FUNDAMENTALS OF NURSING PRACTICE

BSN 1-E || FINALS TERM

II. INTRODUCTION TO INTEGRAL 5) Local infection - limited to the specific part of

COMPONENTS OF CLIENT CARE
Nursing care is an integral part of health care
services. Nursing encompasses all aspects of
healthcare services including that of health
promotion, disease prevention, and restoration of
client's care. Nurses play a significant role in various
health care setting as they provide care to clients,
both well and sick.
A. ASEPSIS AND INFECTION
PREVENTION
Definition of Terms:
• Asepsis - Freedom from disease-causing
organisms
• Medical Asepsis - All practices intended to
confine a specific microorganism to a specific
area. Limits number, growth, and transmission
of microorganisms.
• Infection - the growth of microorganisms in
body tissues where they are not usually found.
• Infectious agent - referred to as the
microorganism.
the body where microorganisms remain.
o For example, abscess, urinary bladder
infection
6) Systemic infection – the microorganisms
spread and damage different parts of the body.
o For example, arthritic swelling, Human
Immunodeficiency virus (HIV).
7) Bacteremia - the culture of the individual’s
blood reveals microorganisms.
8) Septicemia - a systemic infection resulting
from bacteremia.
o The most common infections that lead
to septicemia include UTI, lung
infections, kidney infections
9) Acute infection - appear suddenly or last a
short time.
10) Chronic infection - may occur slowly, over a
very long period, and may last months or years.
Chain of Infection

Types of Infection:
1) Nosocomial - Infections that originate in the
hospital. This can be developed during the
client’s stay in the hospital.
o Healthcare-associated infections
(HAIs) - infections that originate in any
1) Etiologic Agent
healthcare setting, and of hospital-
- Number of microorganisms present
acquired conditions.
- Virulence and potency (pathogenicity) -
2) Endogenous - This can cause nosocomial
ability to enter the body
infections that can originate from the clients
- Susceptibility of the host - ability to live in the
themselves.
host's body
o e.g. Escherichia coli - causes improper
catheterization technique (urinary tract)
2) Portal of Exit from Reservoirs
o Staphylococcus aureus- causes
- Before infection can establish, microorganisms
inadequate hand hygiene (surgical
must leave reservoir.
sites, pneumonia)
3) Exogenous - this can cause nosocomial
3) Method of transmission
infections from the hospital environment and its
- Direct transmission - involves immediate and
personnel.
um direct transfer of microorganisms from
4) Iatrogenic infections - direct result of
individual to another. (touching, kissing, biting,
diagnostic or therapeutic procedures
sexual intercourse)
o For example, bacteremia that results
- Indirect transmission
from an intravascular infusion line.

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 FUNDAMENTALS OF NURSING PRACTICE
BSN 1-E || FINALS TERM

o Vehicle-borne Factors Increasing Susceptibility to

▪ Any substance that serves as Infection
intermediate means to
transport and introduce an 1) Immunizations
infectious agent into a o Schedule for greatest protection
susceptible host this is through ▪ 0 to 6 years
a suitable portal of entry ▪ 7 to 18 years
▪ For example food or water may ▪ Adult
become contaminated by the o Immunizations can be given later if
food handler okay who carries missed.
Hepatitis A and could be 2) Age
ingested by the susceptible o Newborn
host o 0 to 6 years
o Vector-borne o 7 to 18 years
▪ Animal or insect o Adult
▪ Is an animal or flying crawling o Older adults - Immunity to infection
insect that serves as an decreases with advancing age.
immediate means of transform
transporting the infectious 3) Heredity
agent the transform the o Influences the development of infection
transmission may occur by that some individuals have a genetic
injecting salivary fluid during susceptibility to certain infections.
biting or by depositing faces of o Example: deficient in serum
other materials on the skin immunoglobulin
through bites or traumatized 4) Stress
skin area o Elevate blood cortisol
- Airborne transmission (Droplet nuclei) o Prolonged elevation of blood cortisol
i. depletes energy,
4) Portal of Entry to the Susceptible Host ii. leads to a state of exhaustion,
- Skin is barrier to infectious agents. and
o Break can readily serve as portal of iii. decreased resistance to
entry infection.
- Microorganisms often enter body by same 5) Nutrition
route they used to leave source o Resistance to infection depends on
- Medical interventions can also be the portal of adequate nutritional status
entry and it could be tubes catheter, cases of o Prolonged elevation of blood cortisol
patients who have surgical wounds i. antibodies are proteins,
ii. the ability to synthesize
5) Susceptible Host antibodies may be impaired
- Compromised host when protein intake is
o Individual more likely than others to depleted.
acquire an infection 6) Medical Therapies
- Variables o Resistance to infection depends on
o Age (very young or very old) adequate nutritional status
o Clients receiving immune suppression o Example: radiation therapy to cancer
treatment destroys not only cancer cells but also
o Clients with immune deficiency normal cells.
conditions 7) Preexisting conditions
o Disease(s) lessens the body’s
defenses against infection
o Example: Diabetes mellitus

