Asepsis

Medical asepsis
1. Includes all practices intended to confine a specific microorganism to a specific area
Contents
1.

1 Asepsis

2.

2 Infection

3.

3 Inflammation

4.

4 Immune Response

5.

5 Types of Immunity

6.

6 Nosocomial Infection

7.

7 Factors Increasing Susceptibility to Infection

8.

8 Universal Precautions (UP)

9.

9 Body Substance Isolation (BSI)

10.

10 Standard Precautions

11.

11 Transmission-based Precautions

12.

12 Managing Equipment Used for Isolation Clients

13.

13 Bloodborne Pathogen Exposure

14.

14 Puncture/Laceration

2. Limits the number, growth, and transmission of microorganisms

3. Objects referred to as clean or dirty (soiled, contaminated)

Surgical asepsis
1.

Sterile technique

2.

Practices that keep an area or object free of all microorganisms

3.

Practices that destroy all microorganisms and spores

4.

Used for all procedures involving sterile areas of the body

Principles of Aseptic Technique

1.

Only sterile items are used within sterile field.

2.

Sterile objects become unsterile when touched by unsterile objects.

3.

Sterile items that are out of vision or below the waist level of the nurse
are considered unsterile.

4.

Sterile objects can become unsterile by prolong exposure to airborne

microorganisms.

5.

Fluids flow in the direction of gravity.

6.

Moisture that passes through a sterile object draws microorganism

from unsterile surfaces above or below to the surface by capillary
reaction.

7.

The edges of a sterile field are considered unsterile.

8.

The skin cannot be sterilized and is unsterile.

9.

Conscientiousness, alertness and honesty are essential qualities in

maintaining surgical asepsis

Infection

Signs of Localized Infection

Localized swelling

Localized redness

Pain or tenderness with palpation or movement

Palpable heat in the infected area

Loss of function of the body part affected, depending on the site and
extent of involvement

Signs of Systemic Infection

Fever

Increased pulse and respiratory rate if the fever high

Malaise and loss of energy

Anorexia and, in some situations, nausea and vomiting

Enlargement and tenderness of lymph nodes that drain the area of

infection

Factors Influencing Microorganisms Capability to Produce Infection

Number of microorganisms present

Virulence and potency of the microorganisms (pathogenicity)

Ability to enter the body

Susceptibility of the host

Ability to live in the hosts body

Anatomic and Physiologic Barriers Defend Against Infection

Intact skin and mucous membranes

Moist mucous membranes and cilia of the nasal passages

Alveolar macrophages

Tears

High acidity of the stomach

Resident flora of the large intestine

Peristalsis

Low pH of the vagina

Urine flow through the urethra

NANDA Diagnosis

Risk for Infection

o

State in which an individual is at increased risk for being invaded

by pathogenic microorganisms

Risks factors
o

Inadequate primary defenses

Inadequate secondary defenses

Related Diagnoses

Potential Complication of Infection: Fever

Imbalanced Nutrition: Less than Body Requirement

Acute Pain

Impaired Social Interaction or Social Isolation

Anxiety

Interventions to Reduce Risk for Infection

Proper hand hygiene techniques

Environmental controls

Sterile technique when warranted

Identification and management of clients at risk

Chain of Infection
1.

The chain of infection refers to those elements that must be present

to cause an infection from a microorganism

2.

Basic to the principle of infection is to interrupt this chain so that an

infection from a microorganism does not occur in client

3.

Infectious agent; microorganisms capable of causing infections are

referred to as an infectious agent or pathogen

4.

Modes of transmission: the microorganism must have a means of

transmission to get from one location to another, called direct and
indirect

5.

Susceptible host describes a host (human or animal) not possessing

enough resistance against a particular pathogen to prevent disease or
infection from occurring when exposed to the pathogen; in humans
this may occur if the persons resistance is low because of poor
nutrition, lack of exercise of a coexisting illness that weakens the
host.

6.

Portal of entry: the means of a pathogen entering a host: the means

of entry can be the same as one that is the portal of exit
(gastrointestinal, respiratory, genitourinary tract).

7.

Reservoir: the environment in which the microorganism lives to

ensure survival; it can be a person, animal, arthropod, plant, oil or a
combination of these things; reservoirs that support organism that are
pathogenic to humans are inanimate objects food and water, and other
humans.

8.

Portal of exit: the means in which the pathogen escapes from the
reservoir and can cause disease; there is usually a common escape
route for each type of microorganism; on humans, common escape
routes are the gastrointestinal, respiratory and the genitourinary tract.

Breaking the Chain of Infection

Etiologic agent

Correctly cleaning, disinfecting or sterilizing articles before use

Educating clients and support persons about appropriate methods to

clean, disinfect, and sterilize article

Reservoir (source)

Changing dressings and bandages when soiled or wet

Appropriate skin and oral hygiene

Disposing of damp, soiled linens appropriately

Disposing of feces and urine in appropriate receptacles

Ensuring that all fluid containers are covered or capped

Emptying suction and drainage bottles at end of each shift or before

full or according to agency policy

Portal of exit

Avoiding talking, coughing, or sneezing over open wounds or sterile

fields

Covering the mouth and nose when coughing or sneezing

Method of transmission

Proper hand hygiene

Instructing clients and support persons to perform hand hygiene

before handling food, eating, after eliminating and after touching
infectious material

Wearing gloves when handling secretions and excretions

Wearing gowns if there is danger of soiling clothing with body

substances

Placing discarded soiled materials in moisture-proof refuse bags

Holding used bedpans steadily to prevent spillage

Disposing of urine and feces in appropriate receptacles

Initiating and implementing aseptic precautions for all clients

Wearing masks and eye protection when in close contact with clients
who have infections transmitted by droplets from the respiratory tract

Wearing masks and eye protection when sprays of body fluid are
possible

Portal of entry

Using sterile technique for invasive procedures, when exposing open

wounds or handling dressings

Placing used disposable needles and syringes in puncture-resistant

containers for disposal

Providing all clients with own personal care items

Susceptible host

Maintaining the integrity of the clients skin and mucous membranes

Ensuring that the client receives a balanced diet

Educating the public about the importance of immunizations

Modes of Transmission
1. Direct contact: describes the way in which microorganisms are transferred from
person to person through biting, touching, kissing, or sexual intercourse; droplet
spread is also a form of direct contact but can occur only if the source and the host
are within 3 feet from each other; transmission by droplet can occur when a person
coughs, sneezes, spits, or talks.
2. Indirect contact: can occur through fomites (inanimate objects or materials) or
through vectors (animal or insect, flying or crawling); the fomites or vectors act as
vehicle for transmission
3. Air: airborne transmission involves droplets or dust; droplet nuclei can remain in the
air for long periods and dust particles containing infectious agents can become
airborne infecting a susceptible host generally through the respiratory tract

Course of Infection
1. Incubation: the time between initial contact with an infectious agent until the first
signs of symptoms the incubation period varies from different pathogens;
microorganisms are growing and multiplying during this stage
2. Prodromal Stage: the time period from the onset of nonspecific symptoms to the
appearance of specific symptoms related to the causative pathogen symptoms range
from being fatigued to having a low-grade fever with malaise; during this phase it is
still possible to transmit the pathogen to another host
3. Full Stage: manifestations of specific signs & symptoms of infectious agent; referred
to as the acute stage; during this stage, it may be possible to transmit the infectious
agent to another, depending on the virulence of the infectious agent
4. Convalescence: time period that the host takes to return to the pre-illness stage;
also called the recovery period; the host defense mechanisms have responded to the
infectious agent and the signs and symptoms of the disease disappear; the host,
however, is more vulnerable to other pathogens at this time; an appropriate nursing
diagnostic label related to this process would be Risk for Infection

Inflammation

The protective response of the tissues of the body to injury or infection; the
physiological reaction to injury or infection is the inflammatory response; it may be
acute or chronic

Bodys response

1. The inflammatory response begins with vasoconstriction that is followed by a brief

increase in vascular permeability; the blood vessels dilate allowing plasma to escape
into the injured tissue
2. WBCs (neutrophils, monocytes, and macrophages) migrate to the area of injury and
attack and ingest the invaders (phagocytosis); this process is responsible for the
signs of inflammation
3. Redness occurs when blood accumulates in the dilated capillaries; warmth occurs as
a result of the heat from the increased blood in the area, swelling occurs from fluid
accumulation; the pain occurs from pressure or injury to the local nerves.

Immune Response

1. The immune response involves specific reactions in the body to antigens or foreign
material
2. This specific response is the bodys attempt to protect itself, the body protects itself
by activating 2 types of lymphocytes, the T-lymphocytes and B-lymphocytes
3. Cell mediated immunity: T-lymphocytes are responsible for cellular immunity
o

When fungi , protozoa, bacteria and some viruses activate T-lymphocytes,

they enter the circulation from lymph tissue and seek out the antigen

Once the antigen is found they produce proteins (lymphokines) that increase
the migration of phagocytes to the area and keep them there to kill the
antigen

After the antigen is gone, the lymphokines disappear

Some T-lymphocytes remain and keep a memory of the antigen and are
reactivated if the antigen appears again.

4. Humoral response: the ability of the body to develop a specific antibody to a specific
antigen (antigen-antibody response)
o

B-lymphocytes provide humoral immunity by producing antibodies that

convey specific resistance to many bacterial and viral infections

Active immunity is produced when the immune system is activated either

naturally or artificially.

Natural immunity involves acquisition of immunity through developing

the disease

Active immunity can also be produced through vaccination by

introducing into the body a weakened or killed antigen (artificially
acquired immunity)

Passive immunity does not require a host to develop antibodies, rather

it is transferred to the individual, passive immunity occurs when a
mother passes antibodies to a newborn or when a person is given
antibodies from an animal or person who has had the disease in the
form of immune globulins; this type of immunity only offers temporary
protection from the antigen.

