HNN112

NOTES
By Danai
Harawa
2 HNN112 DANAI HARAWA

Foundational Concepts of Nursing: Hand Hygiene

 Describe what is hand hygiene
The reduction of harmful infectious agents by the application of alcohol
based hand rubs without the addition of water, or by hand washing with
plain or medicated/antimicrobial soap and water.

 Describe the 5 moments of hand hygiene

- Before touching a patient
- Before a procedure
- After a procedure
- After touching a patient
- After touching a patients surroundings

Risk Management: Falls, Pressure Injuries, And Healthcare

Associated Infections
 Identify high risk practices in nursing (e.g. falls, pressure injury, healthcare
associated infections)
- Falls
To minimise falls risk assessment should be put into practise. The following
are examples of risk assessments.
Physical Environment
+ Furniture
+ Space
+ Equipment
Work Practises
+ Training
+ Adequate staff numbers
+ Work hours
Patients Ability to Assist
+ Cognitive signs
+ Physical signs
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+ Behavioural signs
+ Clinical constraints

- Pressure Injuries
Pressure injuries are a result of low quality pressure area care. Pressure area
care is conducted for anyone who does not have the capability to reposition
themselves or when there is constant pressure on the body.

- Health care associated infections

Health Care associated infections are infections that are picked up in a
clinical setting, this is due to various factors such as poor hand hygiene or
lack of care and cross contamination.

 Describe the role of the Australian Commission on Safety and Quality in

Health Care
The Australian Commission on Safety and Quality in Health Care a body
that have the role to lead and coordinate national improvements in safety
and quality in health care. Their role also includes focusing on patient
safety, partnering with patients, consumers and communities, focusing on
quality cost and value, and supporting health professionals to provide safe
and high quality care.

 Describe and demonstrate appropriate use of body mechanics for safe

manual handling consistent with the “no lift” policy
Body mechanics that are consistent with the no lift policy and showcase safe
manual handling include minimising risks that occur from bending, twisting,
awkward postures and patient’s previous history of falls.
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Optimising Patient Outcomes

 Describe the role of the nurse in patient assessment
The role of the nurse in patient assessment includes ****

 Describe and compare common nursing assessment frameworks

Gordons 11 Functional Health Patterns
+ Health Perception/Management
+ Nutrition and Metabolism
+ Elimination
+ Exercise and Activity
+ Sleep and Rest
+ Cognition and Perception
+ Self Perception and Self Concept
+ Roles and Relationships
+ Sexuality and Reproduction
+ Coping and Stress Tolerance
+ Values and Beliefs
Systems
+ CNS
+ CVS
+ Respiratory
+ Skin
+ Endocrine
+ Renal
 Define and identify subjective and objective data
Subjective Data is the information that is personal to the patient and cannot
be measured. If a patient tells you they had runny faeces that is subjective
data because you cannot know that information unless being told.

Objective Data is the information we can gather utilising our 5 senses, it is

either a measurement or an observation.
+ Temperature
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+ Blood Pressure
+ Respirations
+ Wound appearances
+ Ambulation description
 Identify patient cues, cluster them and identify patient potential and actual
problems
+ Symptoms
+ Areas of Risks
+ Alteration in function
 Perform a nursing handover using the ISBAR tool
I - Introduce yourself
+ Who you are
+ Why you’re calling them
+ Where you’re calling from
S - Situation
+ Short description of the situation and what has happened
B - Background
+ Do not be over detailed, keep it short and simple
+ History of the patient
A – Assessment
+ State what the problem is
+ State what you have already done (own interventions)
R – Request / Recommendation
+ Clarify what it is that you will want or need
+ What they should do

 Utilise therapeutic communication whilst taking a health history

Therapeutic communication is defined as the face-to-face process of interacting
that focuses on advancing the physical and emotional wellbeing of a patient.
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The Detiorating Patient

