Sphygmomanometer (manual)

– cuff - different sizes

– pressure control bulb

– pressure gauge – marked with numbers

Procedures

Make sure that the client has not smoked or ingested caffeine.

Position the patient in sitting position,

Blood pressure usually taken in left arm

Wrap the deflated cuff evenly around the upper arm, not over clothing

Room quiet so blood pressure can be heard

Sphygmomanometer must be clearly visible

Identify brachial artery for correct placement of stethoscope

Close the valve on the pump by turning the knob clockwise.

Pump up the cuff until the sphygmomanometer registers about 30 mm Hg

above the point where the brachial pulse disappeared.

Release the valve on the cuff carefully so that the pressure decreases at the

rate 2-3 mmHg per second.

As the pressure falls, identify the manometer


54

Auscultate the client's blood pressure the First sound heard – systolic

pressure and Last sound heard or change - diastolic pressure

Record - systolic/diastolic with accurate gauge.

Parenteral Drug Administration

A. Intradermal Injection

Definition: It is an injection given into the dermal layer of the skin.

Purpose, is for diagnostic purpose e.g. allergic reaction

Site of Injection

The inner part of the forearm (midway between the wrist and elbow).

Upper arm, at deltoid area for BCG vaccination

B. Sub - Cutaneous Injection

Definition: Injecting of drug under the skin in the subcutaneous tissue, (under the

dermis)

Purpose:

To obtain quicker absorption than oral administration

When it is impossible to give medication orally.

Equipment


55

√ Tray

√ Sterile syringe & needle

√ Alcohol swabs

√ Medication

√ File

√ Medication card and patient chart

√ Receiver

√ Water in a bowel

√ Disposing box

Site of Injection

Outer part of the upper arm

The abdomen below the costal margin to the iliac crest.

The anterior aspect of the thigh

Procedure

Take equipment to the pt's bed side or room


Draw your medication

Expel the air from the syringe

Clean the site (usually it is in upper arms, thighs or abdomen)


56

Grasp the area between your thumb & forefinger to tense it.

Insert the needle elevate about 450 - 600 angle.

Pierce the skin quickly & advance the needle

Aspirate to determine that the needle has not entered a blood vessel

Inject the drug slowly.

After injecting withdraw the needle and massage the area with alcohol swab.

Chart the amount and time of administration immediately.

Take care of the equipment- wash, sterilize and return to its place

C. Intera- Muscular Injection

Definition: It is an introduction of a drug into a body's system via the muscles.

Purpose

To obtain quick action next to the intra- venous route

To avoid an irritation from the drug if given through other route.

Equipment

Tray

Ordered drug (ampoule, vial)

Sterile syringes and needle in a container

Alcohol swab


57

Receiver

A bowl of water for used syringes and needle

File

Sterile jar with sterile forceps

Chart

Sites for I.M. Injection

I. Ventrogluteal muscle

II. Dorsogluteal muscle

III. Deltoid muscle

IV. Vastus Lateralis

Procedure

Prepare tray & take it to the patient's room

Prepare the medication and syringe

Draw the medicine

Expel the air from the syringe

Choose the site of injection (the site for intra- muscular)

Using the iliac crest as the upper boundary divided the buttock into four.

Clean the upper outer quadrant with alcohol swab:

Stretch the skin and inject the medicine


58

Draw back the piston (plunger) to check whether or not you are in the blood

vessel ( if blood returns, withdraw and get new needle & reinject in a

different spot)

Push the drug slowly into the muscle

When completed, withdraw the needle and massage the area with swab

gently to and absorption.

Take care of the equipment you have used & return to their places

Chart the amount, time route and type of the medicine

Check the patient's reaction

Note:

1. The needle for I.M. Injection should be long

2. Injection should not be given in areas such as inflamed, edematous.

D. I.V. INJECTIONS

Definition: It is the introduction of a drug in solution form into a vein. Often the

amount is not more than 10.ml. at a time.

Sites for IV injection

1. Dorsal metacarpal Veins

2. Radial vein

3. Ulnar vein


59

Note:

1. Have a bowl of water to rinse the needle used immediate

2. Make yourself as well as the pt. Comfortable before giving injection.

3. It is the fastest way of drug administration

4. Never recap a used needle

Procedure

Prepare your tray & the medication


Position the patient properly

Place towel under his arm(to protect the bed linen)

Expose the arm and apply tourniquet

Ask pt. To open and close his fist.

Palpate the vein and clean with alcohol swab the site of the injection.

Hold the needle at about 45 angles in line with the veins.

Puncture the vein and draw back to check whether you are in the vein or not.

Once you know that you are in the vein, release the tourniquet and gently

lower the angle of the needle

When it is nearly paralleled to the vein and instills the medications. Give

very slowly unless there is an order to give it fast (Normally 40-60 drops is

given in 1 minute).


60

Check the pt's pulse in between. Any complaint from the patient should not

be ignored.

Apply pressure over the site after removing the needle to prevent bleeding.

Tell patient to flex his elbow.

Watch the patient for few minutes before leaving him.

Remove your equipment

Put the pt. In a comfortable position

Wash, sterilize and place the equipment in order.

Chart the medication given the amount, time & the reaction of the pt.


61

For more information about this lecture notes you can contact the publisher at

www.Soojeede.com or you can contact the author of the books direct, and you will

get more books like this lecture notes wrote as simple language and easy

understandable. Such lecture note book you can get are include

- Health care finance

- Human resource for health

- General pharmacology

- General pathology

- Anatomy and physiology etc

All concerned for public health department students and health service

management students. So the author will promise you that you will satisfy all

lecture note books he wrote.

Contact the author with the following

E-mail: [email protected]



Or contact directly with Mobile or you can get websites: www.soojeede.com

- Mobile No: 002521 61 5 880375- Mogadishu-Somalia

Thank you

http://www.soojeede.com/

mailto:[email protected]



http://www.soojeede.com/

Fundamental of Nursing - Soojeede.comsoojeede.com/wp-content/uploads/2016/12/Soojeedes-Fundamental...

Documents

Transcript of Fundamental of Nursing - Soojeede.comsoojeede.com/wp-content/uploads/2016/12/Soojeedes-Fundamental...