Types of Immunity
Active Immunity

Host produces antibodies in response to natural antigens or artificial antigens

Natural active immunity

Antibodies are formed in presence of active infection in the body

Duration lifelong

Artificial active immunity

o

Antigens administered to stimulate antibody formation

Lasts for many years

Reinforced by booster

Passive Immunity

Host receives natural or artificial antibodies produced from another source

Natural passive immunity

Antibodies transferred naturally from an immune mother to baby through the

placenta or in colostrums

Lasts 6 months to 1 year

Artificial passive immunity

o

Occurs when immune serum (antibody) from an animal or another human is

injected

Lasts 2 to 3 weeks

Nosocomial Infection
1. Nosocomial Infections: are those that are acquired as a result of a healthcare
delivery system
2. Iatrogenic infection: these nosocomial infections are directly related to the clients
treatment or diagnostic procedures; an example of an iatrogenic infection would be a
bacterial infection that results from an intravascular line or Pseudomonas aeruginosa
pneumonia as a result of respiratory suctioning

3. Exogenous Infection: are a result of the healthcare facility environment or

personnel; an example would be an upper respiratory infection resulting from contact
with a caregiver who has an upper respiratory infection
4. Endogenous Infection: can occur from clients themselves or as a reactivation of a
previous dormant organism such as tuberculosis; an example of endogenous
infection would be a yeast infection arising in a woman receiving antibiotic therapy;
the yeast organisms are always present in the vagina, but with the elimination of the
normal bacterial flora, the yeast flourish.
Risks for Nosocomial Infections

Diagnostic or therapeutic procedures

o

Iatrogenic infections

Compromised host

Insufficient hand hygiene

Factors Increasing Susceptibility to Infection

1. Age: young infants & older adults are at greater risk of infection because of reduced
defense mechanisms
o

Young infants have reduced defenses related to immature immune systems

In elderly people, physiological changes occur in the body that make them
more susceptible to infectious disease; some of these changes are:

Altered immune function (specifically, decreased phagocytosis by the

neutrophils and by the macrophages)

Decreased bladder muscle tone resulting in urinary retention

Diminished cough reflex, loss of elastic recoil by the lungs leading to

inability to evacuate normal secretions

Gastrointestinal changes resulting in decreased swallowing ability and

delayed gastric emptying.

2. Heredity: some people have a genetic predisposition or susceptibility to some

infectious diseases
3. Cultural practices: healthcare beliefs and practices, as well as nutritional and
hygiene practices, can influence a persons susceptibility to infectious diseases

4. Nutrition: inadequate nutrition can make a person more susceptible to infectious

diseases; nutritional practices that do not supply the body with the basic components
necessary to synthesized proteins affect the way the bodys immune system can
respond to pathogens
5. Stress: stressors, both physical and emotional, affect the bodys ability to protect
against invading pathogens; stressors affect the body by elevating blood cortisone
levels; if elevation of serum cortisone is prolonged, it decreases the antiinflammatory response and depletes energy stores, thus increasing the risk of
infection
6. Rest, exercise and personal health habits: altered rest and exercise patterns
decrease the bodys protective, mechanisms and may cause physical stress to the
body resulting in an increased risk of infection; personal health habits such as poor
nutrition and unhealthy lifestyle habits increase the risk of infectious over time by
altering the bodys response to pathogens
7. Inadequate defenses: any physiological abnormality or lifestyle habit can influence
normal defense mechanisms in the body, making the client more susceptible to
infection; the immune system functions throughout the body and depends on the
following:
o

Intact skin and mucous membranes

Adequate blood cell production and differentiation

A functional lymphatic system and spleen

An ability to differentiate foreign tissue and pathogens from normal body

tissue and flora; in autoimmune disease, the body has a problem with
recognizing its own tissue and cells; people with autoimmune disease are at
increased risk of infection related to their immune system deficiencies.

Environmental: an environment that exposes individuals to an increased

number of toxins or pathogens also increases the risk of infection; pathogens
grow well in warm moist areas with oxygen (aerobic) or without oxygen
(anaerobic) depending on the microorganism, an environment that increases
exposure to toxic substances also increases risk

Immunization history: inadequately immunized people have an increased

risk of infection specifically for those diseases for which vaccines have been
developed.

Medications and medical therapies: examples of therapies and

medications that increase clients risk for infection includes radiation
treatment, anti-neo-plastic drugs, anti inflammatory drugs and surgery

Diagnostic Tests Used to Screen for Infection

1. Signs and symptoms related to infections are associated with the area infected; for
instance, symptoms of a local infection on the skin or mucous membranes are
localized swelling, redness, pain and warmth
2. Symptoms related to systemic infections include fever, increased pulse &
respirations, lethargy, anorexia, and enlarged lymph nodes
3. Certain diagnostic tests are ordered to confirm the presence of an infection.

Category-specific Isolation Precautions

Strict isolation

Contact isolation

Respiratory isolation

Tuberculosis isolation

Enteric precautions

Drainage/secretions precautions

Blood/body fluid precautions

Disease-specific Isolation Precautions

Delineate practices for control of specific diseases

o

Use of private rooms with special ventilation

Cohorting clients infected with the same organism

Gowning to prevent gross soilage of clothes

Universal Precautions (UP)

Used with all clients

Decrease the risk of transmitting unidentified pathogens

Obstruct the spread of bloodborne pathogens (hepatitis B and C viruses and HIV)

Used in conjunction with disease-specific or category-specific precautions

Body Substance Isolation (BSI)

Employs generic infection control precautions for all clients

Body substances include:

o

Blood

Urine

Feces

Wound drainage

Oral secretions

Any other body product or tissue

Standard Precautions

Used in the care of all hospitalized persons regardless of their diagnosis or possible
infection status

Apply to:

Blood

All body fluids, secretions, and excretions except sweat (whether or not blood
is present or visible)

Nonintact skin and mucous membranes

Combine the major features of UP and BSI

Transmission-based Precautions

Used in addition to standard precautions

For known or suspected infections that are spread in one of three ways:
o

Airborne

Droplet

Contact

May be used alone or in combination but always in addition to standard precautions

Managing Equipment Used for Isolation Clients

Many supplied for single use only

Disposed of after use

Agencies have specific policies and procedures for handling soiled reusable
equipment

Nurses need to become familiar with these practices

Bloodborne Pathogen Exposure

Report the incident immediately

Complete injury report

Seek appropriate evaluation and follow-up

Identification and documentation of the source individual when feasible and legal

Testing of the source for hepatitis B, C and HIV when feasible and consent is given

Making results of the test available to the source individuals health care provider

Testing of blood exposed nurse (with consent) for hepatitis B, C, and HIV please
check these to match style used in book fairly certain it should be caped
antibodies

Postexposure prophylaxis if medically indicated

Medical and psychologic counseling

Puncture/Laceration

Encourage bleeding

Wash/clean the area with soap and water

Initiate first aid and seek treatment if indicated

Mucous membrane exposure (eyes, nose, mouth)

Flush with saline or water flush for 5 to 10 minutes

Postexposure Protocol (PEP) for HIV

Start treatment as soon as possible preferably within hours after exposure

For high-risk exposure (high blood volume and source with a high HIV titer), three
drug treatment is recommended

For increased risk exposure (high blood volume or source with high HIV titer),
three-drug treatment is recommended

For low risk exposure (neither high blood volume nor source with a high HIV titer),
two-drug treatment is considered

Drug prophylaxis continues for 4 weeks

Drug regimens vary and new drugs and regimens continuously being developed

HIV antibody tests should be done shortly after exposure (baseline), and 6 weeks, 3
months, and 6 months afterward

Postexposure Protocol (PEP) for Hepatitis B

Anti-HBs testing 1 to 2 months after last vaccine dose

HBIG and/or hepatitis B vaccine within 1 to 7 days following exposure for

nonimmune workers

Postexposure Protocol (PEP) for Hepatitis C

Anti-HCV and ALT at baseline and 4 to 6 months after exposure

Assessment - First Step in the Nursing

Process

It is systematic and continuous collection, validation and communication of client

data as compared to what is standard/norm.

It includes the clients perceived needs, health problems, related experiences, health
practices, values and lifestyles.

Purpose
To establish a data base (all the information about the client):

nursing health history

physical assessment

the physicians history & physical examination

results of laboratory & diagnostic tests material from other health personnel

FOUR Types of Assessment

1. Initial assessment assessment performed within a specified time on admission
o

Ex: nursing admission assessment

2. Problem-focused assessment use to determine status of a specific problem

identified in an earlier assessment
o

Ex: problem on urination-assess on fluid intake & urine output hourly

3. Emergency assessment rapid assessment done during any

physiologic/physiologic crisis of the client to identify life threatening problems.
o

Ex: assessment of a clients airway, breathing status & circulation after a

cardiac arrest.

4. Time-lapsed assessment reassessment of clients functional health pattern done

several months after initial assessment to compare the clients current status to
baseline data previously obtained.

Activities
1. Collection of data
2. Validation of data
3. Organization of data
4. Analyzing of data
5. Recording/documentation of data

Assessment

Observation of the patient + Interview of patient, family & SO + examination of the

patient + Review of medical record

Collection of data

gathering of information about the client

includes physical, psychological, emotion, socio-cultural, spiritual factors that may

affect clients health status

includes past health history of client (allergies, past surgeries, chronic diseases, use
of folk healing methods)

includes current/present problems of client (pain, nausea, sleep pattern, religious

practices, meds or treatment the client is taking now)

Types of Data
1. Subjective data
o

also referred to as Symptom/Covert data

Information from the clients point of view or are described by the person
experiencing it.

Information supplied by family members, significant others; other health

professionals are considered subjective data.

Example: pain, dizziness, ringing of ears/Tinnitus

2. Objective data

also referred to as Sign/Overt data

Those that can be detected observed or measured/tested using accepted

standard or norm.

Example: pallor, diaphoresis, BP=150/100, yellow discoloration of skin

Methods of Data Collection

1. Interview
o

A planned, purposeful conversation/communication with the client to get

information, identify problems, evaluate change, to teach, or to provide
support or counseling.

it is used while taking the nursing history of a client

2. Observation
o

Use to gather data by using the 5 senses and instruments.

3. Examination
o

Systematic data collection to detect health problems using unit of

measurements, physical examination techniques (IPPA), interpretation of
laboratory results.

should be conducted systematically:

1. Cephalocaudal approach head-to-toe assessment
2. Body System approach examine all the body system
3. Review of System approach examine only particular area affected

Source of data
1. Primary source data directly gathered from the client using interview and
physical examination.
2. Secondary source data gathered from clients family members, significant others,
clients medical records/chart, other members of health team, and related care
literature/journals.
o

In the Assessment Phase, obtain a Nursing Health History - a structured

interview designed to collect specific data and to obtain a detailed health
record of a client.

Components of a Nursing Health History:

Biographic data name, address, age, sex, martial status, occupation,

religion.

Reason for visit/Chief complaint primary reason why client seek consultation
or hospitalization.

