HISTORY &

DEVELOPMENT OF NURSING

By : Ibne Amin
Institute of Nursing Sciences,
Khyber Medical University , Peshawar
 OBJECTIVES
• By the end of presentation learners will be able to:
• Summarize the Ancient Cultures in the field of Nursing.
• Describe site of health care in Ancient Cultures.
• Discuss Islam and Nursing.
• Explain Historical perspective and founder of Nursing.
• Discuss mughal period in Nursing. Define nursing by
WHO and different scholars
• Briefly describe types of Nursing educational programs
• History of Nursing Education in Pakistan
 INTRODUCTION
• Treating the sick is nothing new. People have cared
for the sick throughout history, beginning in ancient
times
• However, considering the long history of nursing, it
was not until fairly recently that nurses received a
formal nursing education.
• Over hundreds of years, nursing has undergone an
evolution, eventually transforming itself into the
respected profession we all know of today.
 NURSING IN ANCIENT TIMES

In some early cultures, the provision of nursing

care was assigned to females, because women
provided nurturing to their infants and it was
assumed that they could provide the same type
of care to the sick and injured.
 NURSING IN ANCIENT TIMES

In other ancient societies, however, men were

designated to care for the sick, because they
were considered priests, spiritual guides or
“medicine men.”
 NURSING IN ANCIENT TIMES
• There was no formal education available in primitive
societies, so the earliest nurses learned the tricks of
the trade via oral traditions that were passed down
from one generation to the next.
• They also learned how to nurse patients back to
health through trial and error and by observing
others who cared for the sick.
 NURSING IN ANCIENT TIMES
The earliest nurses used plants and herbs to heal and
believed that evil spirits and magic could affect one’s
health.
Illness was often viewed as a sign that something was
done to offend the priests or gods.
 NURSING IN ANCIENT TIMES
• The Egyptian healthcare system was the first to maintain
medical records starting at around 3000 B.C.
• Egyptian society was also the first to classify medications
and develop plans to maintain people’s health.
• They were the first to use the concepts of Sutures in
repairing wounds.
• Egyptian physicians are believed to have specialized in
certain diseases (such as internal diseases, fractured
bones, and wounds).
 NURSING IN ANCIENT TIMES
Greece
From1500 B.C. to 100 B.C., Greek philosophers sought to
understand man and his relationship with Gods ,nature and
other men.
They believed that god and goddesses of Greek mythology,
controlled health and illness. Temples were built to honor
the Asclepius , the god of medicine, and were designated
to care for the sick.
The Greeks believed in Apollo, the Greek god of healing
and prayed to him for magic cures for their illness.
 NURSING IN ANCIENT TIMES
Hippocrates was the first who attributed disease to
natural cause rather than supernatural causes and
curses of gods and 400 B.C. ,the famous Greek
physician Hippocrates believed that disease had
natural, not magical, causes.
 NURSING IN ANCIENT TIMES
INDIA
Dating from 2000 to 1200 B.C., the earliest cultures of
India were Hindu. The sacred books of Hindu, Vedas,
were used to guide healthcare practices.
The Vedas included herbs, spices, displays of magic,
and charms. The Indian documented information
concerning prenatal care and childhood illness.
 NURSING IN ANCIENT TIMES
CHINA
The teaching of Confucius (551-479 B.C.) had a powerful impact
on the customs and practices of people of ancient China. One
tradition that exemplified their belief about health and illness
was the yin and yang philosophy.
The Chinese believed that an imbalance between these two
forces would result in in illness, where as balance between the
yin and yang represent good health. The ancient Chinese used a
variety of treatments believed to promote health and harmony,
including acupuncture to affect the balance of yin and yang.
Hydrotherapy, massage, and exercise were used as preventive
health measures.
 NURSING IN ANCIENT TIMES

ROME
In ancient Rome, during the early Christian era,
deaconesses were selected by the church to provide care
for the sick.
Deaconesses had some education and were selected by the
church’s bishops to visit and care for the sick in their
homes.
The deaconess Phoebe is considered to be the first “visiting
nurse” who provided expert home nursing care.
 NURSING IN ANCIENT TIMES
The Roman Empire (27BC. - 476 A.D.) a military
dictatorship, adopted medical practices from the countries
they conquered and the physicians they enslaved. The first
military hospital in Europe was established in Rome. Both
male and female attendants assisted in the care of sick.

Galen was a famous Greek physician who worked in Rome

and made important contribution to the practice of
medicine by expanding his knowledge in anatomy,
physiology, pathology and medical therapeutics.
 NURSING IN ANCIENT TIMES
The Middle Ages
The Middle ages (476BC. To 1450 A.D.) followed the demise of
Roman Empire. Women used herbs and new methods of
healings whereas man continued to use purging and leeching.
This period also saw the Roman Catholic Church become a
central Figure in the organization and management of health
care.
Most of the changes in health care were based on the Christian
concepts of charity and sanctity of human life.
Wives of emperors and other women considered noble were
become nurses.
 NURSING IN ANCIENT TIMES
RENAISSANCE PERIOD
The Renaissance and Reformation period (1500 to 1700) also
known as the rebirth of Europe, followed the middle ages
period. During the renaissance period, a growing interest in
science and technology led to advances in medicine and
public health.
At the time, the rich paid for their sick to be cared for at
home, while the poor were cared for in hospitals. By the time
many poor people arrived at hospitals, they were already very
ill, so they often died in the hospitals.
Being hospitalized had negative connotations for most people,
as hospitals were considered places where people went to
die. It was also referred as the Dark Ages of Nursing.
 NURSING IN ANCIENT TIMES
• Following the Protestant Reformation, monasteries and
convents were closed, and the lands were seized. “Common”
women who were too old or ill to find other jobs started
caring for the sick.
• Although there were a few hospitals in Protestant Europe,
there were no regular system of nursing. Female practitioners
cared for neighbors and family, but their work was unpaid and
unrecognized.
• In Catholic areas, however, the tradition of nursing nuns
continued uninterrupted.
FOUNDATIONS OF MODERN NURSING
• Modern nursing began in the 19th century in
Germany and Britain.
• The practice had spread worldwide by about
1900. British social reformers advocated for the
formation of groups of religious women to staff
existing hospitals in the first half of the 19th
century.
• Two influential women in the field of nursing
during this time period were Elizabeth Fry and
Florence Nightingale.
 THE 19TH AND 20TH CENTURIES
• In the late 19th century, nursing
professionalized rapidly in the United States.
• Women who had served as nurses during the
Civil War realized the importance of a formal
nursing education and played a crucial role in
establishing the first nurse training schools.
• Hospitals began setting up nursing schools
that attracted women from both working-class
and middle-class backgrounds.
 The 19th and 20th Centuries
• The first permanent school of nursing founded
in the United States was the nurse training
school at the Women’s Hospital of
Philadelphia, which was established in 1872.
• During the second half of the 20th century,
the number of graduate programs in nursing
grew rapidly.
 THE 19TH AND 20TH CENTURIES

• Graduate nursing programs focusing on

clinical specialties laid the basis for the
expansion of advanced practice nursing.
• By the end of the 1960s, there were 1,343
nursing schools with 1,64,545 nursing
students enrolled, according to the National
Student Nurses Association (NSNA)
 NURSING IN ISLAM
• Nursing in Islam is a healthcare services related to
caring patient, individual, family, and community
as manifestation of love for Allah and the Prophet
Muhammad(PBUH).
• Nursing as a profession is not new to Islam. In
fact, it is attributive to sympathy and
responsibility towards the concerned in need.
• This undertaking had started during the
development of Islam as a religion, a culture, and
civilization.
 NURSING IN ISLAM
1.“ heal the breasts of believers ” ‫رَ ودَ ص‬
َ‫ فشَيَونَ ين م ؤ م مَ وق‬Tawba -14
2. “ and a healing for the diseases in your
hearts ” ‫رَ ودَ ص ال يف امَ َل ءَ افَ ش‬
َ‫و‬Yonos – 57
3.“ we send down stag by stage in the Qur'an
those
and who
that believe”
which is a Israa – 82
healing َ‫َآر َقل‬toَ‫امَ ن‬
and a‫ ا‬mercy
‫َنرَو‬
َ ‫ينَم مؤ ملللزَةمََنح‬
‫نَ ن‬
‫وََ ه‬when
4. “and ‫فَ ش‬ I ‫ا‬am
‫َ ء‬ill,
‫ “و‬it is He who cures me ”
َ‫ ََ رَ مَنَ يفشَي‬Shoaara – 80
‫اذَ َإووَ هفَتَض‬
 NURSING IN ISLAM

• And there are many statements of our

prophet. Muhammad (PBUH) related to this
subject example:
– Our God create treatment for every disease
some people know it and some of them
don’t.
– Seek for treatment and medical help.
 THE FIRST MUSLIM NURSE
• The first professional nurse in the history of Islam
is a woman named, Rufaidah bento Saad Al
Aslamiah, from the Bani Aslam tribe in Madina Al
Monawarah
• She lived at the time of Prophet Muhammad
(saw) and was among the first people in Medina
to accept Islam
• Rufaidah received her training and knowledge in
medicine from her father, a physician whom she
assisted regularly
 THE FIRST MUSLIM NURSE
After the Muslim state was established in Medina, she
would treat the ill in her tent set up outside the mosque
During times of war, she would lead a group of volunteers
to the battlefield and would treat casualties and injured
soldiers.
Rufaidah is described as a woman possessing the qualities
of an ideal nurse: compassionate, empathetic, good leader
and a great teacher, passing on her clinical knowledge to
others she trained.

.
 THE FIRST MUSLIM NURSE
Furthermore, Rufaidah’s activities as someone greatly
involved in the community, in helping those at the more
disadvantaged portions of society symbolize the ethos of
care identified above.

Anas ibn Mâlik said: “Muhammad (PBUH) used to go out to

the battles taking Umm Sulaym and some other women of
the Ansaar with Him; when He fights in the battle, they [i.e.
the women] would give water to the soldiers and treat the
injured.”
FLORENCE NIGHTINGALE
 Florence Nightingale
• She was born in 1820 and died in 1910
• Born in Italy to wealthy English parents
• Frustrated by lack of options for women of her social
background
• Challenged parents and society and traveled to
Germany and throughout Europe to train as a nurse
• Her big opportunity came when the Crimean war
broke out in 1854
 FLORENCE NIGHTINGALE
• Secretary of War asked her to go take charge of the
hospital at Scutari in Turkey.
• Nightingale showed up with 38 trained nurses and
faced a death rate of 40%
• Nightingale found that conditions in the military
hospitals were terrible. The absence of sewers and
laundry facilities, the lack of supplies, the poor food,
and the disorganized medical services contributed to
a death rate of more than 50% among the wounded.
 Florence Nightingale
• She established cleanliness and sanitation rules
• Patients received special diets and plenty of food
• Improved water supply
• Patients received proper nursing care
• Nightingale established a reputation which allowed
her to improve nursing standards at home
• Nightingale’s strong statements about the role of
nurses and their need for lifelong education are still
quoted widely today
 FLORENCE NIGHTINGALE
• Established nursing school at St. Thomas’ Hospital,
London.
• By 1887, had her nurses working in six countries and
U.S.
• She was a nurse, philosopher, statistician, historian,
politician and more
• Today she is considered the founder of modern
nursing
NURSING DEFINITIONS BY SCHOLARS
Nursing definitions by Florence Nightingale
She defined nursing 100 years ago as “ the act of
utilizing the environment of the patient to assist him in
his recovery”
(Nightingale 1860)
NURSING DEFINITIONS BY SCHOLARS
Virginia Henderson’s Definition
“The unique function of the nurse is to assist the
individual, sick or well, in the performance of those
activities contributing to health or its recovery( or to
peace full death) that he would perform independently
if he had the necessary strength, will, or knowledge and
to do this in such a way as to help him gain
independence as rapidly as possible.”
NURSING DEFINITIONS BY SCHOLARS
ANA’s Definition
• In 1980, the ANA (American Nurses Association)
published this definition of nursing “Nursing is the
diagnosis and treatment of human responses to
actual or potential health problems.”
(ANA, 1980, p. 9)
 Nursing Definition WHO
Nursing definition WHO
Nursing encompasses autonomous and collaborative
care of individuals of all ages, families, groups and
communities, sick or well and in all settings. It includes
the promotion of health, the prevention of illness, and
the care of ill, disabled and dying people.
 MUGHAL PERIOD AND NURSING

Maham Anga, a great lady served as a wet Nurse

of King Akbar in Mughal Empire
She nursed during Wars in India and Afghanistan
 TYPES OF NURSING EDUCATION
PROGRAMMES
• NURSING DIPLOMA
• ASSOCIATE OF SCIENCE IN NURSING
• BACHELOR OF SCIENCE IN NURSING (BSN
• RN-TO-BSN (POST RN BSN)
• MASTER OF SCIENCE IN NURSING (MSN)
• DOCTORATE NURSING DEGREE PROGRAMS
• MPH
• MSPH
 HISTORY OF NURSING EDUCATION IN
PAKISTAN
• Initially, the health-care services in Pakistan were ill-
developed and the rate of employment in health-care
jobs in Pakistan was very low. Since 1951 Pakistani
governments have concentrated on the development
and improvement of health care services and one of
the major steps is increasing the rate of funding to PNC
Clinics. The Nursing council (PNC) has also played a key
role to provide world-class health care and nursing
services to the patients.
• Pakistan had a nurse-to-population ratio of 1:32000 in
1960, improving to 1:5199 by 1997
 HISTORY OF NURSING EDUCATION IN
PAKISTAN
• According to figures cited by the Journal of
Pioneering Medical Sciences in 2013, the existing
nurse-patient ratio in Pakistan is approximately 1:50
whereas the ratio prescribed by the Pakistan Nursing
Council (PNC) is 1:10 in general areas and 2:1 in
specialized areas.
• Currently, Pakistan has 162 registered nursing
colleges.
 PAKISTAN NURSING COUNCIL (PNC)
The PNC is an autonomous, regulatory body
constituted under the Pakistan Nursing Council Act
(1952, 1973) and empowered to register (license)
Nurses, Midwives, Lady Health Visitors (LHVs) and
Nursing Auxiliaries to practice in Pakistan. PNC was
established in 1948.
The PNC has involvement in improving and
standardizing public education and clinical nursing
standards. They also oversee the ethical standards and
general welfare of nurses.
 PAKISTAN NURSING COUNCIL (PNC)
Roles/functions of the PNC?
1. PNC sets the curriculum for the education of
Nurses, Midwives, LHVs and Nursing Auxiliaries.
2. PNC inspects educational institutions for approval
based on established standards
3. PNC provides registration (license) to practice.
4. PNC maintains standards of education and practice.
 PAKISTAN NURSING COUNCIL (PNC)
5.PNC works closely with the four provincial Nursing
Examination Boards (NEBs).
6.PNC plays and advisory role for the overall benefit of
Nurses, Midwives, LHVs and Nursing Auxiliaries in the
country.
7.PNC maintains an advisory role for the Federal and
Provincial Government regarding nursing education and
nursing services.
 PAKISTAN NURSING COUNCIL (PNC)
8.PNC communicates policy decisions regarding nursing
education and the welfare of nurses, taken in Council
meetings, to Governments, Nursing Institutions, NEBs and
Armed Forces Nursing Services for implementation.

9.PNC prescribes penalties for fraudulent registration by

intention of removes persons from the Register for
professional misconduct.
 HISTORY OF NURSING EDUCATION IN
PAKISTAN
• 1948: First Nursing School was established in Ganga
Ram small private Hospital Lahore.
• In 1952: first group of 07 girls passed the nursing
course from this school.
• In 1948: Second School of Nursing was opened in JPMC
Karachi.
• This development followed by Bahawalpur, Hyderabad
and Multan, Lady Reading Hospital Peshawar, Civil
Hospital Karachi, Mayo Hospital Lahore.
• In 1951: LHV Training extended to 02years, one year
midwifery and second in nursing emphasized on
community nursing.
HISTORY OF NURSING EDUCATION IN
PAKISTAN
Every year 1800-2000 Registered Nurses, 1200-
1300 Midwives Nurses and 300-400 Lady Health
Visitors are produced in the country.
 THE FUTURE OF NURSING
• International Nurses Day is observed on May 12 across the
globe to acknowledge the role that nurses play in the
healthcare system
• Pakistan is running short of nursing staff and currently
nursing education is in transition period and diploma
education has been replaced by university degree by 2018.
 THE FUTURE OF NURSING
A few universities offer master degree & PhD in
nursing sciences. Recently KMU has started PhD
Nursing ( First ever public sector university of Pakistan).