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 FUNDAMENTALS OF NURSING PRACTICE
BSN 1-E || FINALS TERM
Body Defenses Against Infection:
1) Nonspecific Defenses
- protect person against all microorganisms
regardless of prior exposure
A. Anatomic and Physiological Barriers:
o Intact skin and mucous membranes
o Moist mucous membranes and cilia of
the nasal passages - if it is moist then
there's less likely that the individual
could have dryness of the membranes
and mucosa
o Alveolar macrophages
o Saliva
o Tears
o High acidity of the stomach
o Resident flora of the large intestine
o Peristalsis
o Low pH of the vagina
o Urine flow through the urethra
B. Inflammatory Response
• Inflammation - local, nonspecific defensive
response of the tissues to injurious or infectious
agent
o 5 Signs:
▪ Pain
▪ Swelling
▪ Redness
▪ Heat
▪ Impaired Function
o Suffix: -itis
Stages of Inflammatory Response:
First Stage - the blood vessels at the site of injury
constricts, so this is rapidly followed by dilation of small
blood vessels happening because of the histamine
released by the injured tissue. there will be marked
increase in the blood supply and this is responsible for
the redness that you see and heat in the injury site.
• Vascular and cellular response - at the start of
the first stage of inflammation, blood vessels
constrict
• Leukocytes - White blood cells
• Leukocytosis - When large numbers of
leukocytes are produced, released by bone
marrow into bloodstream
SYHV | BSN 1-E
Second Stage:
• Exudate production – consisting of fluid that
escaped from the dead phagocytic cells, dead
tissue cells, and blood vessels.
• Plasma protein fibrinogen – converted to fibrin
when it is released into the tissue
o Thromboplastin and platelets form an
interlacing network o wall off the are
and prevent spread of the injuries
agent.
• Major type of exudate: serous & hemorrhagic
Third Stage:
• Reparative phase – repair of injured tissues by
regeneration or replacement with fibrous
tissue (scar) formation.
• Regeneration – replacement of destroyed
cells by identical, similar cells.
• Scar formation - fragile, gelatinous tissue in
early stages of repair process
2) Specific (immune) defenses
- directed against identifiable bacteria, viruses,
fungi.
• Antigen - substance that induces a state of
sensitivity or immune responsiveness
(immunity)
• Autoantigen – when proteins originate in
person’s own body.
• Also known as Cellular Immunity
• 3 Groups of Activated T Cells:
o Helper T cells
o Cytotoxic T cells
o Suppressor T cells
ECOLOGIC MODEL
- Disease, defect, disability, or death results from
interactions between:
o Agent
o Host
o Environment
- Disease arises within an ecological system
- An ecologic approach
o necessary to explain disease causation
and occurrence.
AGENT
- Any element, substance, or force whether living
or non-living, its presence can initiate a disease
process.
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AGENT CLASSIFICATION 6) NOISE