History of present Illness includes: usual health status, chronological story,

family history, disability assessment.

Past Health History includes all previous immunizations, experiences with

illness.

Family History reveals risk factors for certain disease diseases (Diabetes,
hypertension, cancer, mental illness).

Review of systems review of all health problems by body systems

Lifestyle include personal habits, diets, sleep or rest patterns, activities of

daily living, recreation or hobbies.

Social data include family relationships, ethnic and educational background,

economic status, home and neighborhood conditions.

Psychological data information about the clients emotional state.

Pattern of health care includes all health care resources: hospitals, clinics,
health centers, family doctors.

Validation of Data

The act of double-checking or verifying data to confirm that it is accurate and

complete.

Purposes of data validation

1. ensure that data collection is complete
2. ensure that objective and subjective data agree
3. obtain additional data that may have been overlooked
4. avoid jumping to conclusion
5. differentiate cues and inferences
Cues

Subjective or objective data observed by the nurse; it is what the client says, or
what the nurse can see, hear, feel, smell or measure.

Inferences

The nurse interpretation or conclusion based on the cues.

Example:
o

Red swollen wound = infected wound

Dry skin = dehydrated

Organization of Data
Uses a written or computerized format that organizes assessment data systematically.
1. Maslows basic needs
2. Body System Model
3. Gordons Functional Health Patterns:
Gordons Functional Health Patterns
1. Health perception-health management pattern.
2. Nutritional-metabolic pattern
3. Elimination pattern
4. Activity-exercise pattern
5. Sleep-rest pattern
6. Cognitive-perceptual pattern
7. Self-perception-concept pattern
8. Role-relationship pattern
9. Sexuality-reproductive pattern
10. Coping-stress tolerance pattern
11. Value-belief pattern

Analyze data

Compare data against standard and identify significant cues. Standard/norm are
generally accepted measurements, model, pattern:
o

Ex: Normal vital signs, standard Weight and Height, normal

laboratory/diagnostic values, normal growth and development pattern

Communicate/Record/Document Data

nurse records all data collected about the clients health status

data are recorded in a factual manner not as interpreted by the nurse

Record subjective data in clients word; restating in other words what client says
might change its original meaning.

Review of clinical record

1. Client records contain information collected by many members of the healthcare
team, such as demographics, past medical history, diagnostic test results and
consultations
2. Reviewing the clients record before beginning an assessment prevents the nurse
from repeating questions that the client has already been asked and identifies
information that needs clarification.

Interview
1. The purpose of an interview is to gather and provide information, identify problems
of concerns, and provide teaching and support.
2. The goals of an interview are to develop a rapport with the client and to collect data
3. An interview has 3 major stages:
1. Opening: purpose is to establish rapport by creating goodwill and
trust; this is often achieved through a self introduction, nonverbal
gestures (a handshake), and small talk about the weather, local sports
team, or recent current event; the purpose of the interview is also
explained to the client at this time.
2. Body: during this phase, the client responds to open and closed-ended
questions asked by the nurse.
3. Closing: either the client or the nurse may terminate the interview, it
is important fro the nurse to try to maintain the rapport and trust that
was developed thus far during the interview process.
4. Types of questions
1. Closed questions used in directive interview
1. Re____ short factual answers; e.g. Do you have pain?
2. Answers usually reveal limited amounts of information
3. Useful with clients who are highly stressed and/or have difficulty
communicating
2. Open-ended questions used in nondirective interview
1. Encourage clients to express and clarify their thoughts and feelings;
e.g. How have you been sleeping lately?

2. Specify the broad area to be discussed and invite longer answers

3. Useful at the start of an interview or to change the subject
3. Leading questions
1. Direct the clients answer; e.g. You dont have any questions about
your medications, do you?
2. Suggests what answer is expected
3. Can result in client giving inaccurate data to please the nurse
4. Can limit client choice of topic for discussion

Nursing History
1. Collection of information about the effect of the clients illness on daily functioning
and ability to cope with the stressor (the human response)
2. Subjective data
o

May be called covert data

Not measurable or observable

Obtained from client (primary source), significant others, or health

professionals (secondary sources).

For example, the client states, I have a headache

Objective data

May be called overt data

Can be detected by someone other than the client

Includes measurable and observable client behavior

For example, a blood pressure reading of 190/110 mmHg.

Physical assessment

1. Systematic collection of information about the body systems through the use of
observation, inspection, auscultation, palpation and percussion
2. A body system format for physical assessment is found below:
o

General assessement

Integumentary system

Head, ears, eyes, nose, throat

Breast and axillae

Thorax and lungs

Cardiovascular system

Nervous system

Abdomen and gastrointestinal system

Anus and rectum

Genitourinary system

Reproductive system

Musculoskeletal system

Psychosocial assessment
1. Helpful framework for organizing data
2. A suggested format for psychosocial assessment is found below:
o

Vocation/education/financial

Home and Family

Social, leisure, spiritual and cultural

Sexual

Activities of daily living

Health Habits

Psychological

3. The developmental of Erickson, Freud, Havighurst, Kohlberg and Piaget may also be
helpful for guiding data collection

Consultation
1. The nurse collects data from multiple sources: primary (client) and secondary (family
members, support persons, healthcare professionals and records)
2. Consultation with individuals who can contribute to the clients database is helpful in
achieving the most complete and accurate information about a client
3. Supplemental information from secondary sources (any source other then the client)
can help verify information, provide information for a client who cannot do so, and
convey information about the clients status prior to admission

Review of literature
1. A professional nurse engages in continued education to maintain knowledge of
current information related to health care
2. Reviewing professional journals and textbooks can help provide additional data to
support or help analyze the client database

Bowel Elimination
The Large Intestine

Primary organ of bowel elimination

Extends from the ileocecal valve to the anus

Functions

Completion of absorption of H2O, Nutrients (chyme from sm. intest. - 1-1.5 L)

Manufacture of some vitamins

Formation of feces

Expulsion of feces from the body

The Small and Large Intestines

Process of Peristalsis

Peristalsis is under control of nervous system

Contractions occur every 3 to 12 minutes

Mass peristalsis sweeps occur 1 to 4 times each 24-hour period

One-third to one-half of food waste is excreted in stool within 24 hours

Peristalic Movements in the Intestine Colonic peristalsis is slow. Mass peristalsis is

strong, few waves per day, stimulated by food in small intestine.

Factors that influence Bowel Elimination

1. Age
2. Diet
3. Position
4. Pregnancy

5. Fluid Intake
6. Activity
7. Psychological
8. Personal Habits
9. Pain
10. Medications
11. Surgery/Anesthesia

Developmental Considerations

Infantscharacteristics of stool and frequency depend on formula or breast feedings

Toddler physiologic maturity is first priority for bowel training (1 2 yrs)

Child, adolescent, adultdefecation patterns vary in quantity, frequency, and

rhythmicity

Older adultconstipation is often a chronic problem

Foods Affecting Bowel Elimination

Constipating foods cheese, lean meat, eggs, & pasta

Foods with laxative effectfruits and vegetables, bran, chocolate, alcohol, coffee

Gas-producing foodsonions, cabbage, beans, cauliflower

Effect of Medications on Stool

Aspirin, anticoagulants pink, red, or black stool

Iron saltsblack stool

Antacids white discoloration or speckling in stool

Antibioticsgreen-gray color

Physical Assessment of the Abdomen

Inspectionobserve contour, any masses, scars, or distension

Auscultationlisten for bowel sounds in all quadrants

Note frequency and character, audible clicks, and flatus

Describe bowel sounds as audible, hyperactive, hypoactive, or inaudible Percussion

expect resonant sound or tympany

Areas of increased dullness may be caused by fluid, a mass, or tumor

Palpationnote any muscular resistance, tenderness, enlargement of organs, masses

Physical Assessment of the Anus and Rectum

Inspection and palpation

Examine anal area for cracks, nodules, distended veins, masses or polyps, fecal mass

Insert gloved finger into anus to assess sphincter tone & smoothness of mucosal
lining

Inspect perineal area for skin irritation secondary to diarrhea

Stool Collection

Medical aseptic technique is imperative

Wear disposable gloves

Wash hands before and after glove use

Do not contaminate outside of container with stool

Obtain stool and package, label, and transport according to agency policy

Patient Guidelines for Stool Collection

Void first so urine is not in stool sample

Defecate into the container rather than toilet bowl

Do not place toilet tissue in bedpan or specimen container

Notify nurse when specimen is available

get to lab quickly (30 min) if anything viable in sample ie. parasites, C-diff. etc

Types of Direct Visualization Studies

Esophagogastroduodenoscopy (EGD)

Colonoscopy

Sigmoidoscopy

Wireless capsule endoscopy

Indirect Visualization Studies

Upper gastrointestinal (UGI)

Small bowel series

Barium enema

Scheduling Diagnostic Tests

1 fecal occult blood test

2 barium studies (should precede UGI) make sure ALL barium is removed*

3 endoscopic examinations

Noninvasive procedures take precedence over invasive procedures

Patient Outcomes for Normal Bowel Elimination

Patient has a soft-formed bowel movement every 1-3 days without discomfort

The relationship between bowel elimination and diet, fluid, and exercise is explained

Patient should seek medical evaluation if changes in stool color or consistency persist

Promoting Regular Bowel Habits

Timing -attend to urges promptly

Positioning have pt. sit up, gravity aids in BM

Privacy close door & pull curtain

Nutrition

Exercise abdominal muscles & thighs

Abdominal settings

Thigh strengthening

Individuals at High Risk for Constipation

Patients on bed rest taking constipating medications

Patients with reduced fluids or bulk in their diet

Patients who are depressed

Patients with central nervous system disease or local lesions that cause pain

*Valsalva maneuver (straining & holding breath) intrathoracic / intracranial pressure

possible brain injury

Nursing Measures for the Patient With Diarrhea

Answer call lights immediately

Remove the cause of diarrhea whenever possible (e.g., medication)