However, there is a lot to be done more as currently

degree program is lacking quality with exception to
some institution, along with surfacing of some ghost
institutions offering degree to remote students even
without attendance, reason behind is the culture of
political nepotism and corruption.
 REFERENCES
1.Craven, R. F., & Hirnle, C. J. (2000). Fundamentals of
Nursing: Human Health and Function. (3rd ed.). New York:
Lippincott.
2.Delaune, S. C., & Ladner, P. K. (2002). Fundamentals of
Nursing:Standards and Practice. (2nd ed.) Canada: Delmar.
3. Erb, G. K., B. (2000). Fundamentals of Nursing: Concepts,
Process and Practice (5th ed.) Addison: Wesley.
4.Potter, P. A & Perry, A. G. (2003). Basic Nursing: Essentials for
Practice (5th ed.) St. Louis: Mosby.
Roles of the Nurse in Health
Care
By : Ibne Amin
BSN,MSN
Khyber Medical University
 Objectives

1. Professional
2. Characteristics of a Profession
3. Role of the Professional nurse
4. Description of Career roles
5. Description of role as Communicator
6. Description of role as a Teacher
7. Description of role as Counselor
 Professional

A person who belongs to one of the profession.

A professional is a member of a profession or any
person who earns their living from a specified
professional activity. The term also describes the
standards of education and training that prepare
members of the profession with the particular
knowledge and skills necessary to perform their
specific role within that profession
 Professionalism
Professionalism refers to professional character, spirit,
or methods. It is a set of attributes, a way of life that
implies responsibility and commitment.

Professionalization is the process of becoming

professional, that is, of acquiring characteristics
considered to be professional.
 Criteria of a Profession
• To provide a needed services to the society.

• To advance Knowledge in its field.

• To protect its members and make it possible to

practice effectively.
 Vocation / Profession

• A vocation is generally a job that requires a

particular set of skills acquired through experience or
through training but not necessarily dependent on a
college degree. These would include plumbing,
electrician, mechanic, etc.
• A profession could be one of the above but generally
references a doctor, lawyer, nurse or other skilled
worker who was required to obtain
college/university training.
 Vocation /Profession

• Though both vocation, as well as profession,

indicates the career or the occupation through which
an individual makes a livelihood, vocation is a
broader term than profession.
• Profession refers to the career that one opts for,
getting extensive training and acquiring special skills
to become eligible for a job in it.
• Profession requires training and qualification
whereas vocation is the innate ability in an individual
towards a particular occupation.
 Vocation /Profession

Vocations almost always carry the connotation of some

kind of manual labor (plumber, carpenter, electrician,
mechanic, etc). By contrast, "profession" implies
some kind of white collar job (historically the
contrast was much stronger, but today any kind of
"knowledge worker", including being a clerk, is
considered a "professional").
 Occupation

Occupation
An activity or task with which one occupies oneself;
usually specifically the productive activity, service,
trade, or craft for which one is regularly paid; a job.
The act, process or state of possessing a place.
 Characteristics of a profession

• Great responsibility
• Accountibility
• Allows Autonomy in decision making
• Involve a skill based on specialized,theoritical
knowledge
• Involve a skill that require training & education
• Integrity is maintained by adherence to a code of
conduct
• Is organized
• Ethical constraints
 Characteristics of a profession

• Self regulation
• Honesty and integrity
• Competency
• Image
• It renders an essential socail service
 Nursing as a Profession
Nursing is recognized increasingly as a profession based
on the following criteria.
• Well defined body of specific and unique knowledge.
• Strong service orientation
• Recognized authority by a professional group
• Code of ethics
• Professional organization that sets standards
• Ongoing research
• Autonomy
 Characteristics of a Professional Nurse
• Caring
• Honest
• Faithful
• Patient
• Good listener
• Accountable
• Competent
• Confident
• Commitment
• Reflective
• Non judgmental
• Safe care provider
 Career Role

A role is a set of expected behaviors associated with a

person’s status or position. Role includes behaviors,
rights, and responsibilities.
Nurses function in a variety of roles every day. Often
roles overlap, which may lead to a conflict in
expectations or responsibilities.
 Roles of a Professional nurse

• Caregiver • Leader
• Counselor • Decision maker
• Teacher • Researcher
• Client advocate
• Change agent
• Communicator
• Team member
• Resource person
 Role as a Care giver

The caregiver is the role most commonly associated

with nursing by the general public. In the role of
caregiver, the nurse provides direct care when clients
are unable to meet their own needs. This includes
physical needs, which can range from total care to
helping a patient with illness prevention(completely
dependent, partialy dependent,supportive-educative
care).
 Role as a Care giver

• Holistic care emphasizes that the whole person is

greater than the sum of their parts.
• This means that nurses also address psychosocial,
developmental, cultural, and spiritual needs.
• The role of caregiver includes all of the tasks and
skills that we associate with nursing care, but also
includes the other elements that make up the whole
person.
 Role as a Counselor

Counseling is the process of helping a client to

recognize and cope with stressful psychologic or
social problem.When acting as a counselor, the nurse
assists clients with problem identification and
resolution. The counselor facilitates client action and
does not tell clients what to do but assists clients to
make their own decisions. Counseling is done to help
clients increase their coping skills.
 Role as a Counselor

Clients are frequently counseled in stress management,

how to deal with chronic conditions, grief and
bereavement. Effective counseling is holistic, in that
it addresses the individual’s emotional, psychological,
spiritual, and cognitive dimensions.
 Role as a Teacher

Teaching is an active process in which one individual

shares information with others to provide them with
the information to make behavioral changes.

Learning is the process of assimilating information with

a resultant change in behavior
 Role as a Teacher

Teaching is an intrinsic part of nursing.The nurse views

each interaction as an opportunity for education;
both client and nurse can learn something from
every encounter with each other. Teaching by nurses
can be formal, informal, intentional, or incidental.
 Role as a Client Advocate

A client advocate is a person who speaks up for or acts

on behalf of the client so as to protect him.In this
role the nurse may represent the client’s need &
wishes to other health professional.
Advocacy empowers clients to be partners in the therapeutic
process rather than passive recipients of care. The
relationship that encourages client empowerment is one of
mutual participation by client and nurse. Clients and families
are actively involved in establishing goals.
 Role as a Client Advocate

Frequently, clients and families do not communicate

their concerns to physicians but will do so to the
nurse with whom a bond has been established.
Nurses function as client advocates by listening and
communicating the expressed concerns to other
health care providers and including those concerns
into care planning.
 Role as a Change Agent

Nurses who function in the role of change agent

recognize that change is a complex process.
The nurse change agent is proactive (takes the
initiative to make things happen) rather than
reactive (responding to things after they have
happened). Change should not be done in a
random manner. It should be planned
carefully and implemented in a deliberate way
to facilitate the client’s progress.
 Role as a Team Member

A vital role of the nurse is that of team member.

The nurse does not function in isolation but
rather works with other members of the
health care team. Collaboration requires the
nurse to use effective interpersonal skills and
promotes continuity of care. They use their
professional and communication skills
applicable to promoting healthy relationships
with clients and colleagues.
 Role as a Resource Person

The nurse functions as a resource person by

providing skilled intervention and information.
Identifying resources and making referrals as
needed also fall under the auspices of this
role. Nurses must consider the client strengths
and access to resources, including physical,
intellectual, economic, social, and
environmental.
 Role as a Leader

• A leader influences others to work together to

accomplish a specific goal.
• The leader role can be employed at different
levels; individual client, family, groups of clients,
colleagues, or the community.
• Effective leadership is a learned process requiring
an understanding of the needs and goals that
motivate people, the knowledge to apply the
leadership skills, and the interpersonal skills to
influence others.
 Role as a Reasercher

• Nurse researchers are scientists who study

various aspects of health, illness and health
care.
• By designing and implementing scientific
studies, they look for ways to improve health,
health care services and health care
outcomes.
 Role as a Communicator

• As a communicator, the nurse understands that

effective communication techniques can help
improve the healthcare environment.
• Barriers to effective communication can inhibit the
healing process.
• The nurse has to communicate effectively with the
patient and family members as well as other
members of the healthcare team.
• In addition, the nurse is responsible for written
communication, or patient charting, which is a key
component to continuity of care.
 Role as a decision maker

• As a decision maker, is to use critical thinking

skills to make decisions, set goals, and promote
outcomes for a patient.
• These critical thinking skills include assessing the
patient, identifying the problem, planning and
implementing interventions, and evaluating the
outcomes.
• A nurse uses clinical judgment - his or her ability
to discern what is best for the patient to
determine the best course of action for the
patient.
 References

kozier & Erb’s Fundamental of Nursing ,8th edition

( Audrey Berman ,Shirlee J. Synder).

Fundamentals of Nursing: Standards & Practice, 2nd Edition

( Sue C. DeLaune Patricia K. Ladner.)

www.slideshare.com

www.google.com
Goals of Nursing and Related Concepts

By : Ibne Amin
BSN , MSN
INS , Khyber Medical University
 OBJECTIVES

By the end of presentation learners will be able to:

• Define basic human needs.

• Define World Health Organization.

• Explain model of conceptual framework for generic BS N

program.

• Define goal of nursing process.

 Human Needs

 Needs are something that are necessary for an

organism to live a healthy life
 Distinguished from wants
Deficiency causes a clear adverse outcome: a
dysfunction or death
 Human Needs
Three types of Needs
1. Objective/Physical E.g. Food, Shelter, security etc…

2.Subjective/ Psychological e.g. Self-esteem, Affection

etc..

3. Self-fulfillment needs e.g. self-actualization

 Maslow's hierarchy of human needs

• American psychologist
• Professor of Psychology at Columbia University
• Creator of Maslow's hierarchy of needs
• A five stage triangle assumes that a person attempts
to satisfy the more basic needs before directing
behavior toward satisfying upperlevel needs
Maslow's Hierarchy of Needs

6
 Basic Human Needs

Maslow,s hierarchy of needs is based on theory that

something will be called basic needs if :
Those needs are not met – cause illness
Those needs are met - can prevent illness
Those needs are an indicator of health/wellness
There is sense of loss if those needs are’nt met
There is satisfaction if those needs are met
 10 Basic Human Needs
1. Clean environment
2. Adequate supply of water
3. Clothing
4. Nutritious food
5. Shelter
6. Health care
7. Communication
8. Fuel and lighting (Energy)
9. Access to education
10. Cultural and spiritual engagement
 World Health Organization

Introduction
• World Health Organization is established on 7th
April 1948.
• It is a specialized, non-political, health agency of
United Nation with headquarter of Geneva,
Switzerland.
• It is responsible for providing leadership on global
health matters.
• Every year 7th April, is celebrated as “World Health
day”.
 WHO…….
Vision
“The attainment by all people, the highest level
of health”
Mission
“To lead strategic collaborative efforts among
Member States and other partners to promote
equity in health, to combat disease, and to
improve the quality of, and lengthen, the lives
of the all peoples of the world.”
Conceptual Framework for generic BSN
program
Cont……
Cont….
Cont….
Cont…..
Cont……
Cont……
Cont…..
 Nursing
Definition: “It is the diagnosis and treatment of human
responses to actual or potential health problems”
(ANA 1980 )
Nursing is the art and science that involves working
with individual, families, and communities to
promote wellness of body, mind, and spirit.
 Nursing……
Definition “ It is assisting the individual, sick or
well in the performance of those activities
contributing to health or its recovery (to
peaceful death) that he will perform unaided,
if he had the necessary strength, will or
knowledge and to do this in such a way as to
help him gain independence as rapidly as
possible” (Virginia Henderson 1960).
 Nursing Process

A systematic problem solving approach used to

identify, prevent and treat actual or potential
health problems and promote wellness.
It involves the following steps
• Assessment
• Nursing Diagnosis
• Planning
• Implementation
• Evaluation
 Goals of Nursing process
It is to identify a client ’s health care status,and actual
and potential health problems, to establish plans to
meet the identified needs, and to deliver specific
nursiong intervention to address those needs.
• An organizational framework for the practice of
nursing
• Orderly, systematic ,central to all nursing care
• Encompass (cover) all steps taken by the nurse in
caring for a patient
 References
• Andrea Ackermann, Mount St. Mary College,
Critical-thinking-the-nursing-process 2001.
• http://www.umanitoba.ca/nursing/courses/12
8,(2005)
• Sara-jo Wiscombe, Nursing Process ,Wallace
Community College ,May 22,2001.
• Tucker C, MODULE A INTRODUCTION TO NURSING
Process, August 21, 2002 .
Communication
By : Ibne Amin
BSN , MSN
INS , Khyber Medical University
[email protected]
 Objectives
At the end of this unit students will be able to
1. Define communication, elements of the
communication process, ways of communication.
2. Identify the characteristics of the effective verbal
communication
3. Describe the factors that's facilitate and interfere with
the effective communication
4. Define ways to respond therapeutically
5. Identify non therapeutically respond
6. Discuss the legal aspects of documentation
 Communication
Communication is regarded as a two- way process of
exchanging ideas, feelings, emotion and information so
as to
– To increase knowledge
– To change existing patterns of behavior & attitudes
– To acquire new skills.
It has two main purposes:
• To influence others
• To gain information
 Components of Communication
It has the following main components
• Sender (source, communicator)
• Receiver (Audience)
• Message (content)
• Channels (medium or pathway)
• Feedback (effect)
 Components of Communication
Sender:
•A sender is a person who encodes & sends the
message to the expected receiver through an
appropriate channel.
•A sender is the source of the message that is
generated to be delivered to the receiver after
appropriate stimulus from the referent.
 Components of Communication
Message:
• The message is the content of communication & may
contain verbal, nonverbal or symbolic language.
• Perception & personal factors of the sender &
receiver may sometimes distort this element & the
intended outcome of communication may not be
achieved. For ex, the same message may be
communicated or perceived differently by two
individuals.
 Components of Communication
Channel:
• A channel is a medium through which a message is
sent or received between two or more people.
• Several channels can be used to send or receive the
message, i.e seeing, hearing, touching, smelling, &
tasting.
• While selecting channels of communication, several
factors must be considered: availability of channels ,
purpose, suitability, types of receivers, types of
message, preference of sender & receivers,
communication skills of the sender, cost, etc.
 Components of Communication
Classification of channels of communication:
• Visual channel: Facial expression, body language,
posture, gestures, pictures & written words, electronic
mails, mass media, etc.
• Auditory channel: Spoken words, sounds, telephone or
mobile communications, delivering audio content (radio,
voicemail), etc.
• Tactile channel: Touch sensations, therapeutic touch, etc.
• Combined channel: Audiovisual media, consoling a person
with touch & spoken words.
 Components of Communication
Receiver:
• A receiver is an individual or a group of individuals
intended to receive, decode & interpret the message
sent by the sender/source of message.
• A receiver also known as decoder.
• He is expected to have the ability & skills to receive,
decode & interpret the message
 Components of Communication
Feedback:
• It is a return message sent by the receiver to the sender.
• It is most essential element of the communication
process as it shows that the receiver has understood the
primary message sent by the sender & the
communication process is now consider complete.

• A successful communication must be a two-way process

where the sender sends the message & receives
feedback from the receiver.
• These feed back could be verbal & nonverbal.
 Types of Communication
1. One way communication
2. Two way communication
3. Verbal communication
4. Non-verbal communication
5. Formal and informal communication
6. Visual communication
7. Telecommunication and internet
 One Way Communication
• The flow of communication is “one-way” from the
communicator to the audience.

• Example - Lectures in classroom

 Two Way Communication
• Two-way method of communication in which both
communicator and audience take part.

• Learning is active
• More likely to influence behavior.
 Verbal Communication
• In Verbal communication, Spoken words are used. It
includes face-to-face conversations, speech.

• The words used vary among individuals according to

culture, socioeconomic background, age, and
education.
 Characteristics of effective verbal
communication
• Simplicity Use of commonly understood words
• Clarity Say exactly what it means
• Timing and relevance
This involves being sensitive to the clients' needs and concerns
• Adaptability Spoken message needs to be altered in accordance with
behavioral cues from the receiver
• Credibility
the quality of being trusted & believed
 Nonverbal communication
• Communication can occur even without words.

• It includes whole range of bodily movements, postures,

gestures and facial expression.

• Silence is non verbal communication, it can speak louder than

words.
 Visual communication
The visual form of communication comprise ;
• Charts
• Graphs
• Pictograms
• Tables
• Maps
• posters
 Telecommunication and internet

• Telecommunication is the process of communication

over distance using electromagnetic instruments
designed for the purpose.