 Describe purpose of vital signs
The purpose of vital signs is to provide an indication of a patient’s progress and
health.
 Describe normal ranges for vital signs
+ Respiratory rate: 12-20bpm
+ Heart rate: 60 – 100bpm
+ Oxygen saturation: 95-100%
+ Systolic Blood Pressure 100 – 130 mm / hg
+ Diastolic Blood Pressure 60 – 90 mm / hg
+ Temperature 36 – 38 Degrees Celsius
* Note: The blood pressure is usually assessed in the persons upper arm
using the brachial artery and a standard stethoscope. It must be 40% of the
arms circumference or 20% wider than the diameter of the midpoint of the
limb.
 Explain anatomy and physiology related to vital signs
 State factors that influence vital signs
+ Temperature can be affected by whether they have too many blankets, had
a cup of tea or a hot/cold shower.
+ Respiratory rate that is high can be affected by pain, exercise (increases
metabolism), Stress (readies the body for fight or flight), medications and
intracranial pressure.
+ Oxygen saturation can be affected by Hemoglobin as if the hemoglobin is
fully saturated with oxygen, the SPo2 will appear normal even if the total
Hemoglobin level is low. Thus leading a person to be potentially anemic.
Circulation, the oximeter will not have an accurate reading if the area under
the sensor has impaired circulation such as if the person is very cold.
Activity such as shivering or excessive movement of the sensor site may
interfere with accurate readings
Dark coloured nail polish or discoloration of the nail bed can cause false
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readings as it interferes with the site.

Carbon Monoxide Poisoning, the pulse oximeter cannot discriminate
between hemoglobin saturated with carbon monoxide versus oxygen. If
there is carbon monoxide poisoning, other measures of oxygenation is
needed.
+ Blood pressure can be affected by age; newborn babies have a mean
systolic pressure of about 75mm Hg. The average of the pressure rises with
age, reaches a peak at the onset of puberty and then tends to decline
somewhat. In older people they have an increased systolic pressure as the
elasticity of the arteries is decreased, this making them more rigid and less
yielding to the pressure of the blood.
Exercise can affect blood pressure as it increases the cardiac output and
hence the blood pressure. Therefore there should be a 20-30 minute period
of rest after physical activity to achieve an accurate reading.
Stress can affect blood pressure as it stimulates the sympathetic nervous
system and increases cardiac output and vasoconstriction of the arterioles,
thus increasing the blood pressure reading.
Ethnicity can affect blood pressure as many Indigenous individuals are
affected by cardiovascular disease, which includes coronary heart disease,
stroke, heart failure and high blood pressure. Thus Indigenous Australians
experiences higher raters of hypertension than non-indigenous Australians.
+ Heart rate can be affected by age, as age increases the heart rate (HR)
gradually decreases overall.
Gender affects the HR, as after puberty, the average pulse of a male is
slightly lower than that of a female.
Exercise affects the HR as it normally increases with activity. The rate of
increase in the professional athlete is often less than the average person
because of greater cardiac size, strength and efficiency.
Pyrexia affects the HR in response to the lowered blood pressure that results
from peripheral vasodilation associated with elevated body temperature, and
because of the increased metabolic rate.
Medications affect HR as some medications decrease the pulse rate and
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others increase it. For example, cardiac glycosides decrease the heart rate,
whereas adrenaline increases it.
Hypocalcaemia affects HR as loss of blood from the vascular system
normally increases HR. In adults, the loss of circulating volume results in an
adjustment of the HR to increase blood pressure as the body compensates
for the lost blood volume. Adults can usually lose up to 10% of their normal
circulating volume without adverse affects.
Stress affects HR as the 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.
Position changes affect HR as 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 HR.
Pathology can affect HR as certain diseases such as various heart conditions
or those that impair oxygenation can alter the resting pulse rate.