o Intense sound above tolerable levels
1) BIOLOGIC LIVING AGENTS o Noise above 70 db may damage
o Like fungi, metazoa, bacteria, viruses, hearing (CDC, WHO)
nematodes, helminths, etc.
7) MECHANICAL
NATURE OF BIOLOGIC AGENT o Forces resulting in tearing, penetrating,
• Infectivity - ability to enter and multiply in the speeding objects
host
• Pathogenicity - ability to produce disease HOST
• Virulence - ability of a microorganism to • Intrinsic factors
produce disease • Host factors:
• Immunogenicity - ability to induce specific o Genetic – retinoblastoma gene
immunity o Age
o Sex / Gender
2) NUTRITIVE (lack or excess) o Ethnic / Racial – closely related to
o Food intake social custom & cultural development
o Carbohydrates, vitamins, fat, protein, o Religion
water, mineral o Family Size
3) CHEMICALS o Nutritional state and constitution
o Pollutants, toxic chemicals, heavy o Human Behavior
metals o Resistance – general or non-specific
4) PHYSICAL also known as immunity
a. Heat
▪ Prolonged exposure to the sun, ENVIRONMENT
inadequate ventilation or • Extrinsic factors
exposure to hot processes. • The sum total of all external conditions and
▪ Effect: burn, stroke, heat influences that affect the life development of an
cramps organism.
b. Cold • Affects both the agent and the host
▪ exposure to cold processes or o Sex / Gender
operations, low outdoor o Ethnic / Racial – closely related to
temperature like winter. social custom & cultural development
▪ Effect: heat loss, frostbite
Physical Biologic Socio-economic
c. Atmospheric pressure changes
Where Natural sites Rural/urban
▪ Generated by low altitude
individuals live, areas
(decompression or “bends” for
work, play
underwater), High altitude,
Plants Economic
Dysbarism (any adverse development
medical condition that results Animals Social disruption
from changes in ambient Revolutions
pressure), Supply of essential
gases
▪ High altitude
d. Extremes temperature: Heat & Cold

5) RADIATION
o Where ion is produced (gamma, xray,
etc)

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 FUNDAMENTALS OF NURSING PRACTICE
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THE LEVER MODEL THE WEB MODEL OF CAUSATION

- The effects never depend on a single isolated
causes
o but rather develop as a result of chains
of causation in
o each link itself is the result of a complex
genealogy of antecedents.

Lever model is in balance when the environment have

a balanced agent and host.

- Uses the Epidemiologic Triad or Triangle

- Agent
- Host
- Environment

• The essence of this concept is that it affects

and is not dependent on a single isolated cause
but rather develop as a result of change of
causation in each link. It could be the result of
genealogy of antecedents.
• E.g. Coronary heart disease, it's evident it has
multiple factors to promote or inhibit the
development of this disease. Some of these
factors are intrinsic (host). Some components
of this are related to stress, medications,
lifestyle practices, and can be subject to
manipulation.

• If the environment altered the host, it becomes THE WHEEL MODEL

- Consists of a hub that represents the host or
more susceptible to the infection or to the
human which has a genetic make up as its core.
agent.
o e.g. At the start of COVID-19, the
COVID-19 virus has the ability to infect
and cause diseases in men. And the
virus itself progresses, and as what
scientists discovered, environmental
change can also facilitate the spread
and how the virus evolves.
o If you live in a crowded place, and then
there’s someone infected and you can
also become susceptible to the
infection. That is the reason why
infected individuals need to undergo
self-quarantine.

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• The core is the cause of the disease and it is • DISEASE-SPECIFIC ISOLATION

through genes, but there are 3 sub-divided o for specific diseases like:
factors that affect and surround the host which ▪ delineating private rooms with
can be found in the environment. special ventilation
o Biologic Environment ▪ sharing of room of client with
o Social Environment others having the same
o Psychological Environment disease.

STANDARD PRECAUTIONS
HAND HYGIENE
- Considered the most effective infection
prevention measures to prevent the
- spread of microorganisms.
- After hand washing, to be able to thoroughly
cleanse the hands, the CDC recommends:
o the use of alcohol-based antiseptic
hand rubs before and after each direct
client contact.

DISINFECTING
- Antiseptics and disinfectants are said to have
bactericidal or bacteriostatic properties
o destroys bacteria
- Commonly used antiseptics and disinfectants
o isopropyl and
o ethyl alcohol (hands, vial stopers),
o hydrogen peroxide (surfaces),
o chlorhexidine gluconate(hands).