• For example radio, TV, internet , telephones, satellite

etc
 Levels of communication

• Intrapersonal communication
• Interpersonal communication
• Transpersonal communication
• Small group communication
• Public communication
 Intrapersonal communication
• It occurs within an individual. This level of
communication is also called self talk, inner thought
and inner dialogue.
 Interpersonal communication
• It is one to one interaction between the nurse and
another person that often occurs face to face.
• Meaningful interpersonal communication results in
exchange of ideas, problem solving, expression of
feelings, decision making and personal growth.
 Transpersonal communication
• It occurs within a person’s spiritual domain. Many
persons use prayer, meditation religious rituals to
communicate with their higher power.
 Small group communication
• It occurs when a small number of persons meet
together. It is usually goal directed and requires an
understanding of group dynamics.
 Public communication
• It is the interaction with the audience. Nurses have
opportunities to speak with groups of consumers
about health related topics, present scholarly work
to colleagues at conferences or lead classroom
discussions
 Therapeutic Communication
“In therapeutic communication the nurse directs the
communications towards the patient to identify his
current health problem, plan, implement & evaluation
the action taken.”
 Therapeutic Communication
Techniques
• Offering self
• Giving broad opening
• Silence
• Exploring
• Focusing
• Providing general leads
• Giving information
• Restating
Technique purpose example

Using silence Sitting quietly (or walking

Accepting pauses or silences that with the client) and
may extend for several seconds or waiting attentively until
minutes without the client is able to put
any verbal response. thoughts and feelings into
words.
Providing Using statements or questions that “Where would you like to
general leads (a) encourage the client to verbalize, begin?”
(b)choose a topic of conversation,
and (c) facilitate continued “And then what?”
verbalization.
Broad Initiates conversation; Tell me something
Opening Encourage the patient to select About your family?
Topics for discussion. What would you like to
discuss?
eg; “What are you
thinking about?”
Technique purpose example

Offeringself Making oneself I‟ll stay with you until

Available on an I‟ll be hear till 12.00
Unconditional basis, Clock.
increasingclient‟s “I’ll stay with you until your family
Feelingof self-worth members arrives.”

Restating Repeating the main thought Eg; “You say that your mother left
expressed by the patient. you when you were five years old.”

Giving Providing, in a simple and direct

information manner, specific
Your surgery is scheduled for 11
factual information the client may or
AM tomorrow.”
may not
“You will feel a pulling sensation
request. When information is not
when the tube is removed
known, the nurse
from your abdomen.”
states this and indicates who has it
“I do not know the answer to that,
or when the
but I will find out from
nurse will obtain it.
Mrs. King, the nurse in charge.”
Technique purpose example

Exploring “Tell me more about

that.”
delving further “Would you describe it
into a subject or an idea more
fully?”
“What kind of work?”
Focusing Concentrating on a single point. “This point seems worth
looking at more closely.”
 Factors influencing communication
process
• Person Socio cultural background
• Language
• Age
• Education
• Ability of communication
• Time and setting
• Emotions and self esteem
 Nontherapeutic response
• Not listening properly
• Rejection (refusing from discussion)
• False hopes
• Too much probing into personal matters
• Changing the subject
• Sharing personal or work related problems
• Reveal confidential information
Legal Aspects of Documentation
 Legal Aspects of Recordkeeping
• Legally, the documentation of the care given to a
patient must be completed.
• If no documentation is recorded, no care was given
at all.
• Hospital accreditation agencies will carefully evaluate
the medical records of patients.
 Legal Aspects of Recordkeeping
• If documentation is not done the hospital and the
practitioner could be accused of patient neglect.
• Proper documentation of care is valuable only in
reference to standards and criteria of care.
 Legal Aspects of Recordkeeping
• For each standard, criteria must be outlined so that
adequacy of patient care be measured.
• Documentation will reflect the standards of the
department.
 Practical Aspects of Recordkeeping
• Recordkeeping is one of the most important parts of
our duties.
• Documentation must be done for each medication,
treatment, and procedure.
• Accounts of patient’s condition and activities must
be charted correctly and be very clear.
• Briefness is important, although a complete account
of each patient encounter
 General Rules for Recordkeeping

• Legible. Print or hand write entries in chart.

• Begin with date and time, then enter order and sign
the chart:
• Errors? Don’t erase, or use correction tape. If a
mistake, drawn a line through it, write date and write
the word error above it, with your initials
• Chart patient complaints and general behavior
 General Rules of Recordkeeping

• Leave no blank or empty lines. Draw a line through

the center of the empty space in order to prevent
someone else from signing in your area.
• Use Standard abbreviations
• Spell Correctly
• Document conversations with patient and healthcare
providers that you feel are important
 References
• Andrea Ackermann, Mount St. Mary College,
Critical-thinking-the-nursing-process 2001.
• http://www.umanitoba.ca/nursing/courses/12
8,(2005)
• Sara-jo Wiscombe, Nursing Process ,Wallace
Community College ,May 22,2001.
• Tucker C, MODULE A INTRODUCTION TO NURSING
Process, August 21, 2002 .
 VITAL SIGNS

By : Ibne Amin
Institute of Nursing Sciences,
Khyber Medical University , Peshawar
 OBJECTIVES
1. Define Vital Signs.
2. Define terms related to Vital sign.
3. Describe the physiological concept of temperature, respiration
and blood pressure.
4. Describe the principles and mechanisms for normal
thermoregulation in the body.
5. Identify ways that affect heat production and heat loss in the
body.
6.Define types of body temperature according to its
characteristics.
7. Identify the sign and symptoms of fever.
 OBJECTIVES
8. Discuss the normal ranges for temperature, pulse,
respiration and blood pressure.
9. List the factors affecting temperature, pulse,
respiration.
10. Describe the characteristics of pulse and respiration.
11. List factors responsible for maintaining normal blood
pressure.
12. Describe various methods and sites used to measure
T.P & B.P.
13. Recognize the signs of alert while taking TPR and B.P.
 INTRODUCTION
Vital sign are the indicator of the body’s physiologic
status and response to physical environment and
psychological stressor.
The vital sign or the cardinal sign are temperature,
pulse, respiration, and blood pressure. The findings are
governed by the vital organs.
 DEFINITION
Vital sign are called cardinal signs because of their
importance. These are the indicator of health status, as
these indicate the effectiveness of circulatory,
respiratory, neural, & endocrine body functions.
1. Temperature
2. Pulse
3. Respiration
4. Blood pressure
5. oxygen saturation
6. Pupillary reaction / pain
 WHEN TO TAKE VITAL SIGNS
• Upon admission.
• On a routine basis.
• Before and after invasive procedure.
• Before and after administration of medication.
• Any deterioration of patient’s general condition.
• Before and after nursing intervention that may
influence vital sign.
• Prior to medical emergency
 TEMPERATURE
Body Temperature: it is the hotness or coldness of the body.
OR
It is balance between the heat produced by the body and
heat lost from the body.

Heat produced – Heat lost = Body temperature

Types: There are two kinds of temperature..

1. Core Temperature
2. Surface Temperature
 TEMPERATURE
Core Temperature: is the temperature of the deep
tissues of the body. It remains constant and varies very
little as + 1 F except when a person has a fever. We
measure it with a thermometer.
Surface Temperature: by contrast the temperature of
the surface or skin, fluctuate (rises or fall) in response
to the environment.
Normal body temperature: is not an exact point on a
scale but a range of temperatures. When measured
orally for an adult, on an average it is between 36-38 C
(96.8 – 100 F)
 Regulation of Body Temperature
The system that regulates body temperature has 3 main parts:
1. Sensors in the periphery and in the core,
2. An integrator in the hypothalamus, and
3. An effector system that adjusts the production and loss of
heat.
Most sensors or sensory receptors are in the skin. The skin has more
receptors for cold than warmth. Therefore, skin sensors detect cold more
efficiently than warmth.
When the skin becomes chilled over the entire body, three physiological processes to
increase the body temperature take place:
1. Shivering increases heat production.
2. Sweating is inhibited to decrease heat loss.
3. Vasoconstriction decreases heat loss.
 Regulation of Body Temperature
Body temperature is regulated by balancing the amount of
heat the body produces with the amount of heat the body
loses. Body heat is produced as a by-product of
metabolism, which is the sum of all biochemical and
physiological processes that take place in the body.
The hypothalamus, a gland located in the brain, acts as a
thermoregulator. It is able to adjust body temperature that
results in either increasing or decreasing heat production
throughout the day.
 • Regulation of Body Temperature
• The anterior Hypothalamus promotes heat loss
through vasodilatation and sweating
• The posterior Hypothalamus promotes: – Heat
conservation by vasoconstriction – Heat production
And maintains the core temperature
 THERMOREGULATION
Thermoregulation: Balance between heat production
and heat loss. When the amount of heat produced by
the body exactly equals the amount of heat lost, the
person is in heat balance.
1. Heat production
2. Heat loss
Heat production in the body is called thermogenesis.
Heat loss to the environment is called thermolysis.
 1. HEAT PRODUCTION
1. Heat production:
Basal metabolic rate: Basal metabolic rate (BMR) is the
total number of calories that your body needs to
perform basic, life-sustaining functions like breathing
and circulation etc.
Muscle activity: Body cells are constantly producing
and breaking down ATP (Adenosine triphosphate) and
these chemical reactions produce heat during.
 1. HEAT PRODUCTION
• Thyroxin: Thyroid hormones stimulate diverse
metabolic activities most tissues, leading to an
increase in basal metabolic rate
• Epinephrine, nor epinephrine and sympathetic
stimulation:
Epinephrine and nor epinephrine are released by the
adrenal medulla and nervous system respectively. They are
the flight/fight hormones that are released when the body
is under extreme stress. During stress, much of the body's
energy is used to combat imminent danger.
 2. HEAT LOSS
• Radiation: The emission of energy as
electromagnetic waves from the body.
• Conduction: It is the transfer of heat from one
surface to the other through direct contact. Heat is
transferred via solid material
• Convection: Convection is the dispersion of heat by air
currents
• Conversion/Vaporization: Evaporation is the
continuous evaporation of moisture from the respiratory
tract and from the mucosa of the mouth as well as from
the skin.
Normal range of body temperature
(Adults)
 FACTORS AFFECTING BODY TEMPERATURE:

• Age Infants greatly influenced by the temperature, children more labile than adult and elderly
are extremely sensitive to environmental change due to decreased thermoregulatory control

• Diurnal variation Body temperature normally change throughout the day, varying as
much as 1.0 °C between early morningand late afternoon The point of highest body temperature
is usually reached between 8pm and 12 midnight and the lowest point is reached during sleep
between 4 a.m. and 6 a.m.

• Exercise
• Hormones Women usually experience more hormone fluctuations than men, progesterone
secretion in women raises body temperature.

• Stress Epinephrine and nor epinephrine increases metabolic activity and heat production
• Environment
FACTORS AFFECTING BODY
TEMPERATURE:
ALTERATION IN BODY TEMPERATURE
 ALTERATION IN BODY TEMPERATURE
The normal range for adults is considered to be between
36°C and 37.5°C (96.8°F to 99.5°F).
There are two primary alterations in body temperature:
1. Pyrexia or Hyperthermia
2. Hypothermia.
1. Pyrexia
A body temperature above the usual range is called pyrexia,
hyperthermia, or (in lay terms) fever. A very high fever, such
as 41°C (105.8°F), is called hyperpyrexia.
Febrile: The client who has a fever is referred to as febrile.
Afebrile: The one who does not, is called afebrile.
 Pyrexia
1. Low Pyrexia: The fever does not rise more than 99
to 100 F
2. Moderate Pyrexia: Body temperature remain between
100-103 degree F
3. High Pyrexia: Body temperature remain between
103- 105 degree F
4. Hyperpyrexia: Temperature above 105 degree F
 Pyrexia (Conti…)
4 Common Types Of Fever
1.Intermittent fever: The body temperature alternates at
regular intervals between periods of fever and periods of
normal or subnormal temperature e.g. Malaria
2.Remittent fever: A wide range of temperature fluctuation
(more than 2 0c) occurs over the 24 hr period, all of which are
above normal e.g. a cold or influenza
3.Relapsing fever: Short febrile periods of a few days are
interspersed with periods of 1 or 2 days of normal
temperature e.g.
4.Constant fever: The body temperature fluctuates minimally
but always remains above normal e.g. typhoid fever
 Pyrexia (Conti…)
Fever Spikes: A temperature that rises to fever level
rapidly following a normal temperature and then
returns to normal within a few hours is called a fever
spike. Bacterial blood infections often cause fever
spikes.
Inverse Fever: The highest range of temperature is
recorded in morning hours and lowest in the evening.
Hectic Or Swinging Fever: When difference between
high and low temperature is very great.
 ALTERATION IN BODY TEMPERATURE
In some conditions, an elevated temperature is not a true
fever. Two examples are heat exhaustion and heat stroke.
Heat exhaustion: is a result of excessive heat and
dehydration. Signs of heat exhaustion include paleness,
dizziness, nausea, vomiting, fainting, and a moderately
increased temperature (38.3°C to 38.9°C [101°F to 102°F]).
Heat stroke: Persons experiencing heat stroke generally
have been exercising in hot weather, have warm, flushed
skin, and often do not sweat. They usually have a
temperature of 41.1°C (106°F) or higher, and may be
delirious, unconscious, or having seizures
 Stages / Phases of Fever

Invasion, onset of Fever, Period of rising

Onset Also called Cold or Chilled Phase

Stadium, fever has reached its peak level and

remains constant
Course Also called Plateau Phase

Defervescence, elevated temperature declines

ABATEMEN Also called as Flush Phase
T
 Clinical Manifestation of Fever
ONSET (COLD OR CHILL PHASE)
Increased heart rate, Increased respiratory rate and depth, Shivering
Pallid, cold skin ,Complaints of feeling cold , Cyanotic nail beds
“Gooseflesh” appearance of the skin ,Cessation of sweating
COURSE (PLATEAU PHASE)
Absence of chills ,Skin that feels warm , Photosensitivity , Glassy-eyed
appearance , Increased pulse and respiratory rates , Increased thirst
Mild to severe dehydration , Drowsiness, restlessness, delirium, or
convulsions ,Herpetic lesions of the mouth , Loss of appetite (if the
fever is prolonged) ,Malaise, weakness, and aching muscles
DEFERVESCENCE (FEVER ABATEMENT/FLUSH PHASE)
Skin that appears flushed and feels warm , Sweating , Decreased
shivering , Possible dehydration
 Hypothermia
Hypothermia is a core body temperature below the lower
limit of normal i.e. 95 F or 35 C. The three physiological
mechanisms of hypothermia are
(a) Excessive heat loss,
(b) Inadequate heat production to counteract heat loss,
(c) Impaired hypothalamic thermoregulation
If skin and underlying tissues are damaged by freezing cold, this
results in frostbite. Frostbite most commonly occurs in hands,
feet, nose, and ears in which ice crystal forms inside the cell and
damage it.
Clinical Manifestation of Hypothermia
• Decreased body temperature, pulse, and respirations
• Severe shivering (initially)
• Feelings of cold and chills
• Pale, cool, waxy skin
• Frostbite (discolored, blistered nose, fingers, toes)
• Hypotension
• Decreased urinary output
• Lack of muscle coordination, Disorientation, drowsiness
progressing to coma
 Types of Hypothermia
1.Induced hypothermia: is the deliberate lowering of
the body temperature to decrease the need for oxygen
by the body tissues such as during certain surgeries.
2. Accidental hypothermia: can occur as a result of
(a) exposure to a cold environment,
(b) immersion in cold water, and
(c) lack of adequate clothing, shelter, or heat.
In older adults, the problem can be compounded by a
decreased metabolic rate and the use of sedative
medications.
 Sites to Measure Temperature

 Oral
 Rectal
 Axillary
 Tympanic membrane
 Temporal artery

Condition of resident determines which is the best site for measuring body
temperature.
Advantages and Disadvantages of Sites for Body
Temperature Measurement
Types Of Thermometer
Thermometer
 Thermometer
Two parts of thermometer-bulb and stem
• Blub is fragile part, containing mercury, sensitive to
temperature.
•Stem is hollow tube in which mercury can rise.
There are two scales, Fahrenheit and Celsius