If there is impaction, obtain physician order for rectal examination

Give special care to the region around the anus

After diarrhea stops, suggest the intake of fermented dairy products

Fecal seepage may indicate impaction

Preventing Food Poisoning

Never buy food with damaged packaging

Never use raw eggs in any form

Do not eat ground meat uncooked

Never cut meat on a wooden surface

Do not eat seafood that is raw or has unpleasant odor

Clean all vegetables and fruits before eating

Refrigerate leftovers within 2 hours of eating them

Give only pasteurized fruit juices to small children

Methods of Emptying the Colon of Feces

Enemas

Rectal suppositories

Rectal catheters

Digital removal of stool

Types of Enemas

Cleansing high volume

Retention - oil

Return-flow bag of solution taken in (100-300 ml fluid) for pt with gas

Retention Enemas

Oil-retentionlubricate the stool and intestinal mucosa easing defecation

Carminativehelp expel flatus from rectum

Medicatedprovide medications absorbed through rectal mucosa

Anthelminticdestroy intestinal parasites

Nutritiveadminister fluids and nutrition rectally

Bowel Training Programs

Manipulate factors within the patient's control

Food and fluid intake, exercise, time for defecation

Eliminate a soft, formed stool at regular intervals without laxatives

When achieved, discontinue use of suppository if one was used

Types of Colostomies each has different stool consistency

Sigmoid colostomy

Descending colostomy

Transverse colostomy

Ascending colostomy

Ileostomy

Location of (A) a Sigmoid Colostomy and (B) a Descending Colostomy

Location of (C) a Transverse Colostomy and (D) an Ascending Colostomy
Location of an Ileostomy

Colostomy Care

Keep patient as free of odors as possible; empty appliance frequently

Inspect the patient's stoma regularly

Note the size, which should stabilize within 6 to 8 weeks

Keep the skin around the stoma site clean and dry

Measure the patient's fluid intake & output

Explain each aspect of care to the patient and self-care role

Encourage patient to care for and look at ostomy

Normal-Appearing Stoma
Patient Teaching for Colostomies

Community resources are available for assistance

Initially encourage patients to avoid foods high in fiber

Avoid foods that cause diarrhea or flatus

Drink two quarts of water daily

Teach about medications

Teach about odor control (intake of dark green vegetables helps control odor)

Resume normal activity including work and sexual relations

Comfort Measures

Encourage recommended diet and exercise

Use medications only as needed

Apply ointments or astringent (witch hazel)

Use suppositories that contain anesthetics

Characteristics of Normal Stool

1. Color varies from light to dark brown foods & medications may affect color
2. Odor aromatic, affected by ingested food and persons bacterial flora
3. Consistency formed, soft, semi-solid; moist
4. Frequency varies with diet (about 100 to 400 g/day)
5. Constituents small amount of undigested roughage, sloughed dead bacteria and
epithelial cells, fat, protein, dried constituents of digestive juices (bile pigments);
inorganic matter (calcium, phosphates)

Common Bowel Elimination Problems

1. Constipation abnormal frequency of defecation and abnormal hardening of stools
2. Impaction accumulated mass of dry feces that cannot be expelled
3. Diarrhea increased frequency of bowel movements (more than 3 times a day) as
well as liquid consistency and increased amount; accompanied by urgency,
discomfort and possibly incontinence
4. Incontinence involuntary elimination of feces
5. Flatulence expulsion of gas from the rectum
6. Hemorrhoids dilated portions of veins in the anal canal causing itching and pain
and bright red bleeding upon defecation.

Charting
Purpose of Charting:
To make record of
1. The significant observation of the patients condition both mental and physical.
2. The medication, treatment, diets and nursing care given and the reaction of the
patient to this care.
3. The incident which might have some bearing on the patients condition.

General Rules for Charting:

1. All recording on the chart must be printed, except the written signature of the nurse.
2. The written signature of the nurse should consist of her initial of first name and fill
last name.
(a) The signature should stand alone on the line just below the notations recorded by
her.
(b) The signature of the nurse should be of a size that will insure legibility without
attracting attention.
3. A nurse making a series of statements or notations signs for the series and not for
each individual statement or notation.
4. The nurse should not go off duty without making the necessary notations on the
charts of each patient assigned to her to cover the time of the assignment.
5. All recording on the chart should be neat, legible, intelligent and meaningful.
6. Statements must be accurate, relevant and concise.
(a) Terse statements instead of complete sentence are used.
(b) Correct spelling and only acceptable and official abbreviations are to be used.
7. Authentic recording is essential as a chart often plays an important part in the
presentation of court evidence.
8. Print the proper headings for all new pages or sheets to be added to the chart using
blue or black ink.
9. Keep all recordings within limits provided by the pale. Begin each separate notation
on the horizontal lines where it intersects the vertical limiting lines.

10. Do not use ornamental lettering for recording on the chart.

11. Blue or black ink should be used for recording between the hours of 7:00am to
11:00pm.
12. Red ink should be used for recording between the hours of 11:00pm to 7:00am.
13. The midnight lines are to be drawn in red ink. Write the date and the day of the new
day between the midnight lines.
14. In the hour column, record the time of treatment, medication, appearance of
symptoms, doctors visit, etc.
15. In the observations column:
(a) Record any of all symptoms, complaints or change in the condition of the
patient.
(b) Record all start and p.r.n. treatments and medications given.
(c) Record the results and effects of the medications and treatments.
(d) Record routine nursing procedures involved in the care of the patient.
(e) Record each time the attending physician visits the patient.
16. Never print the word patient when charting. The chart in itself is a record for the
individual patient and all notations are in regard to the person for whom the record is
kept.
17. Do not write the orders of the doctor as Dr. Smith ordered backrest elevated two
inches.
18. Arrange the different sheets on the chart in correct order.
19. Errors in charting:
(a) Do not erase errors made in charting
(b) When an error has been made, draw a line through the error from the upper left
hand corner to the lower right hand corner to inchide the necessary space containing
the error and write the word ERROR under which the nurse signs her name.
(c) An error in charting should not necessarily invoke recopying of the entire page.
Consult the supervisor or headnurse before copying a page on which you have made
an error. It is necessary to recopy, the original page must be filed at the back of the
chart.

General Rules for Printing:

1. Printing is the most consistently legible of all forms of writing for that reason should
be used for recording on hospital charts.
2. Print well formed, individual letters in each ward.

3. Properly space all printed letters and words.

4. Do not use more than one space for each letter, regardless of the shape of that
letter.
5. Separate printed words by a space the size of single letter.
6. Do not use unnecessary curves tails or fancy strokes in making the printed letters.
7. Make all printed letters stand erect.
8. To avoid illegibility, do not make too much of a forward backward slant to the letters.
9. Make all printed letters conform in appearance to those in the sample alphabet.
10. Make each printed letter rest on the line.
11. Always make the small letter 2/3 the height of capital ones.
12. Make the letter U curved at the bottom, make the letter V with art acute angle at
the bottom.
13. Cross the letter t, horizontally at the upper third of its height.
14. Make the use of the word bed to remember on which side of the stem to make the
loop for the letters b and d.
15. For practice in printing use only those letters which are illustrated in the sample
alphabet.
16. Print numbers that are to be used in charting as well as letters.

Example of Data to be Charted:

1. All doctors orders.
(a) Medicines given, the time at which they are, and when, used to relieve a condition that
should respond to treatment within a short time.
(b) Inspections, or punctures done, time result, and by whom.
(c) Treatment given, time and effect on patients condition during or after the treatment, or
results of flow in cases or irrigations, etc.
(d) Operation delivery, kinds, time, TPR after.
2. When recording the dressing of wound, state condition of the letter, if there is discharge,
mention and change in the treatment or dressing by whom and time.
3. Symptoms
a. Subjective
b. Objectives:
(b1)All conditions that call for particularly careful attention to their record e.g. following
surgical operation or X-ray or other treatment that may-have harmful effects, accidents,

chills, convulsions and when patient is very ill.

(b2)Menstruation.
(b3)Nature of excreta or order discharges, etc.
4. Amount of sleep.
5. Appetite and amount of food taken.

Communication
Definition

It is the process of exchanging information or feelings between two or more people.

It is a basic component of human relationship, including nursing.

The Communication process

Referent

Or stimulus motivates a person to communicate with another. It may be an object,

emotion, idea or act.

Sender

Also called the encoder, is the person who initiates the interpersonal communication
or message

Message

The information that is sent or expressed by the sender.

Channels

It means, conveying messages such as through visual, auditory and tactile senses.

Receiver

Also called the decoder, is the person to whom the message is sent

Feedback

Helps to reveal whether the meaning of the message is received

Modes of Communication
Verbal communication- uses the spoken or written word
1. Pace and Intonation

The manner of speech, as in the pace or rhythm and intonation, will modify the
feeling and impact of the message. For example, speaking slowly and softly to an
excited client may help calm the client.

2. Simplicity

Includes the use of commonly understood words, brevity, and completeness.

Nurses need to learn to select appropriate, understandable terms based on the age,
knowledge, culture and education of the client. For example, instead of saying to a
client, the nurses will be catheterizing you tomorrow for a urinalysis, I would be
more appropriate to say, Tomorrow we need to get a sample of your urine, so we
will collect it by putting a small tube into your bladder.

3. Clarity and Brevity

A message that is direct and simple will be more effective. Clarity is saying precisely
what is meant, and brevity is using the fewest words necessary.

The goal is to communicate clearly so that all aspects of a situation or circumstances

are understood. To ensure clarity in communication, nurses also need to speak slowly
and enunciate carefully.

4. Timing and Relevance

No matter how clearly or simply words are stated or written, the timing needs to be
appropriate to ensure that words are heard.

This involves sensitivity to the clients needs and concerns. E.g., a client who is
enmeshed in fear of cancer may not hear the nurses explanations about the
expected procedures before and after gallbladder surgery.

5. Adaptability

What the nurse says and how it is said must be individualized and carefully
considered. E.g., a nurse who usually smiles, appears cheerful, and greets his clients
with an enthusiastic Hi, Mrs. Jones! notices that the client is not smiling and
appears distressed. It is important for the nurse to then modify his tone of speech
and express concern in his facial expression while moving toward the client.

6. Credibility

Means worthiness of belief, trustworthiness, and reliability. Nurses foster credibility

by being consistent, dependable, and honest.

Nurses should convey confidence and certainly in what they are saying, while being
to acknowledge their limitations (e.g., I dont know the answer to that, but I will
find someone who does.

7. Humor

The use of humor can be a positive and powerful tool in nurse- client relationship,
but it must be used with care. When using humor, it is important to consider the
clients perception of what is considered humorous.

Non-verbal Communication- uses other forms, such as gestures or facial expressions,

and touch.
1. Personal Appearance

When the symbolic meaning of an object is unfamiliar the nurse can inquire about its
significance, which may foster rapport with the client.