 List terms used to describe vital signs

+ Afebrile – absence of a fever
+ Apical pulse – The pulse to determine the HR this is located at the apex of
the heart
+ Apnea – absence of respirations
+ Bradycardea – slow pulse rate
+ Dysrhytmia – irregular pulse rate
+ Eupnoea – normal, quiet breathing
+ Febrile – chance of a fever
+ Hypertension – high blood pressure
+ Hypotension – low blood pressure
+ Hypoventilation – very shallow respirations
+ Pyrexia – high temperature
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 Identify possible nursing interventions to assist patient’s with abnormal vit

al signs
+ Blood Pressure ***
+ Heart Rate ***
+ Temperature – If an individual has a low temperature, an intervention
would be to warm them up (blankets or hot fluids). If an individual has high
temperatures then the intervention would be to cool them down and
medication such as panadol if possible to bring it down, as a fever may be an
underlying cause.
+ Oxygen saturation – If an individual has low oxygen saturation then the
intervention would be to place them onto oxygen rather than the individual
relying on room air. The L’s of oxygen would primarily depend on the
levels that the spo2 was recorded at.
+ Respiration ***

 Describe evaluation criteria for nursing interventions ***

+ Problem identification
+ Goal of care
+ Nursing intervention
+ Reasoning for intervention
+ Evaluation (has the intervention met the outcome, yes or no? if not
continue back)

Infection Control
 Define the terms microorganism and health care associated infections
+ Microorganisms are defined as an organism that can only be seen and
detected by a microscope.
+ Health care associated infections are defined as infections that are
contracted by a patient whilst awaiting medical treatment or care in a
clinical setting.
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 Identify modes of transmission

Modes of transmission for infection include direct transmission which is
+ Direct contact (skin to skin, mucous membrane, soil)
+ Droplet (contact with aerosols produced by spray from sneezing,
coughing, talking)
+ Vertical transmission (From mother to baby)
Modes of transmission for infection also include indirect transmission which
is
+ Airborne (agent suspended in particles in the air)
+ Vehicle borne (age transferred by inanimate object such as stethoscope or
pen)
+ Vector borne (agent transferred by animate object such as a mosquito,
flea, fly or tick)
+ Vector borne can be further divided into mechanical which is where the
agent does not multiply or undergo any physiological change in the vector.
Vector borne can also be further divided into biological which is where the
agent undergoes a type of physiological change within the vector

 Describe the chain of infection

The chain of infection is described as
+ Aetiological agent (Microorganism)
+ Reservoir (Source)
+ Portal of exit from reservoir
+ Method of transmission
+ Portal of entry to the susceptible host
+ Susceptible host
 Describe principles of infection control including hand hygiene, prevention
of cross infection, disinfection and sterilisation techniques, standard and
transmission based precautions
+ Hand Hygiene is the process of using an alcohol based sanitiser to destroy
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any potential microorganisms that may be found upon the hands. There are 5
moments for hand hygiene
- Before touching the patient
- Before a procedure
- After a procedure
- After touching a patient
- After touching their belongings
+ Prevention of cross infection refers to minimising the possibility of
carrying any harmful pathogens to another susceptible host.
+ Disinfection and Sterilisation is the process of following a procedure with
chemicals to disinfect any potential microorganisms that may lie upon
equipment that is being used in the clinical setting.
+ Standard and Transmission based precautions means to follow any
procedures that may be required in order to prevent any microorganisms
passing from individual to individual. This may include wearing PPE when
entering a patient’s room.

Hygiene Care, Nutrition and Hydration

 Describe relationship between hygiene and health
The relationship between hygiene and health is that when an individual has
good hygiene or assisted with their hygiene daily they are able to rid of any
microorganisms that may lay on their body and any build up of dirt over
time. This includes daily activities such as showering, changing into clean
clothes and brushing your teeth.
 Identify factors that influence individuals’ hygiene
Factors that influence an individuals hygiene include
+ Culture, in western cultures it is ideal that an individual bathes or showers
once a day. However in other cultures, many may only bathe or shower once
a week. Factors in cultures such as communal or private bathing are also
included and body odour might be offensive in some cultures but widely
accepted in others.
+ Religion, as ceremonial washings are practised by some religions
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+ Environments, for example finances may affect the availability of facilities