Mercury, a liquid metal, with silvery appearance is used in

thermometers, because it is very sensitive to a small changes in
temperature, expansion of mercury is uniform, easily visible.
 Temperature: Safety Precautions
• Hold rectal and axillary thermometers in place
• Stay with resident when taking temperature
• Prior to use, shake liquid in glass down
• Shake thermometer away from resident and hard
objects
• Wipe from end to tip of thermometer prior to
reading
• Delay taking oral temperature for 10 - 15 minutes
if resident has been smoking, eating or drinking
hot/cold liquids
 Conti…
• Oral – most common, most convenient
• Rectal – registers one degree Fahrenheit higher than
oral, most accurate
• Axillary – least accurate; registers one degree
Fahrenheit lower than oral
• Tympanic – probe inserted into the ear canal
 PULSE
The pulse is an index of the heart’s rate and rhythm.
Pulse provides valuable data about person’s
cardiovascular status.
DEFINITIONS- “The pulse is a wave of blood created by
contraction of the left ventricle of the heart.”
 Physiology of Pulse
Blood flows through the body in a continues circuit.
Electrical impulses originating from the SA node travel
through heart muscle to stimulate cardiac contraction.
Approximately 60 to 70 ml (stroke volume) of blood
enters the aorta with each ventricular contraction.
With each stroke volume ejection, the wall distends,
creating a pulse wave that travels rapidly toward the
distal ends of the arteries.
When a pulse wave reaches a peripheral artery, it can be
felt by palpating the artery lightly against underlying bone
or muscles.
 Regulation of Pulse
Pulse is regulated by the Autonomic Nervous System through the
Sino-atrial node.( Often called pace-maker.)
• Para sympathetic stimulation decreases the heart rate
• Sympathetic stimulates increase the heart rate.
The quantity of blood forced out of the left ventricle during each
contraction is called stroke volume.(70 ml for an average adult).
Cardiac output = Stroke volume × Pulse rate =70ml × 80 BPM
=5600 ml =5.6 L/min
The number of pulsing sensation occurring in 1minute is the pulse rate.
The volume of blood pumped by the heart during 1 minute is the Cardiac output.
Pulse rate X Stroke Volume = Cardiac out put
70 beats per minute X 70 ml / beat = 4.9 L/min
60 beats per minute X 85 ml / beat = 5.1 L/min
 Pulse assessment:
A pulse is commonly assessed by palpation (feeling) or
auscultation using stethoscope. A pulse is normally palpated by
applying moderate pressure with the three middle fingers of the
hand. The pads on distal aspects of the finger are the most
sensitive areas for detecting a pulse with gentle pressure. A
stethoscope is used for assessing apical pulse. While palpating a
pulse a nurse should assess the followings…….
 Pulse Rate
 Pulse Rhythm
 Pulse Volume
 Character
 Bilateral Equality
 Conti..
Pulse Rate :- It is stated as number of pulses or beats
per minute. Count the pulses for not less than half
minute. BPM
• Normal 60-100 b/min (80/min)
• Adult PR > 100 BPM is called tachycardia
• Adult PR < 60 BPM is called bradycardia
 Conti..
Pulse Volume, or force, refers to the strength of the pulse
when the heart contracts. The pulse volume is also called
the pulse strength or quality, refers to the force of blood
with each beat
It can be range from absent to bounding.
• Bounding- Strong full force pulse.
• Thready / weak- Difficult to palpate, a pulse of
diminished strength.
• Absent- No palpable pulse.

Volume is influenced by the forcefulness of the heartbeat, the

condition of the arterial walls, and hydration or dehydration.
 Conti …
Pulse Rhythm refers to the regularity, or equal spacing,
of all the beats of the pulse. Normally, the intervals
between each heartbeat are of the same duration.
A pulse with an irregular rhythm is known as a
dysrhythmia or arrhythmia.
• Equal time elapses between beat of a normal pulse;
this steady beat is called Pulsus regularis.
• A pulse with an irregular rhythm is referred to an
Arrhythmia.
 Conti…
Bilateral Equality or Symmetry of Pulse
When assessing peripheral pulse to determine the
adequacy of blood flow to a particular area of the body.
To check the blood flow of bilateral is important.
 Types of Pulse
1. Peripheral pulse is a pulse located away from the
heart, for example, in the foot or wrist. Assessed via
fingers
2. The apical pulse, in contrast, is a central pulse; that
is, it is located at the apex of the heart. It is also
referred to as the point of maximal impulse (PMI).
Assessed or taken via stethoscope
Pulse Sites
 Pulse Sites
1. Radial – base of thumb
2. Temporal – side of forehead
3. Carotid – side of neck
4. Brachial – inner aspect of elbow
5. Femoral – inner aspect of upper thigh
6. Popliteal - behind knee
7. Dorsalis pedis – top of foot
8. Posterior tibial
9. Apical pulse – over apex of heart
– taken with stethoscope
– left side of chest
Reason For Using Specific Pulse Site
Variations in Pulse by Age
 Factors Affecting Pulse
• Age
• Sex
• Exercise or Physical training
• Body fluids
• Position
• Drugs
• Illness
• Emotions
• Temperature
 Factors Affecting Pulse
Age
As age increases, the pulse rate gradually decreases
overall. See Table 29–2 for specific variations in pulse
rates from birth to adulthood.
Sex
After puberty, the average male’s pulse rate is slightly
lower than the female’s.
Exercise
The pulse rate normally increases with activity. The rate
of increase in the professional athlete is often less than in
the average person because of greater cardiac size,
strength, and efficiency.
 Factors Affecting Pulse
Hypovolemia/dehydration. Loss of blood from the
vascular system increases pulse rate. In adults, the
loss of circulating volume results in an adjustment
of the heart rate to increase blood pressure as the
body compensates for the lost blood volume.
Stress. In response to stress, sympathetic nervous
stimulation increases the overall activity of the
heart. Stress increases the rate as well as the force
of the heartbeat. Fear and anxiety as well as the
perception of severe pain stimulate the sympathetic
system
 Factors Affecting Pulse
Fever
The pulse rate increases (a) in response to the lowered
blood pressure that results from peripheral vasodilation
associated with elevated body temperature and (b)
because of the increased metabolic rate.
Medications.
Some medications decrease the pulse rate, and others
increase it. For example, cardiotonics (e.g., digitalis
preparations) decrease the heart rate, whereas
epinephrine increases it.
 Factors Affecting Pulse
Position. When a person is sitting or standing, blood
usually pools in dependent vessels of the venous
system. Pooling results in a transient decrease in the
venous blood return to the heart and a subsequent
reduction in blood pressure and increase in heart rate.
Pathology. Certain diseases such as some heart
conditions or those that impair oxygenation can alter
the resting pulse rate.
 Respiration:
Respiration: Respiration is the mechanism the body
uses to exchange gases between the atmosphere and
the blood and the blood and the cell. Respiration
involves the following processes....
Ventilation; the movement of gases between in and
out of the lungs (inspiration and expiration).
Diffusion; the movement of oxygen and carbon dioxide
between the alveoli and the red blood cells.
Perfusion; the distribution of red blood cells to and
from the capillaries.
 Physiological control:
The respiratory center (medulla oblangata) in the brain stem
regulates the involuntary (adults normally breathe in a
smooth, uninterrupted pattern, 12- 20 times / min) control of
respiration.
Ventilation is regulated by CO2, O2, and hydrogen ion
concentration (PH) in the arterial blood.
The most important factor in the control of ventilation is the
level of CO2 in the arterial blood.
An elevation in the Co2 level causes the respiratory control
system in the brain to increase the rate and depth of
breathing.
The increased ventilatory effort removes excess CO2 by
increasing exhalation.
 Mechanism of breathing:

1. Inspiration/ inhalation ( active process)

2. Expiration / exhalation ( passive process)
3. Pause
 Mechanism of breathing
1. Inspiration:
During this phase the respiratory center sends impulses
along the phrenic nerve, causing the diaphragm to
contract.
Abdominal organs move downward and forward,
increasing the length of the chest cavity to move air into
the lungs.
The diaphragm moves approximately 1 cm, and the ribs
retract upward from the body’s midline approximately 1.2
- 2.5 cm.
During a normal, relaxed breath, a person inhales 500ml
of air. This amount is referred as Tidal volume.
 Mechanism of breathing
2. Expiration / Exhalation:
During expiration the diaphragm relaxes and the abdominal
organs return to their original position.
The thorax decreases in size, and thus the lungs are
compressed.
The ribs move downward and inward
The sternum moves inward
3.Pause: the relaxation time between inspiration and
expiration.
The normal (breath) rate and depth of ventilation is called Eupnoea,
interrupted by sigh.
 Types of breathing
1. Costal (thoracic)
Observed by the movement of the chest up ward and
downward.
Commonly used for adults
2. Diaphragmatic (abdominal)
Involves the contraction and relaxation of the
diaphragm, observed by the movement of abdomen.
Commonly used for children.
 Factors affecting respiration:
• Body position
• Exercise
• Acute pain
• Medications
• Smoking
• Hemoglobin function
• Anxiety
• Abdominal trauma
• Neurological Injury
BEAMS-HAAN
 Characteristics of the respiration:
When the respiration rate is taken, several
characteristics should be noted:
• Rate,
• Rhythm,
• Depth, and
• The quality or characteristics of breathing.
 Characteristics of the respiration:
Respiratory Rate: It is the number of respirations per
minute. The normal respiration rate for healthy adults
at rest is 12 to 20 cycles per minute. Children have a
more rapid rate of breathing than adults. Respiratory
Rate Ranges of Various Age Groups
Newborn 1– 30–50
2 years old 20–30
3–8 years old 18–26
9–11 years old 16–22
12–Adult 12–20
 Characteristics of the respiration:
Respiratory Rate:
Tachypnea—quick, shallow breaths
Bradypnea—abnormally slow breathing
Apnea—cessation of breathing
 Characteristics of the respiration:
Respiratory Rhythm: It refers to the regular and equal
spacing of breaths. In a regular respiratory rhythm, the
cycles of inspiration and expiration have about the
same rate and depth. With irregular breathing patterns,
the depth and amount of air inhaled and exhaled and
the rate of respirations per minute will vary.
 Characteristics of the respiration:
Respiratory Depth: The depth of respiration is the
volume of air that is inhaled and exhaled. It is described
as either “shallow” or “deep.” Rapid but shallow
respirations occur in some disease conditions, such as
high fever, shock, and severe pain.
Hyperventilation refers to deep and rapid respirations,
and hypoventilation refers to shallow and slow
respirations.
 Characteristics of the respiration:
Respiratory Quality: Respiratory quality or character
refers to breathing patterns — both normal and
abnormal. Labored breathing refers to respirations that
require greater effort from the patient.
Dyspnea—difficult and labored breathing during which the individual
has a persistent, unsatisfied need for air and feels distressed
Orthopnea—ability to breathe only in upright sitting or standing
positions
Breath Sounds: Normal respirations do not usually
have any noticeable sounds. However, certain diseases
and illnesses can cause irregular respiration sounds.
 Characteristics Of The Respiration:
• Abnormal breath sounds that are audible without
amplification include the following:
• Stridor: A shrill, harsh sound, heard more clearly during
inspiration but that can occur during expiration. This sound
may occur when there is airway blockage, such as in
children with croup and patients with laryngeal
obstruction. –
• Stertor (stertorous breathing): Noisy sounds during
inspiration, sounds similar to those heard in snoring.
• Crackles (also called rales): Crackling sounds resembling
crushing tissue paper, caused by fluid accumulation in the
airways.
 Characteristics Of The Respiration:
• Rhonchi — Rattling, whistling, low-pitched sounds made in
the throat. Rhonchi can be heard in patients with
pneumonia, chronic bronchitis, cystic fibrosis, or COPD.
• Wheezes — Sounds similar to rhonchi but more high
pitched, made when airways become obstructed or
severely narrowed, as in asthma or COPD.
• Cheyne-Stokes breathing — Irregular breathing that may
be slow and shallow at first, then faster and deeper, and
that may stop for a few seconds before beginning the
pattern again. This type of breathing may be seen in certain
patients with traumatic brain injury, strokes, and brain
tumors.
Assessment of respiration Respiratory rate

• Eupnoea ( 12 – 20/ min)

• Ventilatory depth: The depth of respiration is
assessed by observing movement of chest wall
A deep respiration involves a full expansion of the lungs
with full exhalation.
• Ventilatory depth: Diaphragmatic breathing results
from the contraction and relaxation of the diaphragm
and is best observed by watching abdominal
movements.
 Conti…
Ventilatory diffusion and perfusion:
The respiratory process of diffusion and perfusion can
be evaluated by measuring the oxygen saturation of the
blood.
• Color of skin
• Capillary refill
 Alterations In Respirations
Apnea: Absence of breathing.
Eupnea: Normal breathing
Orthopnea: Only able to breathe comfortable in upright position
(such as sitting in chair), unable to breath laying down.
Dyspnea: Subjective sensation related by patient as to breathing
difficulty.
Paroxysmal nocturnal dyspnea attacks of severe shortness of
breath that wakes a person from sleep
Hyperpnea: Increased depth of breathing
Tachypnea: Increased frequency without blood gas abnormality
Bradypnea: is a respiratory rate that is lower than normal for
age.
 Alterations in respiration
• Hyperventilation: Increased rate or depth, or
combination of both.
• Hypoventilation: Decreased rate or depth, or some
combination of both.
• Kussmaul's Respiration: is a deep and labored
breathing pattern often associated with severe
metabolic acidosis, particularly diabetic ketoacidosis
(DKA) but also kidney failure.
 Blood Pressure
BLOOD PRESSURE
Blood pressure (BP) is one of the most important vital signs
because it aids in diagnosis and treatment, especially for
cardiovascular health. Blood pressure readings are almost
always taken at every medical visit, even if it is the only vital
sign obtained.
Definition: Blood pressure is the amount of force
exerted on the arterial walls while the heart is pumping
blood— specifically, when the ventricles contract.
 Blood Pressure
Blood pressure is measured by gauging the force of this
pressure through two specific readings: Systolic and
Diastolic.
Systolic blood pressure is the highest pressure that
occurs as the left ventricle of the heart is contracting.
Diastolic blood pressure is the lowest pressure level
that occurs when the heart is relaxed and the ventricle
is at rest and refilling with blood.
 Blood Pressure
Blood pressure is read in millimeters (mm) of mercury
(Hg), or “mmHg”. Blood pressure is recorded using just
the systolic (highest pressure) reading over the diastolic
(lowest pressure), similar to writing a fraction.
For example, 120/80 would indicate a systolic pressure of
120 (mmHg) and a diastolic reading of 80 (mmHg).
 Conti..
Pulse pressure: PP is the difference between the systolic
and diastolic readings and calculated by subtracting the
diastolic reading from the systolic reading. If the blood
pressure is 120/80, the pulse pressure is 40.
In general, a pulse pressure that is greater than 40 mmHg is
considered widened, and one that is less than 30 mmHg is
considered to be narrowed.
.
 Conti..
Pulse pressure
A widened pulse pressure may be an indicator for
cardiovascular disease and anemia
A narrowed pulse pressure may be an indicator for
congestive heart failure (CHF), stroke, or shock.
Although pulse pressure is useful in predicting
cardiovascular risk in patients, it should not be used
alone and depends on various other factors, such as
the patient’s BP and age.
 Physiology and Regulation:
There are two basic mechanisms for regulating blood
pressure:
(1) short-term mechanisms, which regulate blood
vessel diameter, heart rate and contractility
(2)long-term mechanisms, which regulate blood
volume
 Conti..
2. Long-term mechanisms, which regulate blood
volume Kidneys regulate arterial blood pressure by
Direct renal mechanism
Indirect renal (renin-angiotensin-aldosterone)
mechanism
 Physiology of arterial blood pressure
A person’s blood pressure reflects the interrelation ship
of followings…..
1. Cardiac out put
2. Peripheral Vascular Resistance
3. Blood volume
4. Blood viscosity
5. Artery elasticity
Blood Pressure Guidelines
Blood Pressure Guidelines
 Factors affecting blood pressure
• Race
• Exercise
• Age
• Diurnal variation
• Stress
• Gender
• Medications
 Blood Pressure Assessment
Equipment used are
blood pressure cuff, a sphygmomanometer, and a stethoscope.
Types of sphygmomanometers:
• Mercury
• Aneroid
• Electronic
1. Direct (invasive, arterial blood pressure monitoring)
2. Indirect
I. Auscultatory method
II. Palpatory method
 Blood Pressure Assessment
1.Direct method- A monitor is used for this method. This is
a continuous method which measures mean pressures. A
needle or catheter is inserted into the brachial, radial or
femoral artery and a monitor displays arterial pressure in
wave form.
Direct (invasive) blood pressure monitoring is
recommended in sick and compromised patients, those
who are at risk of developing major blood loss during
surgery or for whom abnormal blood gases are anticipated
(patients with respiratory disease or undergoing
thoracotomies).
 Blood Pressure Assessment
2. Indirect method- Taking blood pressure by using
sphygmomanometer.
Palpatory method
In the palpatory method of blood pressure
determination, instead of listening for the blood flow
sounds, the nurse uses light to moderate pressure to
palpate the pulsations of the artery as the pressure in
the cuff is released. The pressure is read from the
sphygmomanometer when the first pulsation is felt
 Conti..
The auscultatory method is most commonly used in
hospitals, clinics, and homes. External pressure is applied to
a superficial artery and the nurse reads the pressure from
the sphygmomanometer while listening with a stethoscope.
When carried out correctly, the auscultatory method is
relatively accurate.
When taking a blood pressure using a stethoscope, the
nurse identifies phases in the series of sounds called
Korotkoff’s sounds. The systolic pressure is the point where
the first tapping sound is heard while the diastolic pressure
is the point where the sounds become inaudible .
 BP Assessment sites:
1. Upper arm
2. Thigh
3. Leg
4. Forearm
Upper arm (using brachial artery (commonest)
Thigh around popliteal artery
Fore -arm using radial artery
Leg using posterior tibial or dorsal pedis
 Alteration in Blood Pressure
1.Hypertension
2.Hypotension:
3. Orthostatic Hypotension or Postural Hypotension
 Alteration In Blood Pressure
1. Hypertension:
It is an often a symptomatic disorder characterized by
persistently elevated blood pressure. The diagnosis of
hypertension is made when an average of two or more
diastolic readings on at least two visits is 90 mm Hg or
higher. Or
when the average of multiple systolic blood pressures on
two or more subsequent visits is consistently higher than
135 mm Hg.
 Alteration in Blood Pressure
2.Hypotension: is generally considered present when
the systolic blood pressure falls 90 mm Hg or below.
3.Orthostatic Hypotension or Postural Hypotension:
It occurs, when a normotensive person develops
symptoms of and low blood pressure when rising to an
upright position. Or change his position from lying to
sitting and to standing position.
 REFERENCES

kozier & Erb’s Fundamental of Nursing ,8th edition

( Audrey Berman ,Shirlee J. Synder).