How a person dresses is often an indicator of how person feels. E.g. For acutely ill
clients n hospital or home care settings, a change in grooming habits may signal that
the client is feeling better. A man may request a shave, or a woman may request a
shampoo and some makeup.

2. Posture and Gait

The ways people walk and carry themselves are often reliable indicators of selfconcept, current mood, and health. Erect posture and an active, purposeful stride

suggest a feeling of well being. Slouched posture and slow, shuffling gait suggest
depression or physical discomfort.

The nurse clarifies the meaning of the observed behavior, e.g. You look like it really
hurts you to move. Im wondering how your pain is and if you might need something
to make you more comfortable?

3. Facial Expression

No part of the body is as expressive as the face

Although he face may express the persons genuine emotions, it is also possible to
control these muscles so the emotion expresses does not reflect what the person is
feeling. When the message is not clear, it is important to get feedback to be sure of
the intent of expression.

Nurses need to be aware of their own expressions and what they are communicating
to others. It is impossible to control all facial expression, but the nurse must learn to
control expressions of feelings such as fear or disgust in some circumstances.

Eye contact is another essential element of facial communication

4. Gesture

Hand and body gestures may emphasize and clarify the spoken word, or they may
occur without words to indicate a particular feeling or give a sign

Electronic Communication- many health care agencies are moving toward electronic
medical records where nurses document their assessments and nursing care.
E-mail

Most common form of electronic communication.

Advantage: It is fast, efficient way to communicate and it is legible. It provides a

record of the date and time of the message that was sent or received.

Disadvantage: risk of confidentiality

When Not to Use Email:

a. When information is urgent

b. Highly confidential information (e.g. HIV status, mental health, chemical dependency)
c. Abnormal lab data

Agencies usually develop standards and guidelines in use of e-mail

Factors Influencing the Communication Process

1. Development

Language, psychosocial, and intellectual development move through stages across

the lifespan.

2. Gender

Girls tend to use language to seek confirmation, minimize differences, and establish
intimacy. Boys use language to establish independence and negotiate status within a
group.

3. Values and Perception

Values are the standards that influence behavior, and perceptions are the personal
view of event.

4. Personal Space

Personal space is the distance people prefer in interactions with others.

Proxemics is the study of distance between people in their interactions

Communication 4 distances:

a. Intimate: Touching to 1
b. Personal: 1 to 4 feet
c. Social: 4 to 12 feet
d. Public: 12 to 15 feet
5. Territoriality

Is a concept of the space and things that an individual considers as belonging to the
self

6. Roles and Relationships

Choice of words, sentence structure, and tone of voice vary considerably from role to
role. (E.g. nursing student to instructor, client and primary care provider, or parent
and child).

7. Environment

People usually communicate most effectively in a comfortable environment.

8. Congruence

The verbal and nonverbal aspects of message match. E.g., when teaching a client
how to care for a colostomy, the nurse might say, You wont have any problem with
this. However, if the nurse looks worried or disgusted while saying this, the client is
less likely to trust the nurses words.

9. Interpersonal Attitudes

Attitudes convey beliefs, thoughts, and feelings about people and events.

Caring and warmth convey a feeling of emotional closeness

Respect is an attitude that emphasizes the other persons worth and individuality. A
nurse coveys respect by listening open mindedly even if the nurse
disagrees.Acceptance emphasizes neither approval nor disapproval .The nurse
willingly receives the clients honest feelings.

Communication in Nursing
Communication
1. Is the means to establish a helping-healing relationship. All behavior communication
influences behavior.
2. Communication is essential to the nurse-patient relationship for the following
reasons:
3. Is the vehicle for establishing a therapeutic relationship.
4. It the means by which an individual influences the behavior of another, which leads
to the successful outcome of nursing intervention.

Basic Elements of the Communication Process

1. Sender is the person who encodes and delivers the message
2. Messages is the content of the communication. It may contain verbal, nonverbal,
and symbolic language.
3. Receiver is the person who receives the decodes the message.
4. Feedback is the message returned by the receiver. It indicates whether the
meaning of the senders message was understood.

Modes of Communication
1. Verbal Communication use of spoken or written words.
2. Nonverbal Communication use of gestures, facial expressions, posture/gait,
body movements, physical appearance and body language

Characteristics of Good Communication

1. Simplicity includes uses of commonly understood, brevity, and completeness.

2. Clarity involves saying what is meant. The nurse should also need to speak slowly
and enunciate words well.
3. Timing and Relevance requires choice of appropriate time and consideration of
the clients interest and concerns. Ask one question at a time and wait for an answer
before making another comment.
4. Adaptability Involves adjustments on what the nurse says and how it is said
depending on the moods and behavior of the client.
5. Credibility Means worthiness of belief. To become credible, the nurse requires
adequate knowledge about the topic being discussed. The nurse should be able to
provide accurate information, to convey confidence and certainly in what she says.

Communicating With Clients Who Have Special Needs

1. Clients who cannot speak clearly (aphasia, dysarthria, muteness)
a. Listen attentively, be patient, and do not interrupt.
b. Ask simple question that require yes and no answers.
c. Allow time for understanding and response.
d. Use visual cues (e.g., words, pictures, and objects)
e. Allow only one person to speak at a time.
f. Do not shout or speak too loudly.
g. Use communication aid:Pad and felt-tipped pen, magic slate, pictures denoting basic
needs, call bells or alarm.
2. Clients who are cognitively impaired
a. Reduce environmental distractions while conversing.
b. Get clients attention prior to speaking
c. Use simple sentences and avoid long explanation.
d. Ask one question at a time
e. Allow time for client to respond
f. Be an attentive listener
g. Include family and friends in conversations, especially in subjects known to client.
3. Client who are unresponsive
a. Call client by name during interactions
b. Communicate both verbally and by touch
c. Speak to client as though he or she could hear
d. Explain all procedures and sensations
e. Provide orientation to person, place, and time
f. Avoid talking about client to others in his or her presence
g. Avoid saying things client should not hear
4. Communicating with hearing impaired client

a. Establish a method of communication (pen/pencil and paper, sign-language)

b. Pay attention to clients non-verbal cues
c. Decrease background noise such as television
d. Always face the client when speaking
e. It is also important to check the family as to how to communicate with the client
f. It may be necessary to contact the appropriate department resource person for this type
of disability
5. Client who do not speak English
a. Speak to client in normal tone of voice (shouting may be interpreted as anger)
b. Establish method for client o signal desire to communicate (call light or bell)
c. Provide an interpreter (translator) as needed
d. Avoid using family members, especially children, as interpreters.
e. Develop communication board, pictures or cards.
f. Have dictionary (English/Spanish) available if client can read.

Reports

Are oral, written, or audiotape exchanges of information between caregivers.

Common reports
1.
2.
3.
4.
5.

Change-in-shift report
Telephone report
Telephone or verbal orders only RNs are allowed to accept telephone orders.
Transfer report
Incident report

Documentation
1. Is anything written or printed that is relied on as record or proof for authorized
person.
2. Nursing documentation must be:
o

accurate

comprehensive

flexible enough to retrieve critical data, maintain continuity of care, track

client outcomes, and reflects current standards of nursing practice

3. Effective documentation ensures continuity of care saves time and minimizes the risk
of error.

4. As members of the health care team, nurses need to communicate information about
clients accurately and in timely manner
5. If the care plan is not communicated to all members of the health care team, care
can become fragmented, repetition of tasks occurs, and therapies may be delayed or
omitted.
6. Data recorded, reported, or communicated to other health care professionals are
CONFIDENTIAL and must be protected.

Confidentiality
1. Nurses are legally and ethically obligated to keep information about clients
confidential.
2. Nurses may not discuss a clients examination, observation, conversation, or
treatment with other clients or staff not involved in the clients care.
3. Only staff directly involved in a specific clients care has legitimate access to
the record.
4. Clients frequently request copies of their medical record, and they have the right to
read those records.
5. Nurses are responsible for protecting records from all unauthorized readers.
6. When nurses and other health care professionals have a legitimate reason to use
records for data gathering, research, or continuing education, appropriate
authorization must be obtained according to agency policy.
7. Maintaining confidentiality is an important aspect of profession behavior.
8. It is essential that the nurse safe-guard the client right to privacy by carefully
protecting information of a sensitive, private nature.
9. Sharing personal information or gossiping about others violates nursing ethical codes
and practice standards.
10. It sends the message that the nurse cannot be trusted and damages the
interpersonal relationships.

Guidelines of Quality Documentation and Reporting

1. Factual

a. A record must contain descriptive, objective information about what a nurse sees, hears,
feels, and smells.
b. The use of vague terms, such as appears, seems, and apparently, is not acceptable
because these words suggest that the nurse is stating an opinion.
Example:
The client seems anxious (the phrase seems anxious is a conclusion without supported
facts.)
2. Accurate
a. The use of exact measurements establishes accuracy. (example: Intake of 350 ml of
water is more accurate than the client drank an adequate amount of fluid
b. Documentation of concise data is clear and easy to understand.
c. It is essential to avoid the use of unnecessary words and irrelevant details
3. Complete
a. The information within a recorded entry or a report needs to be complete,
containing appropriate and
essential information.
Example:
The client verbalizes sharp, throbbing pain localized along lateral side of right ankle,
beginning approximately 15 minutes ago after twisting his foot on the stair. Client rates
pain as 8 on a scale of 0-10.
4. Current
a. Timely entries are essential in the clients ongoing care. To increase accuracy and
decrease unnecessary duplication, many healthcare agencies use records kept near the
clients bedside, which facilitate immediate documentation of information as it is collected
from a client
5. Organized
a. The nurse communicates information in a logical order.
Example:
An organized note describes the clients pain, nurses assessment, nurses interventions,
and the clients response

Legal Guidelines for Recording

1. Draw single line through error, write word error above it and sign your name or
initials. Then record note correctly.
2. Do not write retaliatory or critical comments about the client or care by other health
care professionals.

Enter only objective descriptions of clients behavior; clients comments

should be quoted.

3. Correct all errors promptly

o

Errors in recording can lead to errors in treatment

Avoid rushing to complete charting, be sure information is accurate.

4. Do not leave blank spaces in nurses notes.

o

Chart consecutively, line by line; if space is left, draw line horizontally through
it and sign your name at end.

5. Record all entries legibly and in blank ink

o

Never use pencil, felt pen.

Blank ink is more legible when records are photocopied or transferred to

microfilm.