INFECTION PREVENTION AND

CONTROL
STANDARD PRECAUTION
- Hand hygiene
- Use of PPE

ISOLATION
- Transmission-based precaution.
- Measures designed to prevent the spread of
infections

• CATEGORY-SPECIFIC ISOLATION
PRECAUTION
o Strict isolation
o Respiratory isolation
o Enteric precautions
o Blood and body fluid precaution

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 FUNDAMENTALS OF NURSING PRACTICE
BSN 1-E || FINALS TERM
B. SAFETY
INTRODUCTION
- Preventing injuries and assisting the injured
- Common causes of injury & death:
o Motor vehicle crashes
o Falls, fire, and burns
o Poisoning
- Nurses need to be aware of what constitutes a
safe environment and how to prevent possible
causes of injury.
FACTORS AFFECTING SAFETY
• Age
• Development
• Lifestyle
• Mobility status
• Health status
• Sensory–perceptual alterations
• Cognitive awareness
• Emotional state
• Ability to communicate
• Safety awareness
• Environmental factors
AGE & DEVELOPMENT
- Very young children - only through
knowledge and experience that children learn
what is potentially harmful.
- Very old individuals - have difficulty with
movement and diminished sensory-neurologic
functions which can cause injury.
Selected Safety Hazards throughout
Lifespan:
1) Developing Fetus
o exposure to maternal smoking, alcohol
consumption, addictive drugs, x-rays
(first trimester)
2) Newborns and Infants
o falling, suffocation when enlarged in
cords, choking, ingested objects, crib
injuries, burns
3) Toddlers
o poisoning, running into objects, burns
4) Preschoolers
o injury from traffic or playground,
suffocation
SYHV | BSN 1-E
5) Adolescents
o vehicular crashes, recreational injuries,
firearms
6) Other Adults
o falling, burns, pedestrian and
automobile
LIFESTYLE
- Unsafe work, home environments
- Access to firearms, illicit drugs
- Insufficient funds
MOBILITY & HEALTH STATUS
- Alterations such as paralysis, muscle
weakness, and diminished balance
- Spinal cord injuries
- Impaired mobility as in hemiplegia or leg casts
- Weakened levels of alertness
SENSORY-PERCEPTUAL ALTERATIONS
- Environmental stimuli
- Impaired touch perception, hearing, taste,
smell, and/or vision
COGNITIVE AWARENESS
- Ability to respond appropriately through
thought and action
- Altered judgment from disease or medications
- Wandering in a state of confusion
EMOTIONAL STATE
- Extremes can alter the ability to perceive
environmental hazards.
- Such as stress, depression
SAFETY AWARENESS
- Information crucial to safety
- Unfamiliar equipment, substances
ENVIRONMENTAL FACTORS
• Health Care Setting
o Diagnostic errors, often unintended
o IOM establishment of "culture of safety"
o Domino effect from nurse to client
• Workplace
o Chemicals, machinery
o Fatigue
o Noise and air pollution
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• Home
o Well-maintained flooring, carpets
o Non-skid bathtub or shower
o Fire safety planning, alarms
• Community
o Street lighting
o Safe water and sewage treatment
o Regulation of food sanitation
• Disaster Planning
o In the community
o Nurses caring for selves
ASSESSMENT PHASE
- Nursing history and physical examination
o Risk assessment tools
▪ Specific and general safety
risks
o Home hazard appraisal
▪ Falls
▪ Fire
▪ Poisoning
▪ Suffocation
- National patient safety goals
o IOM's report To Err Is Human
o Newest goal
▪ Reduce harm associated with
clinical alarm systems
▪ High risk of injury if alarms
silenced, turned off, ignored
- Disasters
o Know and understand the chain of
command
o Client's safety is top priority
o Know the organization's disaster
response plan
o National Disaster Risk Reduction and
Management Council
DIAGNOSING PHASE
- Potential for: falls, infection, suffocation,
poisoning, suicide
- Lack of knowledge (accident prevention)
- Willingness for knowledge enhancement
(accident prevention)
PLANNING PHASE
- Desired outcomes associated with preventing
injury
o Change health behavior
o Modify the environment
SYHV | BSN 1-E
o Particular outcomes depend on
individual
IMPLEMENTING PHASE
- Promoting safety across the lifespan
o Observation or prediction of potentially
harmful situations in order to avoid
harm
- Client teaching
o Empowering clients to protect
themselves and their families from
injury
Promoting Safety Across the Lifespan:
1) Newborns and infants
o Accidents are leading cause of death.
o Parents need to learn level of
observation needed to maintain
safety.
o Identify and remove common hazards
o First aid, including CPR and
interventions for airway obstruction
o Common accidents:
▪ Burns
▪ Suffocation or choking
▪ Automobile crashes
▪ Falls
▪ Poisoning
2) Toddlers
o "Toddler-proofing" home
o Physical trauma from falling, banging
into objects, getting cut by sharp
objects
o Use of federally approved car
restraints
o Removing or securing all potentially
hazardous items
o Inspect and remove sources of lead:
▪ Lead paint chips
▪ Fumes from leaded gasoline
▪ Any "leaded" substances
3) Preschoolers
o Control of environment must continue.
o Keep matches, medicines, and other
hazards out of reach
o Safety education must begin.
▪ How to cross the street
▪ What traffic signals mean
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▪ How to ride bicycles and other 8) Older Adults