Fundamentals of Nursing: Standards & Practice, 2nd Edition

( Sue C. DeLaune Patricia K. Ladner.)

www.slideshare.com

www.google.com

97
Skin Management

Zia Ullah
Lecturer, KMU
 Objectives:

By the end of this presentation students will be

able to:
1. Define decubetic ulcer (bed sore)
2. List the causes of decubetic ulcer
3. Apply nursing interventions to prevent
decubetic ulcer
4. Identify risk factors of bed sore

2
 Pressure Ulcers

A pressure ulcer is a wound with localized area

of tissue necrosis.
It is also known as pressure sore, bed sore,
Decubitus Ulcer or distortion sore.
– Depending on the depth of the ulcer a pressure
ulcer may be an acute wound or chronic wound.
– The underlying cause is pressure.
– Most pressure ulcers develop when soft tissue is
compressed between a bony prominences and
external surface for a prolonged period of time.
 Cont.…

Two mechanisms contributes to the pressure ulcer

development.
1. External pressure that compressed blood vessels
2. Friction and shearing forces that tear and injure
blood vessels and abrade the top layer of skin.
Friction: it is a force acting parallel to skin surface.
E.g. sheet rubbing.
Shearing force: It is the combination of friction and
pressure, commonly occur due to Fowler’s position.
 Risk Factors

Immobility :Some one who sits or lies most of

the time is at risk for a pressure ulcer because
immobility causes prolonged pressure on the body
area.
Inadequate Nutrition: protein-calorie
malnutrition predispose a person to pressure ulcer
formation because poorly nourished cells are easily
damaged. It causes weight loss, muscle atrophy,
and loss of subcutaneous tissue
 Cont.…

Urinary Incontinence: the moisture associated

with urinary incontinence is believed to increased
the risk for skin damage due the chemical irritation
from the ammonia in the urine.
Decreased Mental Status: Individuals with a
reduced level of awareness, for example, those
who are unconscious, heavily sedated, or have
dementia, are at risk for pressure ulcers because
they are less able to recognize and respond to pain
associated with prolonged pressure.
 Cont.…

Diminished Sensation: Paralysis, stroke, or

other neurologic disease may cause loss of
sensation in a body area. Loss of sensation
reduces a person’s ability to respond to trauma, to
injurious heat and cold, and to the tingling (“pins
and needles”) that signals loss of circulation.
 Cont.…

Advanced Age: The aging process brings about several

changes in the skin and its supporting structures, making
the older person more prone to impaired skin integrity.
These changes include the following:
 Generalized thinning of the epidermis
 Decreased strength and elasticity of the skin due to
changes in the collagen fibers of the dermis
 Increased dryness due to a decrease in the amount of oil
produced by the sebaceous glands
 Diminished pain perception due to a reduction in the
number of cutaneous end organs responsible for the
sensation of pressure and light touch
 Diminished venous and arterial flow due to aging
vascular walls.
 Cont..

Chronic Medical Conditions: Certain chronic

conditions such as diabetes and cardiovascular
disease are risk factors for skin breakdown and
delayed healing. These conditions compromise
oxygen delivery to tissues by poor perfusion and
thus cause poor and delayed healing and increase
risk of pressure sores.
 Cont..

Other Factors: Other factors contributing to the

formation of pressure ulcers are poor lifting and
transferring techniques, incorrect positioning, hard
support surfaces, and incorrect application of
pressure relieving devices.
Common Sites of Pressure Ulcers
 Stages of Pressure Ulcer

Based ,on the observable depth of tissue

damage,there are four stages of ulcers
Stage 1
Stage 2
Stage 3
Stage 4
In 2007, two new stages were added:
Suspected deep tissue injury and Unstageable.

20
 Stages of Pressure Ulcer

Stage 1 Pressure ulcer

Skin is intact and shows a non blanchable,
localized redness or erythema over a bony
prominence. Redness remains after pressure is
released. Signs and symptoms may include pain,
firm, soft, warm or cool compared to adjacent
tissue. – EPIDERMIS
Involves only the epidermal layer of skin

21
 Stages of Pressure Ulcer

Stage 2 Pressure ulcer

A partial thickness skin loss. Superficial break in the
epidermis or partial thickness loss of dermis. Presents as
a shiny or dry shallow ulcer without slough or bruising.
In this stage the ulcer may be refered as blister or
abrasion.

22
 Stages of Pressure Ulcer

Stage 3 Pressure ulcer

Skin break with deep tissue involvement down to
subcutaneous layer. Full thickness skin tissue loss.
Subcutaneous fat may be visible but bone, tendon or
muscle is not exposed.

24
 Stages of Pressure Ulcer

Stage 4 Pressure ulcer

Skin break with deep tissue involvement down to the
bone, tendon, or muscle. Full thickness tissue loss with
exposed bone, tendon or muscle. Slough or eschar may
be present on some parts of the wound bed. Often
include undermining and tunneling. Stage 3 and 4 are
considered Full Thickness wounds

23
 Stages of Pressure Ulcer

Unstageable: Full thickness tissue loss in which

the base of the ulcer is covered by slough
(yellow, gray, green or brown) and/or eschar
(brown or black) in the wound bed.
The slough or eschar must be removed before the
true stage can be determined.
 Stages of Pressure Ulcer

Suspected Deep Tissue Injury (SDTI):

It is a purple or maroon localized area of
discoloured intact skin or blood filled blister
because of damage to underlying soft tissue.
Level of tissue necrosis is suspected to be deep.
 Risk Assessment

Several scales exist to assess patients at risk for

pressure ulcer development.eg
• The Norton Scale
• Braden Scale
• Waterlow scale
Beside this,we also use (PUSH )3.0 tool for
monitoring
Ulcer healing
PUSH=Pressure Ulcer Scale for Healing
The Norton Scale
Braden Scale
Waterlow Scale
 Pressure ulcer management

Pressure Ulcer management include:

 Prevention

Treatment
 Prevention

1). Position Changes:

Changing position frequently and consistently is crucial
to preventing bed sores. Expert advise shifting
position about every 15 minutes that you are in a
wheel chair and atleast once every two hours,even
during the night, if you spend most of your time in
bed.
 Prevention
Rule of 300
Reposition bedridden patients according to
the “ Rule of 30”
• HOB elevated no more than 30 degree
• Place body in 30, laterally incline position
• Hips and shoulder 30 from supine
• Support with pillow or wedges
 Prevention

2)Skin Inspection: Daily skin inspection for

pressure ulcer & skin care , is an integral part
of prevention
3)Nutrition: A healthy diet is important in
preventing skin breakdown and in wound
healing. Adequate hydration to maintain the
skin integrity. Because an inadequate intake
of calories,protein, vitamins and iron is
believed to be a risk factor for pressure Ulcer
development.
 Prevention

4). Lifestyle changes:

Quitting smoking
Exercise- Daily exercise improve circulation
5).Pressure-relieving Devices:
Such as air mattress, water mattress.
So prevention focuses on local pressure reduction,
Skin care, improve general condition
 Treatment of PU

1) Changing Position often.

2) Using support surfaces
3) Cleaning
4) Controlling incontinence
5) Removal of damaged tissue(debridement).
6) Dressing
7) Oral antibiotics
8) Healthy Diet.
9) Surgical repair
 Role of Nurse in prevention &
Management of Bed Sores
The Nurse must continuously assess the client
who are at risk for pressure ulcer development
Assess the client for:
• The predisposing factors for bed sore
development.
• Skin condition at least twice a day.
• Inspect each pressure site.
• Palpate the skin for increased warmth.
• Inspect for dry skin, moist skin, breaks in skin
 Role of Nurse in prevention &
Management of Bed Sores
• Evaluate level of mobility
• Evaluate circulatery status (edema,periphral
pulse)
• Assess neurovascular status
• Determine presence of Incontinence
• Evaluate nutritional and hydration status
• Note present health problems
 Nursing Interventions

Patient with decreased sensory perception

• Assess pressure points for signs of bed sore
development
• Provide pressur-redistribution surface.
Patient with Incontinence
• Assess need for incontinence management.
• Following each incontinent episode, clean area
and dry thoroughly
• Protect skin with moisture-barrier ointment.
 Nursing Interventions

Intervention to avoid Friction and shear

• Reposition patient using draw sheet and lifting off
surfaces
• Avoid dragging the patient in bed.
• Use proper positioning technique.
• Use comfort devices appropriately.
Patient with decreased Activity or mobility
• Establish individualized turning schedule
• Change position at least once in two hours & more
frequently for the highest risk individuals.
 Nursing Interventions

Clients with poor Nutrition

• Provide adequate nutrition and fluid intake.
• Assist with intake as necessary.
• Consult dietition for nutritional evaluation.
• Evaluate the ulcer progress every 4-6 days.
• Assist the physician or surgeon in debridement.
• Educate the patient and familyregarding the risk
factors and prevention of bed sores.
 References

kozier & Erb’s Fundamental of Nursing ,8th

edition( Audrey Berman ,Shirlee J. Synder).
RCNS Hussain (RN, BScN) 36
Pressure Ulcer/Bed Sores & Skin
Management

By : Ibne Amin
Institute of Nursing Sciences,
Khyber Medical University , Peshawar
 Pressure Ulcer/Bed Sores & Skin
Management
At the end of the session , learners will be able to:
1. Define decubetic ulcer (bed sore)
2. List the causes of decubetic ulcer
3. Identity risk Factars of bedsores
4. Apply nursing interventions to prevent
decubetic ulcer.

2
 Anotomy of Skin

Skin consists of 3 main layers

• Epidermis :
-the superfaicial portion of the skin
-composed of epithelial tissue
• Dermis :
-the deeper layer of the skin
-Primirily composed of connective tissue
• Hypodermis :
- also called the subcutaneous layer
-Consists of areolar and adipose tissue

3
 Anotomy of Epidermis
The epidermis is the outer layer that forms the protective covering. A
protective barrier of stratified squamous epithelium consisting of 5
layers
1 .Stratum corneum: 20-30 rows of flat dead cells continually shed ,surrounded
by lipid hence water repellent. Barrier to light, heat,water,chemicals & bacteria
2. Stratum lucidum: 3-4 layers clear flat dead cells ,contain precursor of keratin.
Present only in the finger tips,palms of the hand, & soles of the feet
3. Stratum granulosum: Cells degenerating with production of keratin
4. Stratum spinosum: 8-10 rows of cells that produce protein but can not
duplicate ,provide strength and flexibility. Langerhan cells
5. Stratum basale: Deepest layer made of columnar cells continually dividing,
gradually migrating to surface. Merkle cells, Melanocytes, stem cells
,keratinocytes

4
 Anotomy of Epidermis

Four principle Cells of Epidermis:

• Melanocytes: Produce melanin pigment causing brown
colouration of skin and protects skin from UV light damage
• Langerhan Cells: Immune cells which help in defence.
Situated in stratum spinosum, they help process and present
foreign antigens to the immune system
• Merkel Cells: Within the basal layer, close to hair follicles;
involved in touch sensation
• Keratinocytes : Produce the protein Keratin, which help
protect the skin and underlying tissue from heat, chemicals,
and microbes
5
 Anotomy of Dermis

Connective tissue layer composed of collagen &

elastic fibres,fibroblasts, macrophages and fat
cells.Contain hair follicles,glands,nerves and
blood vessels.
It is consists of 2 layers:
• Papiliary dermis
• Reticular dermis

6
 Anotomy of Dermis

1: Papiliary dermis: The upper 20% layer of

dermis.Finger like projection are called dermal papillea
that anchors epidermis to dermis. It has extensions
protruding into the epidermis called Rete pegs which also
contain small capillary loops that feed epidermis.
• Meissner’s corpuscles (sensation of touch, shape and
texture) ,
• Pacinian corpuscles (deep pressure and vibrational
sensation) , and
• free nerve ending for sensation of heat , cold ,pain .

7
 Anotomy of Dermis

Reticular dermis:
• The lower layer of dermis.
• It is dense irregular connective tissue ,made up of
collagen, elastin and ground substance as well as hair
follicles, sweat and sebaceous glands
• provide strength, extensibility and elasticity to the
skin.

8
 Anotomy of Dermis
Fibroblasts are the predominant cell type in the dermis and
produce collagen and elastin which provide strength and
flexibility to the skin.In addition, there are blood vessels,
sebaceous glands, sweat glands, hair follicles, sensory
receptors and fat cells.
• Myofibroblasts - contractile, important in healing of wounds
• Macrophages - derived from vascular leucocytes; phagocytic and
stimulate fibroblasts
• Mast cells - contain histamine
• Lymphocytes - mediate immune function
• Sensory receptors

9
 Functions of the Skin

• Physical barrier (Protection )

• Vitamin D production
• Immunity
• Sensation
• Identity
• Temperature control (thermoregulation)
• Excretion and Absorbtion

10
 Pressure Ulcer/ Bed sores
A Pressure Ulcer or Bed Sore or Decubitus Ulcer is a localized
injury to the skin and underlying tissue,usually over a body
prominence,as a result of prolonged unrelieved pressure.
OR
A pressure ulcer is a wound with localized area of tissue
necrosis.
It is also known as pressure sore, bed sore, Decubitus Ulcer or
distortion sore.
Depending on the depth of the ulcer a pressure ulcer may be an
acute wound or chronic wound.
The underlying cause is pressure.
Most pressure ulcers develop when soft tissue is compressed between a bony prominences and external
surface for a prolonged period of time.

11
 Pressure Ulcer/ Bed sores

Two mechanisms contribute to the pressure ulcer

development.
1. External pressure that compressed blood vessels
2. Friction and shearing forces that tear and injure
blood vessels and abrade the top layer of skin.
Friction: it is a force acting parallel to skin
surface. e.g. sheet rubbing.
Shearing force: It is the combination of friction
and pressure, commonly occur due to Fowler’s
position.
Pathophysiology of Pressure Ulcers
 Etiology of Pressure Ulcer

Pressure ulcers are due to localized ischemia,a

deficiency in the blood suply to the tissue.The tissue
is compressed between two surfaces, usually the
surface in the bed and the boney skeleton,with
greater than 32 mm of pressure. As a result the
tissue is deprived of oxygen & other nutrients and
consequently the tissue dies.
Reactive Hyperemia Vasodialation

16
 Common Sites of Pressure Ulcers

A) Supine Position
• Heels (calcaneus)
• Sacrum
• Elbows (olecranon process)
• Scapulae
• Back of Head (Occipetal bone)

12
 Common Sites of Pressure Ulcers

B) In lateral position
• Malleolus (medial & leteral)
• Knee (medial & lateral condyles)
• Greater trochantor
• Ilium
• Shoulder (acromial process)
• Ear
• Parietal and temporal bone

13
 Common Sites of Pressure Ulcers

C) In Prone position
• Toes (phalanges)
• Knee (patellas)
• Genitalia (men)
• Breast (women)
• Shoulder (acromial process)
• Cheek and ear (Zygomatic bone)

14
 Common Sites of Pressure Ulcers

D) Fowler’s Position
• Heels (calcaneus)
• Pelvic (ischial tuberosity)
• Sacrum
• Vertebrae (spinal processes)

15
 Risk Factors

Risk Factors

Intrinsic Extrinsic

17
 Risk Factors

1) Intrinsic Factors perception

• Malnutrition
• Dehydration • Altered mental status
• Age>70 years • Impaired circulation,
• Decreased mobility • Illness
• Increased temperature (malignancy, diabetes, stroke,
pneumonia, heart failure,
• Excessive perspiration sepsis, hypotension, renal
• Urinary/fecal failure, anemia,
incontinence, immunocompromised patients
• Decreased sensory
18
 Risk Factors

2) Extrinsic Factors
• Pressure
• Shear
• Friction
• Moisture
Other factor contributing to the formation of bed
sores are poor lifting or transferring
techniques,incorrect positioning,hard support
surfaces etc

19
 Stages of Pressure Ulcer

Based ,on the observable depth of tissue

damage,there are four stages of ulcers
Stage 1
Stage 2
Stage 3
Stage 4
In 2007, two new stages were added:
Suspected deep tissue injury and Unstageable.