Legal Guidelines for Recording

6. If order is questioned, record that clarification was sought.

o

If you perform orders known to be incorrect, you are just as liable for
prosecution as the physician is.

7. Chart only for yourself

o

Never chart for someone else.

You are accountable for information you enter into chart.

8. Avoid using generalized, empty phrases such as status unchanged or had good
day.
o

Begin each entry with time, and end with your signature and title.

Do not wait until end of shift to record important changes that occurred
several hours earlier. Be sure to sign each entry.

9. For computer documentation keep your password to yourself.

o

Maintain security and confidentiality.

Once logged into the computer do not leave the computer screen unattended

Ethico-Moral Aspects in Nursing

Ethos - comes from Greek work w/c means character/culture
- Branch of Philosophy w/c determines right and wrong
Moral - personal/private interpretation from what is good and bad.

Ethical Principles:
1. Autonomy the right/freedom to decide (the patient has the right to refuse despite
the explanation of the nurse) Example: surgery, or any procedure
2. Nonmaleficence the duty not to harm/cause harm or inflict harm to others (harm
maybe physical, financial or social)
3. Beneficence- for the goodness and welfare of the clients
4. Justice equality/fairness in terms of resources/personnel
5. Veracity - the act of truthfulness
6. Fidelity faithfulness/loyalty to clients

Moral Principles:
1. Golden Rule
2. The principle of Totality The whole is greater than its parts
3. Epikia There is always an exemption to the rule
4. One who acts through as agent is herself responsible (instrument to the crime)
5. No one is obliged to betray herself You cannot betray yourself
6. The end does not justify the means
7. Defects of nature maybe corrected
8. If one is willing to cooperate in the act, no justice is done to him
9. A little more or a little less does not change the substance of an act.
10. No one is held to impossible

Law - Rule of conduct commanding what is right and what is wrong. Derived from an AngloSaxon term that meansthat which is laid down or fixed
Court - Body/agency in government wherein the administration of justice is delegated.
Plaintiff - Complainant or person who files the case (accuser)
Defendant - Accused/respondent or person who is the subject of complaint
Witness- Individual held upon to testify in reference to a case either for the accused or
against the accused.

Written orders of court

Writ legal notes from the court
1. Subpoena
a. Subpoena Testificandum a writ/notice to an individual/ordering him to appear in
court at a specific time and date as witness.
b. Subpoena Duces Tecum- notice given to a witness to appear in court to testify
including all important documents
Summon notice to a defendant/accused ordering him to appear in court to answer the
complaint against him
Warrant of Arrest - court order to arrest or detain a person
Search warrant - court order to search for properties.
Private/Civil Law - body of law that deals with relationships among private individuals
Public law - body of law that deals with relationship between individuals and the
State/government and government
agencies. Laws for the welfare of the
general public.
Private/Civil Law :
1. Contract law involves the enforcement of agreements among private individuals or
the payment of compensation for failure to fulfill the agreements
o

Ex. Nurse and client nurse and insurance

Nurse and employer client and health agency

An agreement between 2 or more competent person to do or not to do

some lawful act.

It maybe written or oral= both equally binding

Types of Contract:
1. Expressed when 2 parties discuss and agree orally or in writing the terms and conditions
during the creation of the
contract.

Example: nurse will work at a hospital for only a stated length of time (6
months),under stated conditions (as volunteer, straight AM shift, with
food/transportation allowance)

2. Implied one that has not been explicitly agreed to by the parties, but that the law
considers to exist.

Example: Nurse newly employed in a hospital is expected to be competent and to

follow hospital policies and procedures even though these expectations were not
written or discussed.

Likewise: the hospital is expected to provide the necessary supplies, equipment

needed to provide competent, quality nursing care.

Feature/Characteristics/Elements of a lawful contract:

1. Promise or agreement between 2 or more persons for the performance of an action or
restraint from certain actions.
2. Mutual understanding of the terms and meaning of the contract by all.
3. A lawful purpose activity must be legal
4. Compensation in the form of something of value-monetary
Persons who may not enter into a contract: minor, insane, deaf, mute and ignorant

Tort law

Is a civil wrong committed against a person or a persons property.

Person/persons responsible for the tort are sued for damages

Is based on:
o

ACT OF COMMISSION something that was done incorrectly

ACT OF OMMISION something that should have been done but was not.

Classification of Tort
Unintentional Tort
1. Negligence

Misconduct or practice that is below the standard expected of ordinary, reasonable

and prudent person

Failure to do something due to lack of foresight or prudence

Failure of an individual to provide care that a reasonable person would ordinarily use
in a similar circumstance.

An act of omission or commission wherein a nurse fails to act in accordance with the
standard of care.

Doctrines of Negligence:
a. Res ipsa loquitor the thing speaks for itself the injury is enough proof of negligence
b. Respondeat Superior let the master answer command responsibility
c. Force majuere unforeseen event, irresistible force
2. Malpractice

stepping beyond ones authority

6 elements of nursing malpractice:

a. Duty the nurse must have a relationship with the client that involves providing care
and following an acceptable
standard of care.
b. Breach of duty

the standard of care expected in a situation was not observed by the nurse

is the failure to act as a reasonable, prudent nurse under the circumstances

something was done that should not have been done or nothing was done when it
should have been done

c. Foreseeability a link must exist between the nurses act and the injury suffered
d. Causation it must be proved that the harm occurred as a direct result of the nurses
failure to follow the
standard of care and the nurse should or could have known
that the failure to follow the standard of care could
result in such harm.
e. harm/injury physical, financial, emotional as a result of the breach of duty to the
client Example: physical injury,
medical cost/expenses, loss of wages, pain and
suffering
f. damages amount of money in payment of damage/harm/injury
Intentional Tort

Unintentional tort do not require intent bur do require the element of HARM

Intentional tort the act was done on PURPOSE or with INTENT

o

No harm/injury/damage is needed to be liable

No expert witnesses are needed

Assault

An attempt or threat to touch another person unjustifiably

Example:
o

A person who threatens someone with a club or closed fist.

Nurse threatens a client with an injection after refusing to take the meds
orally.

Battery

Willful touching of a person, persons clothes or something the person is carrying that
may or may not cause harm but the touching was done without permission, without
consent, is embarrassing or causes injury.

Example:
o

A nurse threatens the patient with injection if the patient refuses his meds
orally. If the nurse gave the injection without clients consent, the nurse would
be committing battery even if the client benefits from the nurses action.

False Imprisonment

Unjustifiable detention of a person without legal warrant to confine the person

Occurs when clients are made to wrongful believe that they cannot leave the place

Example:
o

Telling a client no to leave the hospital until bill is paid

Use of physical or chemical restraints

False Imprisonment Forceful Restraint=Battery

Invasion of Privacy

intrusion into the clients private domain

right to be left alone

Types of Invasion the client must be protected from:

1.

use of clients name for profit without consent using ones name, photograph for
advertisements of HC agency or provider without clients permission

2.

Unreasonable intrusion observation or taking of photograph of the client for

whatever purpose without clients consent.

3.

Public disclosure of private facts private information is given to others who have no
legitimate need for that.

4.

Putting a person in a false/bad light publishing information that is normally

considered offensive but which is not true.

Defamation

communication that is false or made with a careless disregard for the truth and
results in injury to the reputation of a person

Types:
1. Libel defamation by means of print, writing or picture
o

Example:
1. o writing in the chart/nurses notes that doctor A is incompetent
because he didnt respond immediately to a call

2. Slander defamation by the spoken word stating unprivileged (not legally protected)
or false word by which a reputation is damaged
o

Example:
1. Nurse A telling a client that nurse B is incompetent
2. Person defamed may bring the lawsuit
3. The material (nurses notes) must be communicated to a 3rd party in
order that the persons reputation maybe harmed

Public Law:
Criminal Law deals with actions or offenses against the safety and welfare of the public.
1. homicide self-defense
2. arson- burning or property
3. theft stealing

4. sexual harassment
5. active euthanasia
6. illegal possession of controlled drugs
Homicide killing of any person without criminal intent may be done as self-defense
Arson willful burning of property
Theft act of stealing

Health

As defined by the World Health Organization (WHO): state of complete physical,

mental and social well-being, not merely the absence of disease or infirmity.

Characteristics
1. A concern for the individual as a total system
2. A view of health that identifies internal and external environment
3. An acknowledgment of the importance of an individuals role in life
*A dynamic state in which the individual adapts to changes in internal and external
environment to maintain a state of well being

Models of Health and Illness

1. Health-Illness Continuum (Neuman) Degree of client wellness that exists at any
point in time, ranging from an optimal wellness condition, with available energy at its
maximum, to death which represents total energy depletion.
2. High Level Wellness Model (Halbert Dunn) It is oriented toward maximizing the
health potential of an individual.This model requires the individual to maintain a continuum
of balance and purposeful direction within the environment.
3. Agent Host environment Model (Leavell) The level of health of an individual or
group depends on the dynamic relationship of the agent, host and environment

Agent any internal or external factor that disease or illness.

Host the person or persons who may be susceptible to a particular illness or

disease

Environment consists of all factors outside of the host

4. Health Belief Model Addresses the relationship between a persons belief and
behaviors. It provides a way of understanding and predicting how clients will behave in
relation to their health and how they will comply with health care therapies.
Four Components

The individual is perception of susceptibility to an illness

The individuals perception of the seriousness of the illness

The perceived threat of a disease

The perceived benefits of taking the necessary preventive measures

5. Evolutionary Based Model Illness and death serves as a evolutionary function.

Evolutionary viability reflects the extent to which individuals function to promote survival
and well-being. The model interrelates the following elements:

Life events

Life style determinants

Evolutionary viability within the social context

Control perceptions

Viability emotions

Health outcomes

6. Health Promotion Model A complimentary counterpart models of health protection.

Directed at increasing a clients level of well being. Explain the reason for clients
participation health-promotion behaviors. The model focuses on three functions:

It identifies factors (demographic and socially) enhance or decrease the participation

in health promotion

It organizes cues into pattern to explain likelihood of a clients participation healthpromotion behaviors

It explains the reasons that individuals engage in health activities

Illness

State in which a persons physical, emotional, intellectual, social developmental or

spiritual functioning is diminished or impaired. It is a condition characterized by a
deviation from a normal, healthy state.

3 Stages of Illness

1. Stage of Denial Refusal to acknowledge illness; anxiety, fear, irritability and

aggressiveness.