to practise daily hygiene or many may live in a home where there is limited
resources such as shampoo, soap, shaving lotions and deodorants.
+ Developmental level as children learn hygiene in their homes. Practises
will vary according to the individual’s age.
+ Health and energy as ill people may not have the motivation or energy to
attend to hygiene.
+ Personal preferences as many will prefer to bathe and others to shower and
many will prefer to do so in the morning and others to night.
 Identify possible nursing interventions to assist patient’s with hygiene
problems
+ Bed bath
+ Aiding them with brushing their teeth
+ Supplying soaps
 Define the terms nutrition and hydration
+ Nutrition: The process of providing or obtaining food that is necessary for
health and growth.
+ Hydration: The process of causing something to absorb water, for example
the human body needs adequate amounts of water to function properly.
 Describe healthy weight range ***
 Calculate body mass index
+ BMI = Weight in KG / Height in M’s (2) | 72/(1.7 x 1.7) = 24.9
 State dietary guidelines and nutritional requirements ***
 Identify the factors that influence nutritional status
+ Decrease in taste
+ Loss of appetite
+ Nutrient absorption
+ Financial barriers
+ Depression
+ Menopause
+ Culture
+ Pregnancy
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 Describe common nutritional problems and their symptoms experienced by

patients ***
+ Lack of appetite - when an individual does not have the desire to eat and often
feels full.

Elimination
 Identify the factors that influence elimination patterns
Urinary elimination
+ Frequency and Nocturia
Nocturia is when an individual wakes up more than once in the night to
void. In regards to frequency factors such as fluid intake can affect this
+ Urgency
A sudden strong desire to void it is common with those who have unstable
bladder contractions.
+ Dysuria
Voiding that is painful or difficult this is often to do with infections called a
UTI.
+ Enuresis
Involuntary urination in children beyond the age when voluntary bladder
control is normally acquired.
+ Urinary incontinence
When an individual cannot control their voiding.
Faecal elimination
+ Diet
+ Physical activity
+ Psychological factors
+ Defecation habits
+ Medications
+ Diagnostic procedures
+ Anaesthesia / Surgery
+ Pathological conditions
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+ Pain
+ Pregnancy
 Distinguish between normal and abnormal urine and faeces
Characteristics of faeces
+ Colour – Normal: Brown
Abnormal: Grey, clay or white – absence of bile pigment
Black or tarry – Drug (iron), malaena (bleeding from UGI tract), diet high in
red meat and dark green vegetables (spinach) or licorice. Also certain
medications such as phenylbutazone, oxyphenbutazone or bismuth
compounds.
Red – Bleeding from lower GI tract (rectum) or some foods such as beetroot
or cocoa.
Pale tan – Malabsorption of fats, diet high in milk and milk products or low
in meat.
Green – Intestinal infection, ingestion of spinach or senna laxatives or rapid
transit times.
+ Consistency – Normal: Soft formed
Abnormal: Constipation (hard, dry, pebbles) – Dehydration, lack of fibre,
lack of fluids, lack of exercise, motility disorder (Hirschspruns disease),
endocrine disorders (hypothydroidism, diabetes mellitus), psychiatric
disorders (depression, anorexia nervosa, dementia), local pathology (tumors,
structure and fissure), drug induced (anticholinergics, antihistamines,
tranquillisers, opiates, antacids, laxative abuse)
Diarrhoea – Gastrointestinal infections, food or drug intolerance
(antibiotics), impaction with overflow, short bowel syndrome, inflammatory
bowel disorders (ulcerative colitis or Chrons disease) or radiation enteritis.
Encopresis (faecal incontinence) – Uncontrolled Diarrhoea from any cause,
neurogenic disorders (paraplegia, spinal bifida, caudal equine lesions),
cognitive deficits (dementia, Alzheimer’s disease)
+ Shape - Normal: Tubular as in the shape of the rectum
Abnormal: Narrow, pencil shaped or string like stool – Obstructive tumors
or strictures of the rectum or anus
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+ Amount – Normal: 100-200g per day