20
 Stages of Pressure Ulcer

Stage 1 Pressure ulcer

Skin is intact and shows a non blanchable, localized
redness or erythema over a bony prominence.
Redness remains after pressure is released. Signs and
symptoms may include pain, firm, soft, warm or cool
compared to adjacent tissue. – EPIDERMIS
Involves only the epidermal layer of skin

21
 Stages of Pressure Ulcer

Stage 2 Pressure ulcer

A partial thickness wound. Superficial break in
the epidermis or partial thickness loss of
dermis. Presents as a shiny or dry shallow
ulcer without slough or bruising. In this stage
the ulcer may be refered as blister or abrasion

22
 Stages of Pressure Ulcer

Stage 3 Pressure ulcer

Skin break with deep tissue involvement down to
subcutaneous layer. Full thickness skin tissue loss.
Subcutaneous fat may be visible but bone, tendon or
muscle is not exposed. Slough may be present but
does not obscure the depth of tissue loss. May
include undermining and tunneling. Epidermis
,dermis and subcutanous tissue involved.

24
 Stages of Pressure Ulcer

Stage 4 Pressure ulcer

Skin break with deep tissue involvement down
to the bone, tendon, or muscle. Full thickness
tissue loss with exposed bone, tendon or
muscle. Slough or eschar may be present on
some parts of the wound bed. Often include
undermining and tunneling. Stage 3 and 4 are
considered Full Thickness wounds.

23
 Stages of Pressure Ulcer

Unstageable: Full thickness tissue loss in which

the base of the ulcer is covered by slough
(yellow, gray, green or brown) and/or eschar
(brown or black) in the wound bed.
The slough or eschar must be removed before
the true stage can be determined.
 Stages of Pressure Ulcer

Suspected Deep Tissue Injury (SDTI):

It is a purple or maroon localized area of

discoloured intact skin or blood filled blister
because of damage to underlying soft tissue.
Level of tissue necrosis is suspected to be deep.
 Risk Assessment

Several scales exist to assess patients at risk for

pressure ulcer development.eg
• The Norton Scale
• Braden Scale
• Waterlow scale
Beside this,we also use (PUSH )3.0 tool for monitoring
Ulcer healing
PUSH=Pressure Ulcer Scale for Healing
 Pressure ulcer management

Pressure Ulcer management include:

 Prevention

Treatment
 Prevention

Bed sores are easier to prevent than to treat.Although

wound can develop inspite of the most scrupolous
care,it is possible to prevent them in many cases.
1) Position Changes
2) Skin Inspection
3) Nutrition
4) Lifestyle changes
5) Use pressure relieving devices

25
 Prevention

1). Position Changes:

Changing position frequently and consistently is crucial
to preventing bed sores. Expert advise shifting
position about every 15 minutes that you are in a
wheel chair and atleast once every two hours,even
during the night, if you spend most of your time in
bed.
 Prevention

Rule of 300
Reposition bedridden patients according to the
“ Rule of 30”
• HOB elevated no more than 30 degree
• Place body in 30, laterally incline position
• Hips and shoulder 30 from supine
• Support with pillow or wedges
 Prevention

2)Skin Inspection: Daily skin inspection for

pressure ulcer & skin care , is an intrgral part of
prevention
3)Nutrition: A healthy diet is important in
preventing skin breakdown and in wound healing.
Adequate hydration to maintain the skin
integrity. Because an inadequate intake of
calories,protein, vitamins and iron is believed to
be a risk factor for pressure Ulcer development.
 Prevention

4). Lifestyle changes:

Quitting smoking
Exercise- Daily exercise improve circulation
5).Pressure-relieving Devices:
Such as air mattress, water mattress.
So prevention focuses on local pressure reduction, Skin care,
improve general condition
 Treatment of PU

1) Changing Position often.

2) Using support surfaces
3) Cleaning
4) Controlling incontinence
5) Removal of damaged tissue(debridement).
6) Dressing
7) Oral antibiotics
8) Healthy Diet.
9) Surgical repair
 Role of Nurse in prevention &
Management of Bed Sores
The Nurse must continuously assess the client who are
at risk for pressure ulcer development
Assess the client for:
• The predisposing factors for bed sore development.
• Skin condition at least twice a day.
• Inspect each pressure site.
• Palpate the skin for increased warmth.
• Inspect for dry skin, moist skin, breaks in skin
 Role of Nurse in prevention &
Management of Bed Sores
• Evaluate level of mobility
• Evaluate circulatery status (edema,periphral pulse)
• Assess neurovascular status
• Determine presence of Incontinence
• Evaluate nutritional and hydration status
• Note present health problems
 Nursing Interventions

Patient with decreased sensory perception

• Assess pressure points for signs of bed sore development
• Provide pressur-redistribution surface.
Patient with Incontinence
• Assess need for incontinence management.
• Following each incontinent episode, clean area and dry
thoroughly
• Protect skin with moisture-barrier ointment.
 Nursing Interventions

Intervention to avoid Friction and shear

• Reposition patient using draw sheet and lifting off surfaces
• Avoid dragging the patient in bed.
• Use proper positioning technique.
• Use comfort devices appropriately.
Patient with decreased Activity or mobility
• Establish individualized turning schedule
• Change position at least once in two hours & more frequently
for the highest risk individuals.
 Nursing Interventions

Clients with poor Nutrition

• Provide adequate nutrition and fluid intake.
• Assist with intake as necessary.
• Consult dietition for nutritional evaluation.
• Evaluate the ulcer progress every 4-6 days.
• Assist the physician or surgeon in debridement.
• Educate the patient and family regarding the risk factors and
prevention of bed sores.
 References

kozier & Erb’s Fundamental of Nursing ,8th

edition( Audrey Berman ,Shirlee J. Synder).
CONCEPT OF SAFETY AND RISK
MANAGEMENT

By : Ibne Amin
BSN,MSN
Khyber Medical University, Peshawar
 OBJECTIVES

By the end of presentation the learners will be able to:

 Define safety and Risk.

 Identify factors affecting safety.

 Identify environmental hazards.

 Identify hazards in hospital environment (Physical &
Microbial) which alter patient safety.

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 CONT......

 Discuss general preventive measures for patient

safety.

 Identify the preventive measures to ensure health

care workers and patient safety.

 Discuss specific safety concerns in hospital

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 DEFINITION OF SAFETY, RISK & HAZARD

 Safety may be defined as freedom from psychological and

physical injury. It is a basic human need which must be met.
(Potter & Perry, 2007)

 Risk is the probability/chance of exposure to danger, harm or

loss.

 Hazard is an agent which has the potential to cause harm.

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 RISK

Risk can be Acute, intermediate, and chronic.

Acute: leads quickly to a health crises like fall, electric

current, radiation.

Intermediate: cause a problem not too fast or too slow.

Like elevated lipid, blood pressure, obesity.

Chronic: behavioral risk like tobacco use, unhealthy diet

use and physical inactivity
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 DIFFERENT FORM OF HAZARD

Physical: Noise, slippery floors, poor lighting, fire.

Chemical: toxic properties of gases, fumes, dust and liquids.

Radiation: X-rays, gamma rays, Microview, ultraviolet rays.
Ergonomics: poor design of equipment, work station, work
flow, method , manual handling.

Psychological: work load, discrimination, ignorance,

negligence, harassment, public dealing, threat of danger.

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 CONT……..
• Biological: Infection by bacteria, viruses, fungi, insect
bite, plant, bird, and contact with infected person.

RISK MANAGEMENT
• Risk management is complex process that involves
identification, analysis, and elimination of the risk
factors.

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 FCATORS AFFECTING SAFETY

• Age and development (old or young child)

• Life styles
• Mobility status
• Sensory Perception
• Safety awareness
• Communication
• Cognitive impairment
• Environmental factor such as Health acre setting, home
and community.

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 ENVIRONMENTAL HAZARDS

Pollution Electricity Radiations

Natural Disaster Violence Accidents

12/7/2019 9
 CONT....

Extreme temperature Poison

Machinery Microorganisms
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 HAZARDS IN HOSPITAL

Electrical Hazards Radiations Equipments out of order

Mercury spill Workplace violence Accidents (Falling)

12/7/2019 11
 CONT....

Stress Non sterile techniques Body Mechanics

 Needle stick injury (HIV, Hep B, Hep C etc )

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Assessment for Environmental Hazard
or Risk
A nurse must assess the environment for any threat to the
client safety.

• Client’s immediate environment.

• Individual risk factors
• Home hazard assessment
• Medication or undergoing for any procedure.

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 General Preventive Measures for
Patient Safety
• Give orientation to the client about unit
• Ensure the provision of basic needs (oxygen, Nutrition,
Temperature)
• Place a call bell within reach of the patient and teach
how and when to use it.
• Have proper lighting in the room
• keep the bed locked and in low position

12/7/2019 14
 CONT.....

• Use infection control measures (hand washing)

• Maintain close supervision of confused patient
• Place all equipment with in easy approach
• Use restrain if required
• Provide clean and calm environment
• Explain the procedures and plans

12/7/2019 15
 CONT……

• Answer the call bell on time

• Use isolation precautions where applicable
• Provide non-slippery, well-fitting footwear.
• Keep floor surface clean and dry.
• Ensure six rights of the patient (right patient, medicine,
dose, rout, time and documentation)

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 Preventive Measures for Health Care
Professionals’ Safety
• Awareness about standard safety policies and
procedures
• Know the emergency phone numbers like
fire, & Security emergency services
• Vaccination e.g. Hepatitis B vaccine
• Use of universal precautions (Hand washing
Protective measures such as using of gloves, gown,
cap, etc)
• Do not recap the needle
• Use of danger box
12/7/2019 17
 CONT.....
• Use proper body mechanics
• Learn proper use of equipments

Needle stick injury is one of the most serious exposures for

health care personnel that may cause blood borne
diseases, such as Hepatitis or AIDS. Always plan safe
handling and disposal of needles before beginning the
procedure. (Craven & Hirnle, 2003)

In case of accident, error or injury complete an incident

report according to policy and inform the supervisor.

12/7/2019 18
 Specific Safety Concerns In Hospitals
• The nurse should be aware of how to protect his/her
client from various kinds of hazards.

Fall:
• Familiarize the client with environment.
• Teach the client how to use the call bell.
• Keep the bed in low position with brakes locked.
• Provide non-slippery footwear
• Toilet should have safety bars for weak patients

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 RESTRAINS
• Obtain consent from the attendants
• It must be in the form of belt or soft clothes
• Restrain should be temporary.
• Apply in such way not to impede blood circulation (not too
tight or too loose).
• Always tie a limb restrain with knot that will not tighten when
pulled.

Mitt Restrain
Limb Restrain
12/7/2019 20
 SIDERAILS

• Help to increase patient’s mobility when on bed

• Helps to prevent fall of unconscious patients.

• When siderails are used then bed should be
maintained at the lowest position.

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 FIRE
• Home fire mostly result from careless disposal of
cigarette, matches, faulty electric wiring.
• In hospital usually from short circuit.
• Organization should have fire alarm, extinguisher and
hydrants system in every area.
• Organization should have fire exit door
• Once the smoke is detected the nurse should follow the
mnemonics RACE for others.
• All nurses, clients and family members including children
should know the steps when they themselves catch fire
STOP, DROP and ROLL for self.

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 CONT………
RACE

• Rescue: if the area is safe to enter, take out the client

• Alarm: Pull the fire alarm to report the exact location

• Confine: Confine the fire by closing all the doors

• Extinguish: Use the fire extinguisher

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 CONT…….
• Stop: Stop where you are

• Drop: Drop to the ground and

cover your eyes and mouth with
your hands.

• Roll: Roll over and over and back

and forth until the flames are out

12/7/2019 24
 Electric Hazards
• Electricity wire should be grounded in good working
order.
• Don not place wire under the carpet or on floor.
• No loose wire or connection
• Grasp the plug not the cord while unplugging
• Keep the electric equipment/wire away from sink,
bathtub and shower.
• Keep all the electric appliance out of the reach of
children.

12/7/2019 25
 Poison
• Lock all potentially toxic agent and medicine as well
• Avoid storing toxic agent in food container.
• Do not remove container label and label the container
• Do not keep poisonous plant at home
• Poison impair the function of respiratory, CNS, GI, CVS,
and Renal failure
• Urgently need specific antidotes

12/7/2019 26
 Lighting

• Adequate light is essential to reduce the risek of fall and

to work easily

• House exterior, interior and specially staircases should

have good lighting

• Night light (dim light )

12/7/2019 27
 BATHROOMS
To minimize the risk of injuries in
toilets, should take care of:

• Place safety bar

• Place raise commode
• Don’t use slippery material in floor
(tiles)
• Use non-slip, well-fitting footwear
• Keep the surface clean and dry
• Should have good lighting

12/7/2019 28
 SECURITY SYSTEM

The most common cause of death is falling asleep while the

ignition source was burning.

• Smoke detector should be installed

• Lead should not be used in house paint
• Especially gas valve should be closed before going to bed
• Secure house from intruders

12/7/2019 29
 REFERENCES
• Christensen, B. L., & Kockrow, E. O. (2006). Foundations and Adult Health Nursing.
(5th ed.). philadelphia: Mosby.

• Craven, R. F., & Hirnle, C. J. (2003). Fundamental of Nursing Human Health and
Function. (4thed.). New York: Lippincott.

• Potter, P.A & Perry, A.G (2007). Basic Nursing: Essentials for Practice. (6th ed.) St.
Louis: Mosby.

• Roger Pressman, ÒSoftware Engineering:A PractitionerÕs ApproachÓ, McGraw-

Hill, 5th edition, ISBN: 0-07-709677-0 (Chapter 6). Retrieved from
http://www.cs.ucl.ac.uk/staff/A.Finkelstein/advmsc/15.pdf

• Faculty & staff safety hand book , The Aga Khan University

• JCIA International patient safety goals

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CONCEPTS OF TEACHING AND
LEARNING
 OBJECTIVES
At the end of this unit; the learners would be
able to:
1. Define teaching and learning
2. Identify the learning needs of the patient at

the clinical site

3. Develop teaching learning plan
4. Perform health teaching at the clinical site
 Definition
Teaching: It is an active process in which one
person shares information with other to provide
them with the information to make behavioral
changes.
Learning : It is the process of assimilating
information with a resultant change in behavior.
or
Learning refers to relatively permanent changes in
behavior resulting from practice or experience
Cont..
 Teaching learning process
Teaching learning process is a planned
interaction that promote behavioral change
that is not a result of maturation and
coincidence.
 Teaching Process

Plane implement Evaluate

 Planning Phase

It includes decision like:

• The needs of the learner
• The achievable goals & objectives to meet the
needs
• Selection of the content to be taught
• Motivation to carry out the goal,
• Strategies most fit to carry out the goals
• Evaluation process to measure learning outcome
 Considerations in planning

• Learner
• Availability of materials
• Time requirement of particular activity
• Strategy need to achieve the objective
• Teacher
 Implementation phase

• Based on the objective, implementation

means to put into action the different
activities in order to achieve the objectives
through the subject matter.
• Interaction of the teacher and learner is
important in the accomplishment of the plan
Use of different teaching style and strategy are
included in this phase
 Evaluation phase

• A match of the objective with the learning

outcome will be made
• Answer the question if the plans and
implementation have been successfully
achieved
 Feedback and Reflection

A continuous process of feedback and reflection

is made in this three phases of teaching.
Feedback is the reflection of the information ;
Reflection is the process embedded in
teaching where the teacher inquires into his
action and provides deep and critical thinking
 Learning

• Defined as a change in an individual’s behavior

caused by experiences or self activity
• Implies that learning can only happen
through the individuals activity or his own
doing
• Can be intentional or unintentional
 Learning Styles

Information enters your brain three in main

ways: sight, hearing and touch, which one you
use the most is called your Learning Style

• Visual Learners learn by sight

• Auditory Learners learn by hearing
• Tactile Learners (kinesthetic) learn by touch
 Visual Learners