2. Stage of Acceptance Turns to professional help for assistance

3. Stage of Recovery (Rehabilitation or Convalescence) The patient goes through of
resolving loss or impairment of function

Rehabilitation
1. A dynamic, health oriented process that assists individual who is ill or disabled to
achieve his greatest possible level of physical, mental, spiritual, social and
economical functioning.
2. Abilities not disabilities are emphasized.
3. Begins during initial contact with the patient
4. Emphasis is on restoring the patient to independence or regain his preillness/predisability level of function as short a time as possible
5. Patient must be an active participant in the rehabilitation goal setting an din
rehabilitation process.
Focuses of Rehabilitation

1. Coping pattern
2. Functional ability focuses on self-care: activities of daily living (ADL); feeding,
bathing/hygiene, dressing/grooming, toileting and mobility
3. Mobility
4. Integrity of skin
5. Control of bowel and bladder function

Definition
Health

Presence or absence of disease

Complete physical, mental, social well-being

Ability to maintain normal roles

Process of adaptation to physical and social environment

Striving toward optimal wellness

Individual definitions

Wellness

State of well-being

Basic aspects include:

Self-responsibility

An ultimate goal

A dynamic, growing process

Daily decision-making in areas related to health

Whole being of the individual

Well-being

Subjective perception of vitality and feeling well

Described objectively, experienced, measured

Can be plotted on a continuum

Dimensions of Wellness
Physical Dimension

Ability to carry out daily tasks

Achieve fitness

Maintain nutrition

Avoid abuses

Social Dimension

Interact successfully

Develop and maintain intimacy

Develop respect and tolerance for others

Emotional Dimension

Ability to manage stress

Ability to express emotion

Intellectual Dimension

Ability to learn

Ability to use information effectively

Spiritual Dimension

Belief in some force that serves to unite

Occupational Dimension

Ability to achieve balance between work and leisure

Environmental Dimension

Ability to promote health measure that improves

o

Standard of living

Quality of life

Models of Health

Medical Model

Agent-Host-Environment Model

Health-Illness Continuum

Medical Model

Provides the narrowest interpretation of health

People viewed as physiologic systems

Health identified by the absence of signs and symptoms of disease or injury

State of not being sick

Opposite of health is disease or injury

Agent-Host-Environment Model

Each factor constantly interacts with the others

When in balance, health is maintained

When not in balance, disease occurs

Travis Health-Illness Continuum

Measure persons perceived level of wellness

Health and illness/disease opposite ends of a health continuum

Move back and forth within this continuum day by day

Wide ranges of health or illness

Ardells Wellness Model

5 Dimensions of Wellness
Nutritional Awareness

Making healthy food choices on a regular basis.

Physical Fitness

Regular exercise program.

Stress Management
Determining the stress factors in one's life is one thing, but doing something about it is
another thing you could do to manage their stress levels

Meditation

positive visualization

taking time out

listening to music

journal writing

regular physical activity are all

Environmental Sensitivity

Living lightly on the earth, helping in anyway you can to keep the planet healthy is
important as personal wellness depends on planetary wellness.

Self- Responsibility

Ardell says, all dimensions of wellness are important, but self-responsibility seems
more equal than all the rest. Personal accountability for our own lifestyle is of utmost
importance

Bellins Model for Competency Improvement

Bellins Health System, focus is health care delivery system

is based upon the belief that outcomes are the results of processes that can be
improved through:

Identification of success metrics,

Setting of goals and the Plan Do Study Act (PDSA) change process.

Statistical process control charts are used to track identified processes for stability
and response to improvement efforts. Measurement is focused on:
o

Growth

Effectiveness

Efficiency

Engagement

Innovation

Iceberg Model

The Iceberg Model shows us that our state of physical health or illness is only the
visible "tip" of the iceberg.

In order to completely understand our physical condition, we need to look beneath

the surface to our
o

Choices of lifestyle (our eating habits, exercise level, addictions to alcohol,

food, adrenaline, shopping, drugs, etc),

Psychological beliefs (the thoughts, feelings, attitudes and beliefs we hold)

Spirituality (our inner life, our belief in a higher power and our degree of
acceptance and love of self and others).

Factors Affecting Health Status, Beliefs, and Practices

Internal Variables

Biologic dimension (genetic makeup, gender, age, and developmental level)

Psychologic dimension (mind-body interactions and self-concept)

Cognitive dimension (intellectual factors include lifestyle choices and spiritual and
religious beliefs)

External Variables

Physical environment

Standards of living

Family and cultural beliefs

Social support networks

Factors Affecting Health Care Adherence

Client motivation

Degree of lifestyle change necessary

Perceived severity of problem

Value placed on reducing the threat of illness

Difficulty in understanding and performing specific behaviors

Degree of inconvenience of the illness itself or of the regimens

Complexity, side effects, and duration of the proposed therapy

Specific cultural heritage that may make adherence difficult

Degree of satisfaction and quality and type of relationship with the health care
providers

Overall cost of prescribed therapy

Illness

A highly personal state

Persons physical, emotional, intellectual, social, developmental, or spiritual

functioning is diminished

Not synonymous with disease

May or may not be related to disease

Only person can say he or she is ill

Disease

Alteration in body function

A reduction of capacities or a shortening of the normal life span

Acute Illness

Characterized by severe symptoms of relatively short duration

Symptoms often appear abruptly, subside quickly

May or may not require intervention by health care professionals

Most people return to normal level of wellness

Chronic Illness

Lasts for an extended period

Usually has a slow onset

Often have periods of remissions and exacerbations

Care includes promoting independence, sense of control, and wellness

Learn how to live with physical limitations and discomfort

Parsons Four Aspects of the Sick Role

Clients are not held responsible for their condition

Clients are not excused from certain social roles and tasks

Clients are obligated to try to get well as quickly as possible

Clients or their families are obligated to seek competent help

Schumans Stages of Illness

Stage 1: Symptom experience

Believe something is wrong

Stage 2: Assumption of the sick role

Accepts the sick role and seeks confirmation

Stage 3: Medical care contact

Seeks advice of a health professional

Stage 4: Dependent client role

Becomes dependent on the professional for help

Stage 5: Recovery or rehabilitation

Relinquish the dependent role Resume former roles and responsibilities

Impact of Illness on the Client

Behavioral and emotional changes

Loss of autonomy

Self-concept and body image changes

Lifestyle changes On the Family

Depends on:
o

Member of the family who is ill

Seriousness and length of the illness

Cultural and social customs the family follows

Impact of Illness: Family Changes

Role changes

Task reassignments

Increased demands on time

Anxiety about outcomes

Conflict about unaccustomed responsibilities

Financial problems

Loneliness as a result of separation and pending loss

Change in social customs

Illness

Is a personal state in which the person feels unhealthy.

Illness is a state in which a persons physical, emotional, intellectual, social,

developmental, or spiritual functioning is diminished or impaired compared with
previous experience.

Illness is not synonymous with disease.

Disease

An alteration in body function resulting in reduction of capacities or a shortening of

the normal life span.

Common Causes of Disease

1. Biologic agent e.g. microorganism
2. Inherited genetic defects e.g. cleft palate
3. Developmental defects e.g. imperforate anus
4. Physical agents e.g. radiation, hot and cold substances, ultraviolet rays
5. Chemical agents e.g. lead, asbestos, carbon monoxide
6. Tissue response to irritations/injury e.g. inflammation, fever
7. Faulty chemical/metabolic process e.g. inadequate insulin in diabetes
8. Emotional/physical reaction to stress e.g. fear, anxiety

Stages of Illness
1. Symptoms Experience- experience some symptoms, person believes something is
wrong 3 aspects physical, cognitive, emotional
2. Assumption of Sick Role acceptance of illness, seeks advice

3. Medical Care Contact- Seeks advice to professionals for validation of real illness,
explanation of symptoms, reassurance or predict of outcome
4. Dependent Patient Role
o

The person becomes a client dependent on the health professional for help.

Accepts/rejects health professionals suggestions.

Becomes more passive and accepting.

5. Recovery/Rehabilitation - Gives up the sick role and returns to former roles and
functions.

Risk Factors of a Disease

1. Genetic and Physiological Factors
o

For example, a person with a family history of diabetes mellitus, is at risk in

developing the disease later in life.

2. Age
o

Age increases and decreases susceptibility ( risk of heart diseases increases

with age for both sexes

3. Environment
o

The physical environment in which a person works or lives can increase the
likelihood that certain illnesses will occur.

4. Lifestyle
o

Lifestyle practices and behaviors can also have positive or negative effects on
health.

Classification of Diseases
1. According to Etiologic Factors
a. Hereditary due to defect in the genes of one or other parent which is transmitted to
the
i. offspring
b. Congenital due to a defect in the development, hereditary factors, or prenatal
infection
c. Metabolic due to disturbances or abnormality in the intricate processes of

metabolism.
d. Deficiency results from inadequate intake or absorption of essential dietary factor.
e. Traumatic- due to injury
f. Allergic due to abnormal response of the body to chemical and protein substances or
to physical stimuli.
g. Neoplastic due to abnormal or uncontrolled growth of cell.
h. Idiopathic Cause is unknown; self-originated; of spontaneous origin
i. Degenerative Results from the degenerative changes that occur in the tissue and
organs.
j. Latrogenic result from the treatment of the disease
2. According to Duration or Onset

Acute Illness An acute illness usually has a short duration and is severe. Signs
and symptoms appear abruptly, intense and often subside after a relatively short
period.

Chronic Illness chronic illness usually longer than 6 months, and can also affects
functioning in any dimension. The client may fluctuate between maximal functioning
and serious relapses and may be life threatening. Is characterized by remission and
exacerbation.

Remission- periods during which the disease is controlled and symptoms are
not obvious.

Exacerbations The disease becomes more active given again at a future

time, with recurrence of pronounced symptoms.

Sub-Acute Symptoms are pronounced but more prolonged than the acute disease.

3. Disease may also be Described as:

a. Organic results from changes in the normal structure, from recognizable anatomical
changes in an organ or tissue of the body.
b. Functional no anatomical changes are observed to account from the symptoms
present, may result from abnormal response to stimuli.
c. Occupational Results from factors associated with the occupation engage in by the
patient.
d. Venereal usually acquired through sexual relation
e. Familial occurs in several individuals of the same family
f. Epidemic attacks a large number of individuals in the community at the same time.
(E.g. SARS)
g. Endemic Presents more or less continuously or recurs in a community. (E.g.
malaria, goiter)
h. Pandemic An epidemic which is extremely widespread involving an entire country or
continent.
i. Sporadic a disease in which only occasional cases occur. (E.g. dengue, leptospirosis)

Leavell and Clarks Three Levels of

Prevention
Primary Prevention

Seeks to prevent a disease or condition at a prepathologic state; to stop something

from ever happening.