Abnormal: Increased or decreased stool volume – Alterations in normal
dietary intake, increased or decreased fibre intake, food intolerances, fasting,
constipation, diarrhea
+ Odor – Normal: Differs subject to diet but tolerable
Abnormal: Pungent – Infection, bleeding, certain foods such as onions or
eggs.
+ Constituents – Normal: Normal faecal content
Abnormal: Pus – Bacterial infection
Mucus – Inflammatory conditions
Blood parasites – Gastrointestinal bleeding, worms (pinworm, hook worm or
tape worm)
Fat, floating stool – Fat Malabsorption
Foreign objects – Accidental ingestion

Characteristics of urine
+ Amount in 24 Hours (Adult) – Normal: 1200 – 1500ml
Abnormal: Under 1200ml / A large amount over intake – Urinary output
normally is approx. equal to fluid intake. Output of less than 30ml/hr may
indicate decreased blood flow to the kidneys and should be reported
immediately. For infants and children the minimum urine output is 1-2
ml/kg/hr
+ Colour – Normal: Straw, amber, transparent
Abnormal: Dark amber / cloudy / dark orange / red or dark brown / mucus
plugs / viscid / thick – Concentrated urine is darker in colour. Dilute urine
may almost appear clear or very pale yellow. Some foods and drugs may
colour urine. Red blood cells in the urine may be evident as pink, bright red
or rust brown urine. Menstrual bleed can also colour urine but should be
confused with hematuria. White blood cells, bacteria, pus or contaminats
such as postactiv fluid, sperm or vaginal discharge may cause cloudy urine
+ Odor – Normal: Faint aromatic
Abnormal: Offensive – Some foods such as asparagus, cause a musty odor.
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Infected urine can have a foetid odor and urine high in glucose has a sweet
odor.
+ Sterility – Normal: No
Abnormal: Microorganisms present – Urine in the bladder is sterile. Urine
specimens however may be contaminated by bacteria from the perineum
during collection.
+ PH – Normal: 4.5 – 8
Abnormal: Under 4.5 or over 8 – Freshly voided urine is normally somewhat
acidic. Alkaline urine may indicate a state of alkalosis, UTI, or a diet high in
fruits or vegetables. More acidic urine (low pH) is found in starvation, with
diarrhea or with a diet high in protein foods or cranberries.
+ Blood – Normal: Not present
Abnormal: Occult (microscopic) / Bright red – Blood may be present in the
urine of people who have UTI, kidney disease or bleeding from the urinary
tract. Specimens may also be contaminated from menstrual flow in the
female person.

Activity and Exercise ***

 Identify the factors that affect patient mobility
+ Growth and development
+ Nutrition
+ Personal Values and Attitudes
+ External factors
+ Prescribed limitations
 Describe effects of immobility
+ Musculoskeletal system
+ Cardiovascular system
+ Respiratory system
+ Metabolic system
+ Urinary system
+ Gastrointestinal system
+ Psychoneurological system
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Sleep and Rest ***

 Describe physiological aspects of sleep and the relationship to health
+ Circadian Rhythms
Biological rhythms exist in plants, animals and humans. In humans, these
are controlled from within the body and synchronised with environmental
factors, such as light and dark.
+ Types of sleep
NREM sleep
REM sleep
+ Sleep cycles

 Identify the factors that influence sleep patterns

+Illness
+ Environment
+ Lifestyle
+ Emotional stress
+ Stimulants and alcohol
+ Diet
+ Smoking
+ Motivation
+ Medications
 Explain common sleep problems and their symptoms experienced by patie
nts
+ Insomnia
+ Excessive daytime sleepiness
+ Parasomnia
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Spirituality and Sexuality

 Define the terms individuality, privacy, dignity, caring
+ Individuality
The quality or character of a person that distinguishes that from another
human being.
+ Privacy
A state in which one is not observed or disturbed by another individual.
+ Dignity
The state of quality of being worthy of honour or respect
+ Caring
Displaying kindness or concern for others
 State the concept of holism, including spirituality
+ Holism
The idea that systems and their properties should be viewed as a whole and
not sperately
 Identify the factors that influence sexuality
+ Family
+ Culture
+ Religion
+ Personal expectations and ethics