• Prefer to see information such as pictures, diagrams,

demonstrations
• Picture words and concepts they hear as images
• Easily distracted in lecture with no visual aids
• Benefit from using charts, maps, notes, and flash
cards when studying
 Auditory Learners

• Prefer to hear information spoken

• Can absorb a lecture with little effort
• May not need careful notes to learn.
• Often avoid eye contact in order to concentrate
• May read aloud to themselves
 Tactile or Kinesthetic Learners
• Prefer touch as their primary mode for taking in
information
• In traditional lecture situations, they should write out
important facts
• Create study sheets connected to vivid examples
• Role-playing can help them learn and
remember important ideas
Remember!
No matter what your Learning Style is it’s very
important to-
• Be involved in class – participate!
• Link classroom experience to the outside world
• Relate class concepts to your own life.
• Ask questions and offer criticism.
• Stimulate further relevant discussion.
• Don’t get distracted – stay “on-task”
• Keep an open mind: there are many ideas beyond your
own.
 Health education

Teaching process providing basic knowledge and

practice of health, so as to be interpreted into
proper health behavior.
 Aims of Health education

1. Health promotion and disease prevention.

2. Early diagnosis and management.
3. Utilization of available health services.
 Specific objectives of health education

1. To make health an asset valued by the community.

2. To increase knowledge of the factors that affect
health.
3. To encourage behavior which promotes and maintains
health.
4. To encourage appropriate use of health services
especially preventive services.
5. To inform the public about medical advances, their uses
and their limitations.
 Teaching Strategies

• Lecture
• Drill & Practice
• Compare & Contrast
• Demonstrations
• Guided & Shared - reading, listening, viewing,
thinking
 Teaching Learning Plan

• A teaching learning plan is a written guide for

trainers, plans in order to achieve the
intended learning outcomes. It provides
specific definition and direction on learning
objectives, equipment, instructional media
material requirements, and conduct of the
training
 learning needs of the patient at the
clinical site
The information given to the patient should be
appropriate for the patient's age, literacy level,
education, and language skills.
Use of medical terminology or jargon should be
avoided. For example, the term's "myocardial
infarction" and "MI" should not be used in place of
"heart attack" unless they have already been defined
for the patient.
 learning needs of the patient at the
clinical site
Family members are the vital links in the
transition from hospital to home care. Families
must be included in discussions and
demonstrations. Family is any person who
plays an important role in the patient's life.
learning needs of the patient at the clinical site

• Patient Assessment:
• Individualized Teaching:
• Safe and Effective Use of Medications:
• Medical Equipment and Supplies:
• Diet and Nutrition:
• Rehabilitation:
• Pain Management:
• Personal Hygiene:
• Psychosocial:
• Community Resources:
• Patient Rights:
• Patient Responsibilities:
• Follow-up Care:
 Patient Teaching

• Patient education is the process by which

health professionals and others impart
information to patients and their caregivers
that will alter their health behaviors or
improve their health status.
Cont..
Cont…
Cont.…
Cont..
Cont..
Cont..
Cont..
Cont..
Cont..
Cont..
Cont…
Cont..
Cont..
Cont..
Cont…
Cont..
Cont..
 References

kozier & Erb’s Fundamental of Nursing ,8th edition

( Audrey Berman ,Shirlee J. Synder).

Fundamentals of Nursing: Standards & Practice, 2nd Edition

( Sue C. DeLaune Patricia K. Ladner.)

www.slideshare.com

www.google.com
Oxygenation: Respiratory Function &
Cardiovascular System.

By: Ibne Amin

Khyber Medical University, Peshawar
 Objectives
At the completion of this unit learners will be able to:
1.Identify factors that can interfere with effective
oxygenation of body tissues.
2.Describe common manifestations of altered
respiratory and cardiovascular function
3.Discuss lifespan-related changes and problems in
respiratory function and cardiovascular system
4.Describe nursing measures to ensure a patient
airway
 Cont..
6.Recognize the emergencies related to
respiratory and cardiovascular system
7.Explain ways that caregivers can decrease the
exposure of clients to infection
8.Differentiate between medical and surgical
asepsis.
5. Apply Nursing Process and teaching plan for a
client with altered respiratory function and
cardiovascular function
 Oxygenation
Oxygen, a clear, odorless gas that constitutes
approximately 21%of the air we breathe, is necessary
for proper functioning of all living cells.
Oxygenation (the delivery of oxygen to the body’s
tissues and cells), is necessary to maintain life and
health.
 PHYSIOLOGY OF OXYGENATION

 The delivery of oxygen to the body’s cells is a process that

depends upon the interplay of the pulmonary, hematologic,
and cardiovascular systems.
 Specifically, the processes involved include ventilation,
alveolar gas exchange, oxygen transport and delivery, and
cellular respiration.
 The absence of oxygen can lead to cellular, tissue, and
organism death.
Anatomy and Physiology of respiration
Respiration
Respiration is the process of gas exchange between
the individual and the environment and involves
following components:
 Pulmonary ventilation –(breathing)
movement of air in and out of the lungs
 Inspiration –(inhalation) act or breathing in
 Expiration –(exhalation) act of breathing out
 External respiration – exchange of O2 and CO2
between alveoli and blood
 Internal respiration – exchange of O2 and CO2
between blood and tissue cells
 Cont.…
The Air way begins at nose and ends at terminal
bronchioles. Air way provides a pathway for transport of
oxygen and carbon dioxide.
Respiratory tract (Air Way) is divided into two:
• Upper Respiratory Tract (URT): consists of
nose, pharynx, larynx and epiglottis.
The main function is to warm, filter and humidify
inspired air.
• Lower Respiratory Tract (LRT): consists of
Trachea, Bronchi, bronchioles and lungs.
Its major function are conduction of air and surfactant
production.
 Factors Affecting Oxygenation
• Age
• Environment
• Life style
• Health Status
• Medication
• Stress
 Age
Oxygenation status can be influenced by age. Older adults are
also more susceptible to respiratory infection because of
decreased activity in the cilia, which normally are an effective
defense mechanism. Other changes includes the following.
• Chest wall and airways become more rigid and less elastic.
• Decreases in muscle strength
• The amount of exchanged air is decreased.
• The cough reflex and cilia action are decreased.
• Mucous membranes become drier and more fragile.
• Decreases in muscle strength and endurance occur.
• If osteoporosis is present, adequate lung expansion may be compromised.
• A decrease in efficiency of the immune system occurs.
• Gastroesophageal reflux disease is more common in older adults and
increases the risk of aspiration
 Environmental Factors
Environmental factors can significantly affect a client’s oxygenation
status. Altitude, heat, cold, and air pollution affect oxygenation.

• The higher the altitude, the lower the PO2 an individual breathes.
As a result, the person at high altitudes has increased respiratory
and cardiac rates and increased respiratory depth, which usually
become most apparent when the individual exercises.
• Healthy people exposed to air pollution, such as smog or
secondhand tobacco smoke, may experience stinging of the eyes,
headache, dizziness, and coughing.
• People who have a history of existing lung disease and altered
respiratory function experience varying degrees of respiratory
difficulty in a polluted environment. Some are unable to perform
self-care in such an environment.
 Lifestyle Factors
Physical exercise or activity increases the rate and depth of
respirations and hence the supply of oxygen in the body.
Sedentary people, by contrast, lack the alveolar expansion and
deep-breathing patterns of people with regular activity.
Clients who are exposed to dust, animal dander, asbestos, or
toxic chemicals in the home or workplace are at increased risk
for alterations in oxygenation.
• Silicosis is seen more often in sandstone blasters and potters
than in the rest of the population
• Asbestosis in asbestos workers
• Anthracosis in coal miners
• Organic dust disease in farmers and agricultural employees
who work with moldy hay
 Health Status
• In the healthy person, the respiratory system can
provide sufficient oxygen to meet the body’s needs.
Diseases of the respiratory system, however, can
adversely affect the oxygenation of the blood.
 Medications
A variety of medications can decrease the rate and
depth of respirations. The most common medications
having this effect are the benzodiazepine sedative-
hypnotics and antianxiety drugs (e.g., diazepam
[Valium], lorazepam [Ativan], midazolam [Versed]),
barbiturates (e.g., phenobarbital), and narcotics such as
morphine and meperidine hydrochloride (Demerol).
 Cont..

• When administering these, the nurse must

carefully monitor respiratory status, especially
when the medication is begun or when the
dose is increased. Older clients are at high risk
of respiratory depression and, hence, usually
require reduced dosages.
 Stress
When stress and stressors are encountered, both
psychological and physiological responses can affect
oxygenation. Some people may hyperventilate in response to
stress. When this occurs, arterial PO2 rises and PCO2 falls. The
person may experience light-headedness and numbness and
tingling of the fingers, toes, and around the mouth as a result.

Physiologically, the sympathetic nervous system is stimulated

and epinephrine is released during stress. Epinephrine causes
the bronchioles to dilate, increasing blood flow and oxygen
delivery to active muscles. Although these responses are
adaptive in the short term, when stress continues they can be
destructive, increasing the risk of cardiovascular disease.
 Maintaining Healthy Oxygenation
Encourage clients to:
1. Leave windows open for ventilation instead of using
an air conditioner or humidifier.
2. Wear a mask when working with hazardous
materials, such as asbestos.
3. Limit physical exertion if it causes shortness of
breath.
4. Refrain from smoking.
5. Change filters on furnaces, heaters, and range
hoods as recommended by manufacturer.
Common Manifestations Of Altered Respiratory
And Cardiovascular Function
• Apnea: Temporary cessation of breathing.
• Dyspnea: Difficulty in breathing. Eg. SOB
• Eupnea: Normal breathing. 12 to 20 b/m
• Hyperpnea: Increased rate and depth of breathing.
• Hyperventilation: Increased pulmonary ventilation
leading to low blood level of CO2
• Hypoventilation: Decreased pulmonary ventilation
leading to increased blood level of CO2
 Cont.…
• Orthopnea: Dyspnea that occurs when a person is
lying down.
• Tachypnea: Accelerated respiration
• Bradypnea: Abnormal slowness of breathing.
• Hypoxia: Low oxygen level in tissues
• Hypercarbia: (c): Accumulation of CO2 in the blood
• Hypoxemia: Reduced oxygen in the blood,
 Cont..
• Tachycardia – heart rate over 100
• Bradycardia – heart rate below 60
 Life span Consideration
Changes
1. Respiratory rate
• New born : 40-80breath /min
• Infant : 30breath /min
• Preschooler: 25breath/min
• Adult : 12-18 breath/min

2. Heart Rate
• New born : 80-200beats/min
• Infant- :80-150 beats /min
• Preschooler-Adult : 55-100 beats /min 21
Blood pressure:

• Newborn -3 days : 65/40

• After one month: 90/55
• Adult : 120/80

22
 Life Span Considerations
Problems
Premature infant:
• Lack of surfactant ( A substance in alveoli which
keeps the lungs wet and prevents collapse).
Infants & Toddlers:
• Risk of upper respiratory tract infections due to
exposure to other children and second hand smoke.
• Risk of airway obstruction also.

23
 Life Span Considerations
Problems
School age children & Adolescents:
• Respiratory infections and respiratory risk factors
such as second hand smoke & cigarette smoking. Can
lead to cardiopulmonary disease if continues.
Young & Middle age adults:
• Multiple cardiopulmonary risk factors due to
unhealthy diet, lack of exercise, stress, drugs &
smoking.

24
 Life Span Considerations
Problems
Older Adults:
• Body systems undergo changes throughout the aging
process, eg, atherosclerosis which leads to increased
BP.
Respiratory system changes-----thoracic cage changes---
-- eg, barrel chest-------decreased ventilation.

25
 Respiratory Emergencies

• Hypoxia
• Hypoventilation:
• Hypercarbia
• Hypoxemia
• Tachypnea:
• Hypoventilation
• Bradypnea
• Dyspnea:

26
 Signs of Hypoxia
• Rapid pulse
• Rapid, shallow respiration & dyspnea
• Increased restlessness
• Flaring of nares
• Substernal / Intercostal retractions.
• Cyanosis

27
 Cardiac Emergencies
• Cardiac Arrest (the abrupt loss of heart function, breathing
and consciousness.)
• Myocardial infarction (MI) (permanent damage to the heart
muscle.)
• Congestive Heart Failure:(Heart failure is a condition in which
the heart can't pump enough blood to meet the body's needs.
Heart failure does not mean that your heart has stopped or is
about to stop working. It means that your heart is not able to
pump blood the way it should.)
• Disturbances of Cardiac Rhythm (Arrhythmias)

28
 Nursing Process
Assessment:
• History Taking / Interviewing

• Physical Examination:-

29
 Nursing Process
Assessment: (History Taking)
• Current respiratory problems
• History of respiratory diseases
• Current or past cardiovascular problems
• Life style
• Presence of Cough
• Signs of hypoxia

30
 Nursing Process

Assessment:
• Sputum / (Characteristics of sputum)
• Description of sputum
• Presence of chest pain
• Presence of risk factors
• Medication history

31
 Nursing Diagnosis
• Primary Nursing Diagnoses

– Ineffective Airway Clearance

– Ineffective Breathing Patterns

– Impaired Gas Exchange

– Decreased Cardiac Output

– Altered Tissue Perfusion

 Secondary Nursing Diagnoses

• Deficient Knowledge

• Activity Intolerance

• Disturbed Sleep Pattern

• Imbalanced Nutrition

• Acute Pain

• Anxiety
 Planning

• Client maintains a patent airway.

• Client mobilizes pulmonary secretions.

34
 Implementation
1. Interventions to Promote Airway Clearance
– Teach the patient effective coughing.
– Initiate postural drainage and chest physiotherapy.
– Monitor hydration.
– Administer medications.
– Monitor environmental and lifestyle conditions.
– Manage artificial airways.
– Suction the airway.
Suctioning an Endotracheal Tube
 Implementation
2. Interventions to Improve Breathing Patterns

– Position client properly.

– Teach controlled breathing exercises.

– Manage chest drainage systems.

 Implementation

3. Interventions to Improve Oxygen Uptake and

Delivery

– Administer oxygen.
• simple mask
• Nasal canula
• Venturi mask
• Rebreathing and Non-rebreathing mask

– Administer blood components.

 Implementation

4. Interventions to Increase Cardiac Output and

Tissue Perfusion

– Manage fluid balance.

– Encourage activity restrictions and assistance
with activities of daily living.
– Position client properly.
– Administer medications.
 Implementation

• Emergency Interventions

– Remove airway obstruction.

– Initiate cardiopulmonary resuscitation (CPR).

 Implementation

• Interventions to Address Associated Nursing

Diagnoses

– Explore lifestyle and activity adaptations.

– Encourage dietary and nutritional modifications.

– Promote comfort measures.

 Asepsis

• Asepsis is the absence of microorganisms.

• Medical asepsis uses practices to reduce the
number, growth, and spread of microorganisms.
Medical asepsis is also referred to as “clean
technique.
• Surgical asepsis, or sterile technique, consists of
those practices that eliminate all microorganisms and
spores from an object or area.