Health Promotion

health education

marriage counseling

genetic screening

good standard of nutrition adjusted to developmental phase of life

Specific Protection

use of specific immunization

attention to personal hygiene

use of environmental sanitation

protection against occupational hazards

protection from accidents

use of specific nutrients

protections from carcinogens

avoidance to allergens

Secondary Prevention

Also known as Health Maintenance. Seeks to identify specific illnesses or conditions

at an early stage with prompt intervention to prevent or limit disability; to prevent
catastrophic effects that could occur if proper attention and treatment are not
provided

Early Diagnosis and Prompt Treatment

case finding measures

individual and mass screening survey

prevent spread of communicable disease

prevent complication and sequelae

shorten period of disability

Disability Limitations

Adequate treatment to arrest disease process and prevent further complication and
sequelae.

Provision of facilities to limit disability and prevent death.

Tertiary Prevention

Occurs after a disease or disability has occurred and the recovery process has
begun; Intent is to halt the disease or injury process and assist the person in
obtaining an optimal health status. To establish a high-level wellness. To maximize
use of remaining capacities

Restoration and Rehabilitation

Work therapy in hospital

Use of shelter colony

Maslows Hierarchy of Basic Human Needs

Definition

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 psychological conditions that an individual must meet to achieve a
state of health or well-being.

Physiologic
1. Oxygen
2. Fluids
3. Nutrition
4. Body temperature
5. Elimination

6. Rest and sleep

7. Sex

Safety and Security

1. Physical safety
2. Psychological safety
3. The need for shelter and freedom from harm and danger

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

Self-Esteem Needs
1. Self-worth
2. Self-identity
3. Self-respect
4. Body image

Self-Actualization Needs
1. The need to learn, create and understand or comprehend
2. The need for harmonious relationships
3. The need for beauty or aesthetics

4. The need for spiritual fulfillment

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

Maslows Characteristics of a Self-Actualized Person

1. Is realistic, sees life clearly and is objective about his or her observations
2. Judges people correctly
3. Has superior perception, is more decisive
4. Has a clear notion of right or wrong
5. Is usually accurate in predicting future events
6. Understands art, music, politics and philosophy
7. Possesses humility, listens to others carefully
8. Is dedicated to some work, task, duty or vocation
9. Is highly creative, flexible, spontaneous, courageous, and willing to make mistakes
10. Is open to new ideas
11. Is self-confident and has self-respect
12. Has low degree of self-conflict; personality is integrated
13. Respect self, does not need fame, and possesses a feeling of self-control
14. Is highly independent, desires privacy

15. Can appear remote or detached

16. Is friendly, loving and governed more by inner directives than by society
17. Can make decisions contrary to popular opinion
18. Is problem centered rather than self-centered
19. Accepts the world for what it is

Moral Theories
Freud (1961)

Believed that the mechanism for right and wrong within the individual is the
superego, or conscience. He hypnotized that a child internalizes and adopts the
moral standards and character or character traits of the model parent through the
process of identification.

The strength of the superego depends on the intensity of the childs feeling of
aggression or attachment toward the model parent rather than on the actual
standards of the parent.

Erikson (1964)

Eriksons theory on the development of virtues or unifying strengths of the good

man suggests that moral development continuous throughout life. He believed that
if the conflicts of each psychosocial developmental stages favorably resolved, then an
egostrength or virtue emerges.

Kohlberg

Suggested three levels of moral development. He focused on the reason for the
making of a decision, not on the morality of the decision itself.

1. At first level called the premolar or the preconventional level, children are responsive
to cultural rules and labels of good and bad, right and wrong. However children
interpret these in terms of the physical consequences of the actions, i.e., punishment
or reward.
2. At the second level, the conventional level, the individual is concerned about
maintaining the expectations of the family, groups or nation and sees this as right.
3. At the third level, people make postconventional, autonomous, or principal level. At
this level, people make an effort to define valid values and principles without regard
to outside authority or to the expectations of others. These involve respect for other
human and belief that relationships are based on mutual trust.

Peter (1981)

Proposed a concept of rational morality based on principles. Moral development is

usually considered to involve three separate components: moral emotion (what one
feels), moral judgment (how one reason), and moral behavior (how one act).

In addition, Peters believed that the development of character traits or virtues is an

essential aspect or moral development. And that virtues or character traits can be
learned from others and encouraged by the example of others.

Also, Peters believed that some can be described as habits because they are in some
sense automatic and therefore are performed habitually, such as politeness, chastity,
tidiness, thrift and honesty.

Gilligan (1982)

Included the concepts of caring and responsibility. She described three stages in the
process of developing an Ethic of Care which are as follows.

1. Caring for oneself.

2. Caring for others.
3. Caring for self and others.

She believed the human see morality in the integrity of relationships and caring. For
women, what is right is taking responsibility for others as self-chosen decision. On
the other hand, men consider what is right to be what is just.

Spiritual Theories
Fowler (1979)

Described the development of faith. He believed that faith, or the spiritual dimension
is a force that gives meaning to a persons life.

He used the term faith as a form of knowing a way of being in relation to an

ultimate environment. To Fowler, faith is a relational phenomenon: it is an active
made-of-being-in-relation to others in which we invest commitment, belief, love, risk
and hope.

Jurisprudence
It embraces:

1. All laws enacted by the legislative body.

2. All regulations promulgated by those in authority.
3. Court decisions.
4. Formal principles upon which laws are based.

Nursing Jurisprudence

Defined as the department of law that comprises all the legal rules and principles
affecting the practice of nursing. It includes not only the study but also the
interpretation of all these rules and principles and their application in the regulation
of the practice of nursing.

It deals with:

1. All laws, rules and regulations.

2. Legal principles and doctrines governing and regulating the practice of nursing.
3. Legal opinions and decisions of competent authority in cases involving nursing
practice.

Sources of Nursing Jurisprudence in the Philippines

The sources are the following:

1. The Constitution of the Republic of the Philippines, particularly the Bill of Rights.
2. Republic Act No. 7164 otherwise known as the Philippine Nursing Law of 1991.
3. Rules and regulations promulgated by the Board of Nursing and/or Professional
Regulation Commission pertaining to nursing practice.
4. Decisions of the Board of Nursing and/or Professional Regulation Commission on
nursing cases.
5. Decisions of the Supreme Court on matters relevant to nursing.

6. Opinions of the Secretary of Justice in like cases.

7. The Revised Penal Code.
8. The New Civil Code of the Philippines.
9. The Revised Rule of Courts.
10. The National Internal Revenue Code as amended

Nursing as a Profession
Profession

Is a calling that requires special knowledge, skill and preparation.

An occupation that requires advanced knowledge and skills and that it grows out of
societys needs for special services.

Professional Nursing

Is an art and a science, dominated by an ideal of service in which certain principles

are applied in the skillful care of the well and the ill, and through relationship with
the client/ patient, significant others, and other members of the health team.

Criteria of Profession
1. To provide a needed service to the society.
2. To advance knowledge in its field.
3. To protect its members and make it possible to practice effectively.

Characteristics of a Profession
1. Education. A profession requires an extended education of its members, as well as
basic liberal foundation.
2. Theory. A profession has a theoretical body of knowledge leading to defined skills,
abilities and norms.
3. Service. A profession provides basic service.
4. Autonomy. Members of a profession have autonomy in decision making and in
practice.

5. Code of Ethics. The profession as a whole has a code of ethics for practice. A
profession has sufficient self-impelling power o retain its members throughout life. It
must not be a mere steppingstone to other occupations.
6. Caring. The most unique characteristic of nursing as a profession is that, it is a
CARING profession.

Nursing

Is a disciplined involved in the delivery of health care to the society.

Is a helping profession

Is service-oriented to maintain health and well-being of people.

Is an art and a science.

Nurse - originated from a Latin word NUTRIX, to nourish.

Characteristics of Nursing
1. Nursing is caring.
2. Nursing involves close personal contact with the recipient of care.
3. Nursing is concerned with services that take humans into account as physiological,
psychological, and sociological organisms.
4. Nursing is committed to promoting individual, family, community, and national health
goals in its best manner possible.
5. Nursing is committed to personalized services for all persons without regard to color,
creed, social or economic status.
6. Nursing is committed to involvement in ethical, legal, and political issues in the
delivery of health care.

Personal Qualities of a Nurse

1. Must have a Bachelor of Science degree in nursing.
2. Must be physically and mentally fit.

3. Must have a license to practice nursing in the country.

A professional nurse therefore, is a person who has completed a basic nursing
education program and is licensed in his country to practice professional
nursing.

Roles of a Professional
1. Caregiver/ Care provider

the traditional and most essential role

functions as nurturer, comforter, provider

mothering actions of the nurse

provides direct care and promotes comfort of client

activities involves knowledge and sensitivity to what matters and what is important
to clients

show concern for client welfare and acceptance of the client as a person

2. Teacher

provides information and helps the client to learn or acquire new knowledge and
technical skills

Encourages compliance with prescribed therapy.

promotes healthy lifestyles

interprets information to the client

3. Counselor

helps client to recognize and cope with stressful psychologic or social problems; to
develop an improve interpersonal relationships and to promote personal growth

provides emotional, intellectual to and psychologic support

Focuses on helping a client to develop new attitudes, feelings and behaviors rather
than promoting intellectual growth.

Encourages the client to look at alternative behaviors recognize the choices and
develop a sense of control.

4. Change agent

Initiate changes or assist clients to make modifications in themselves or in the

system of care.

5. Client advocate

Involves concern for and actions in behalf of the client to bring about a change.

Promotes what is best for the client, ensuring that the clients needs are met and
protecting the clients right.

Provides explanation in clients language and support clients decisions.

6. Manager

makes decisions, coordinates activities of others, allocate resource

evaluate care and personnel

Plans, give direction, develop staff, monitor operations, give the rewards fairly and
represent both staff and administrations as needed.

7. Researcher

participates in identifying significant researchable problems

participates in scientific investigation and must be a consumer of research findings

Must be aware of the research process, language of research, a sensitive to issues

related to protecting the rights of human subjects