42
Decrease the Exposure of Clients to
Infection.

43
Ways That Can Decrease The Exposure Of
Clients To Infection
 Oxygen Therapy
is the administration of oxygen at a concentration greater than
that found in the environmental atmosphere.
Goal:
Is to provide adequate transport of oxygen in the blood while
decreasing the work of breathing and reducing stress on the
myocardium
To prevent Hypoxia
Oxygen administration:
Oxygen therapy is prescribed by the physician who specifies the
concentration, method of delivery and liter flow per minute. The
concentration is of more importance than the liter flow per
minute
 Indications for Oxygen Therapy
Respiratory Conditions
 Lung disease
–Cyanosis
–Tachypnea  Heart Failure
–Hypoxemia  Chest injuries
–Partially obstructed airway  Airway obstruction
Cardiac Conditions  Stroke
–Chest pain
 Shock
–Shock
–Tachycardia  Seizures
–Arrhythmias  Diabetes
Neurological Deficits  Trauma
–CVA  Major blood loss
–Spinal injuries
 Head Injuries
–Coma
 Cont..
Humidifiers – prevent mucous
membranes from drying and becoming
irritated and loosens secretions for easier
expectoration. Oxygen passing through
water picks up water vapor before it
reaches the client
The oxygen passes through sterile
distilled water or tap water and then
along a line to the device through which
the moistened oxygen is inhaled ( e.g. a
Cannula, Nasal Catheter, or Oxygen
Mask).
 Types of Oxygen Delivery

1. Cannula • Simple face masks

2.Face Masks • Partial rebreather masks
• Non-rebreather masks
• Venturi masks

3. Face Tents
4.Transtracheal Oxygen
Delivery 5.Artificial Airways
-Oropharyngeal
- Nasopharyngeal
- Endotracheal
- Tracheostomy
 Nasal Cannula/Nasal Prongs)
• Flow rate up to 6L/min
• Unable to determine exact concentration
• Comfortable – allows patient to eat, drink talk
• Can still be used if patient’ mouth breathing
• Delivers O2 into the patient’s nostrils by way of two small
plastic prongs
• Delivers low concentration of O2 (24% to 45%) at flow rates of
2-6 L/min
• Most common inexpensive device
 Face Masks
Face masks that cover the client’s nose and
mouth may be used for oxygen inhalation.
Exhalation ports on the sides of the masks
allowed exhaled carbon dioxide to escape.
Simple Face Masks delivers oxygen
concentrations from 40% to 60% at liters flows of
5 – 8 L/minute, respectively
Partial Rebreather Masks
delivers oxygen concentrations of 60% to 90% at
liter flows of 6 to 10 L/ minute, respectively. The
oxygen reservoir bag that is attached allows the
client to rebreathe about the first third of the
exhaled air in conjunction with oxygen
 Face Masks

Non Rebreather Masks

It delivers the highest oxygen concentration possible – 95% to
100% - by means other than intubation or mechanical
ventilation at liter flows of 10 – 15 L/ minute,respectively.
Venturi Masks
The venturi masks delivers oxygen concentrations varying from
24% to 40% or 50% at liter flows of 4 to 10 L/ minute.
is often used with air-entrainment nebulizers to
provide humidification and oxygen therapy.
 Face Tents (Face Shield)

Can replace oxygen masks when

masks are poorly tolerated by clients.
Face tents provide varying
concentration of oxygen, for example
30% to 50% concentration of oxygen
at 4 to 8 L/minute.
 Artificial Airways
Oropharyngeal Airways
• An OPA is a device usually made of plastic
• It is inserted into patients mouth and into back of throat
• Helps to maintain an open airway for breathing/ resuscitation
• Use OPA’s only on unconscious patients who DON’T have a gag
reflex
Oropharyngeal airways stimulate the gag reflex and are only
used for clients with altered level of consciousness;
Example:
o Because of general anesthesia
o Overdose
o Head injury
 Suctioning

• NEVER suction for longer than 15 seconds at a time

• NEVER suction as you are inserting the catheter,
place the suction tip in the patients mouth before
starting suction
 Nurses Responsibilities
• The nurse should explain the reason and the
objective for the therapy
• The nurse should know the proper care of and
administration of oxygen
• Instruct the patient and family the methods for
administering oxygen
• Demonstrate safe and appropriate use of oxygen and
oxygen device
• Identify to patient and family the signs and
symptoms indicating the need for oxygen
 References

 Berman, A., Snyder, S. J., Kozier, B., Erb, G., Levett-

Jones, T., Dwyer, T., ... & Park, T. (2010). Kozier and
Erb's fundamentals of nursing (Vol. 1). Pearson
Australia.
 Delaine, S., & Lander, P. (2008). Fundamentals of
nursing standard and practice.
 Waugh, A., & Grant, A. (2001). Ross and Wilson
anatomy and physiology in health and illness.
Churchill Livingstone.

56
Activity and Exercise Pattern

Ibne Amin
Faculty INS, KMU
 Objectives
At the completion of this unit learners will be able to:
1.Define terms mobility, joint mobility, body
alignments and body mechanics.
2. Discuss the benefits of activity and exercise.
3. Identify the principles of gravity that affects balance.
4. Discuss factors affecting mobility.
5. Discuss the effects of immobility on human body.
 Cont...
6.Review A&P of muscular skeletal system and
characteristics of normal movement.
7.Describe the impact of immobility on Physiologic and
Psychological functioning.
8.Apply nursing process while planning for the client
with altered muscular skeletal system.
 Activity –Exercise pattern

Refers to a person’s routine of exercise, activity ,leisure

and recreation. Includes :
a) ADL that requires energy such as dressing, cooking.
b) The type, quality and quantity of exercise
 Activity
Activity can be described as energetic action or as
being in a state of movement, people must move to
obtain food and water to protect them self from
trauma and to meet other basic needs.
Or
Bodily movements produced by skeletal muscles that
require energy expenditure and produces progressive
health benefits.
 KEY FACTS
• Insufficient physical activity is 1 of the 10 leading risk
factors for death worldwide.

• Insufficient physical activity is a key risk factor for

non-communicable diseases (NCDs) such as
cardiovascular diseases, cancer and diabetes.

• Physical activity has significant health benefits and

contributes to prevent NCDs.
 KEY FACTS
• Globally, 1 in 4 adults is not active enough.

• More than 80% of the world's adolescent population

is insufficiently physically active.

• Policies to address insufficient physical activity are

operational in 56% of WHO Member States.

• WHO Member States have agreed to reduce

insufficient physical activity by 10% by 2025.
 WHAT IS PHYSICAL ACTIVITY?
• WHO defines physical activity as “any bodily
movement produced by skeletal muscles that
requires energy expenditure – including activities
undertaken while working, playing, carrying out
household chores, travelling, and engaging in
recreational pursuits”.

• The term "physical activity" should not be confused

with "exercise", which is a subcategory of physical
activity that is planned, structured, repetitive, and
aims to improve or maintain one or more
components of physical fitness. Both, moderate and
vigorous intensity physical activity brings health
benefits.
 Cont…
Exercise:
Is a type of physical activity defined as a planned,
structured, and repetitive bodily movement done
to improve or maintain one or more components
of physical fitness.
Or
It is physical activity for the purpose of conditioning the
body, improving health, and maintaining fitness or it
may be used as a therapeutic measure.
 Types of Physical Activity

Physical activities can be classified as

1) aerobic exercise or
2) anaerobic exercise.

Strengthening and endurance activities can be

further classified as
1) isometric exercise,
2) isotonic exercise, or
3) isokinetic exercise.
 Aerobic Exercise

Ongoing physical activity that raises your

breathing rate and heart rate is called aerobic
exercise
(ehr OH bik).

Aerobic exercises increase the amount of oxygen

that your body takes in and uses.
 Aerobic Exercise

•Examples: Swimming, running, brisk walking, and

cross-country skiing are all forms of aerobic
exercise.
 Anaerobic Exercise

Intense physical activity that lasts for a few

seconds to a few minutes is called anaerobic
exercise.

Most anaerobic exercises develop muscular

strength, muscular endurance, or flexibility.
 Anaerobic Exercise

•Examples: Lifting weights, doing push-ups, and

sprinting are examples of anaerobic activities.
 Isometric Exercise

Isometric exercise (eye suh MET rik) is an exercise in

which muscles contract but very little body
movement takes place.

If you do isometric exercises on a regular basis, the

muscles you use will become stronger.
 Isometric Exercise

Examples: planks, pushing against a wall, climbing,

mountain biking and motocross (grip and upper body
strength), Judo, wrestling, gymnastics and horseback
riding
 Isotonic Exercise

Isotonic exercise (eye suh TAHN ik) involves

contracting and relaxing your muscles through
the full range of a joint’s motion.

Through repetition of isotonic exercises, you can

develop muscular strength and endurance.
 Isotonic Exercise

Examples: Pull-ups, exercises with free weights

(such as biceps curls, bench press, leg extensions,
incline press, squats)
 Isokinetic Exercise

In isokinetic exercise (eye soh ki NET ik) muscles

contract at a constant rate.

These exercises are often used as therapy to

rebuild muscle strength after an injury.
 Isokinetic Exercise

Examples: fitness machines (stationary bike,

bench press machine)
 Cont…
Activity tolerance :
It is the type and amount of exercise or daily
living activities, an individual is able to perform
without any adverse effects.

A program of regular physical activity and exercise

promotes physical and psychological health. It is also
essential treatment modality for chronic illness.
 Cont…
Mobility
•The ability to move or perform any activity.
Range of Motion
• The range of motion of the joint is the maximum
movement that is possible for that joint.
Joint Mobility is defined as the degree to which an
articulation (where two bones meet) can move before
being restricted by surrounding tissues
(ligaments/tendons/muscles etc.).
 Cont.…
Body Alignment
Relation ship of one body part to another.

Body Alignment refers to how the head, shoulders,

spine, hips, knees and ankles relate and line up with
each other.

It is the geometric arrangement of body parts in

relation to each other. Good alignment promotes
optimal balance and maximal body function.
 Cont..
Proper standing body alignment (as noted in Figure) is
characterized by the following:
 Body Mechanics
Efficient, coordinated and safe use of the body to produce
motion and maintain balance during activity.
Involves:
1. Body alignment (Posture)
2. Balance (stability)
3. Coordinated body movement

25
 Principles of Body Mechanics
• Asses the load
• Facing the direction of work reduces the chance of injury
• Keep back straight.
• Holding an object close to the body requires less energy
than holding it farther away.
• Don’t twist
• Push or pull rather than lift

26
Factors affecting Body Alignment &
Activity

• Growth and Development

• Physical Health
• Mental Health
• Nutrition
• Personal Values and Attitudes
• Other Factors

28
Benefits of
Exercise

29
 Psychoneurologic System
Integumentory System 1) Produces a sense of well being
2) Improves self esteem
1) Maintains skin integrity
3) Increase energy level to perform
2) Prevents pressure ulcers
ADL

Respiratory System
1) Increased Ventilation
2) Prevents pooling of
Cardiovascular System secretions.
1) Strengthen heart muscles &
blood supply to heart
2) Increase cardiac output

Metabolic System
1) Increases metabolic rate
Gastrointestinal 2) Increase use of fatty acids
System which reduces serum
1) Improves appetite, cholesterol
digestion & elimination

Urinary System
Muscularskeleton System 1) Prevent urinary stasis
1) Muscles strength, joint flexibility
& ROM increases
2) Bone Density is maintained 30
Benefits of Exercise
 Psychological Benefits

During continuous exercise, your brain releases

endorphins, chemicals that block pain messages
from reaching your brain cells.

People who exercise regularly are likely to be more

self-confident and focused.

People who exercise regularly typically have

reduced stress levels.
 Social Benefits

•Exercise is also an opportunity to have fun.

•Physical activity can be a way to bond with family

and friends.

•Physical activity can build new relationships.

Effects of Immobility

33
 Psychoneurologic System
Integumentory System 1) ADL
1) Reduced Skin turgor 2)  Self esteem
2) Skin breakdown 3) Impair Social Development

Cardiovascular System Respiratory System

1)Cardiac workload 1) Respiratory system
2) Orthostatic Hypotension 2) Pooling of secretions
3) Edema 3) Atelactasis
4) Thrombus formation 4) Hypostatic Pneumonia

Metabolic System
1) Metabolic Rate
Gastrointestinal 2) Anorexia
System 3) Negative Calcium balance
1) Decreased digestion
2) Constipation

Urinary System
Muscularskeleton System 1) Urinary stasis
1) Disuse Osteoporosis 2) Renal calculi
2) Disuse Atrophy 3) Urinary retention
3) Contractures 4) Urinary infection
34
4) Stiffness & Pain Effects of Immobility
 Nursing Process
• Assessment: (activity level, mobility problems,
exercise and fitness goals). Assess gait,
alignment, muscle mass and tone.

• Diagnoses: Activity Intolerance, Impaired

Physical mobility, Self-Care deficit, Impaired Skin
integrity, Altered urinary elimination, Risk for
injury (orthostatic hypotension), Ineffective
breathing pattern.

35
 Nursing Process (Cont,…)

• Planning: Identify clients in need of assistance.

• Implementation: positioning (semi-fowlers etc),

transferring, ROM exercises, moving and turning
in bed.

• Evaluation: Have the goals been met? If not 

modify care plan.

36
Process of Hospitalization

By : Ibne Amin
Institute of Nursing Sciences,
Khyber Medical University , Peshawar
 Objectives

At the end of this unit learners will be able to:

1. Define the term admission, transfer and discharge
2. Discuss the procedure for admission, transfer and
discharge
3. Identify nursing responsibility during admission,
transfer and discharge
4. Discuss nurse role in preparing patients and family for
discharge
5. Discuss the normal reaction of patient being
hospitalized
 Hospital
The word “ Hospital’’ has been derived from the Latin hospes,
signifying a stranger or foreiner, hence a guest.Another noun
derived hospitium came to signify hospitality, that is the
relation between guest and shelterer and hospitality
Types
Government Hospital
Semi Government hospitals
Private hospitals
Special hospital
Hierarchy in Pakistan
BHU-RHC-THQ-DHQ-TCH
 Admission

Admission is a process of receiving a new patient to an

individual unit (ward) of the hospital. OR
It is the entry and acceptance of a patient to stay in a
health facilty.
Purpose of Admission
1.Observation
2.Diagnosis
3.Procedure/Surgery
4.Treatment
 Types of admission

There are two major types of admission,

1. Elective / Planned
2. Emergency
Elective /Planned Admission
In this typ of admission the health care provider e.g.
medical officer plans a convenient date for
admission.Patient is informed well before the time so
as to make him prepare for Admission.Patient is taken
through the admission process from OPD
 Types of admission

In Elective admission there is known medical

condition or complaint that requires further
workup,treatment or surgery
 Types of admission

Emergency Admission
In this type of admission, the patient is being brought to
the hospital in a critical /serious condition which needs
prompt admission and immediate treatment so as to
prevent complication.
 Admission Procedure

1. The admitting department

2. Arrival on Nursing unit
3. Hospital orientation
4. Preventing Dehumanization
 Admission Procedure

1. The admitting department

• Fill out admission form
• Take Admission consent
• Provide identification Band
• Allocate Hospital’s bed
• Take care of personal belonging
 Admission Procedure

2. Arrival on Nursing Unit

• Height & weight
• Vital signs
• Send samples for lab investigation
• Reporting The admission
• Admission Documentation
 Admission Procedure

3. Hospital Orientation
• Ward routine
(doctor, Nurses round)
• Physical facilities in room
(Internet,TV, Bathroom,teleph etc.)
• Hospital services & timing
(meals ,medication, Med/surg.supply ,linen)
• Hospital Policies
(smoking policy, LAMA, MLC)
 Admission Procedure

4. Dehumanization

• Anxiousness or Apprehension
• Fear of Unknown
• Fear of body image changes
• Financial concerns
• Embarressment
 Transfer to other Unit

Reason for Transfer

1. Temporary Assignment
2. Change in patient’condition
3. Quieter environment is required
4. Pt disturbing other patients
5. Patient needs special care or procedure etc.
 Guidelines for Pt’s Transfer

1. Check doctor’s order.

2. Explain to pt and family.
3. Provide detail for safety
4. Hand over to other unit staff
5. Inform other department about pt’s transfer
6. Assemble all personal belonging & medicines
 Patient’s Discharge

Discharge planning Begin at admission

Assess
1. patient’s personal Hx & health Data
2. Pt’s ability to perform ADL
3. Any physical, cognitive, or other functional
limitation
4. Care giver’s responses or ability
5. Financial resources
6. Community support
7. Need for home care assistant
 Discharge Teaching

• Medication
• Activity (rest/ Exercise)
• Diet
• Appointment for next visit (Follow -up)

Day of Discharge
Discharge documentation
 Hospital Discharge

Indication for discharge: After completion of

Required diagnosis,Observation,Procedure,treatment as
suggested by attending physicain or surgeon.
• Progress in the patient's condition
• No change in the patient's condition (Referral)
• After an Expiry
• Leaving Against Medical advice (LAMA)
• Stay against Medical advice (SAMA)
 Reaction to Hospitalization

Illness Behaviour
• Pt not held responsible for their condition
• Excused from certain social role & tasks
• Obligate to try to get well ASAP
• Obliged to seek competent help
 Reaction to Hospitalization conti…

Effect of illness

• Change in Behaviour
• Disruption of privacy & Autonomy
• Lifestyle,Roles and Finances
• Change in self concept, body image
 Discharge of a Patient from the Hospital

The Role of Nurse in discharge planning

• Includes all caregivers involved in the care of the
patient i.e. Pysiotherapist (multidisciplinary).
• Adequate assessment of the patient during all stages
of care to identify discharge needs.
• Assess health teaching needs of clients and family
and provide family members with the knowledge and
skill to care for the client in the home setting e.g.
wound care, range of motion exercise etc.
 Discharge of a Patient from the Hospital

• Ensure discharge is ordered by a medical officer

• Patient and relatives are informed about discharge
• They are educated on the need for continuing
treatment and follow up care
• Ensure patient’s hospital bills are worked out and
submitted to health insurance officer
 Discharge of a Patient from the Hospital

Discharge summaries usually include:

• Description of client’s condition at discharge

• Treatment (e.g. Wound care, Current medication)
• Diet
• Activity level
• Restrictions
 References

Basic clinical Nursing Skill, 1st edition

(Abraham Alano, B.Sc.,M.P.H,HawassaUniversity)
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