wheeled toys o Night driving
o Parents must maintain surveillance. ▪ Accommodation to light
impaired
4) School-age children ▪ Peripheral vision diminished
o Engage in fantasy and magical ▪ Driving in fog should be
thinking avoided.
o Imitate actions of parents and o Fires
superheroes ▪ Forgetting iron or stove left on
o Leading cause of death is accidental ▪ May not extinguish cigarette
injury. completely
o Most frequent causes of death ▪ Potential for burns when
▪ Motor vehicle crashes person bathes or uses heating
▪ Drowning devices
▪ Fires o Risk for wandering
▪ Firearms ▪ Analgesic and sedative use
o Minor injuries o Suicide rate increasing
▪ Swings, bicycles, skateboards,
swimming pools 9) Safety problems across the lifespan
o Domestic violence
5) Adolescents ▪ Child abuse
o Suicide and homicide - two leading ▪ Intimate partner abuse
causes of death ▪ Older adult abuse
o Influencing factors: o Nurses' opportunity to become
▪ Economic deprivation advocates for community support
▪ Family breakup programs
▪ Availability of firearms
Promoting Safety in the healthcare setting:
6) Young Adults - Avoid focus on blame
o Leading causes of death: - Develop trust; share experiences about safety
▪ Motor vehicle crashes - Be active in preventing medication errors
▪ Suicide - Communicate
o Nurses' role in prevention is to
identify: Preventing Specific Hazards:
▪ Depression
▪ Physical complaints 1) Falls
▪ Decrease in social and work o Infants and older adults particularly
roles prone
o Most occur in home
7) Middle-aged Adults o Fear of falling in those who live alone
• Accidental death: o The Joint Commission Standards:
o Motor vehicle crashes most common ▪ Assess, manage client's risk
▪ Decreased reaction time for falls
▪ Decreased visual acuity ▪ Implement interventions based
o Falls on risk
o Burns o Preventing falls in healthcare
• Accidental death: agencies:
o Poisonings ▪ Orient clients to surroundings
o Drowning and explain the call system
• Safety hazard: ▪ Carefully assess client's ability
o Occupational injuries to ambulate and transfer

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▪ Provide walking aids and
assistance as needed
▪ Closely supervise clients at
risk for falls, especially at night
▪ Encourage client to use call
bell to request assistance and
ensure that bell is within easy
reach
▪ Place bedside tables and
overbed tables near bed or
chair so clients do not
overreach
▪ Always keep hospital beds in
low position with wheels
locked when not providing
care so clients can move in or
out of bed easily
▪ Encourage clients to use grab
bars mounted in toilet and
bathing areas and railings
along corridors
▪ Make sure nonskid bath mats
are available in tubs and
showers
▪ Encourage clients to wear
nonskid footwear
▪ Keep environment tidy,
especially light cords out from
underfoot and furniture out of
walkways
▪ Use electronic safety
monitoring devices, rather than
side rails, for confused client
▪ Use mechanical or electronic
ceiling lift to transfer
dependent clients
2) Seizures
o Partial - electrical discharges from
one area of brain
o Generalized - affects whole brain
o Grand mal (tonic-clonic) - involves
entire body
o Take precautions to prevent client
from injury
3) Scalds & Burns
o Common home hazards
▪ Pot handles over edge of
stove
▪ Electrical appliances used to
heat liquids or oils, dangling
cords
SYHV | BSN 1-E
▪ Excessively hot water
o Monitor clients with impaired skin
sensitivity
4) Fires
o Agency fires:
▪ Know fire safety regulations
and agency's fire prevention
practices
▪ RACE - Rescue, Activate,
Confine, Extinguish
▪ PASS - Pull, Aim, Squeeze,
Sweep
o Home fires:
▪ Teach fire safety
▪ Keep emergency numbers by
telephone or in cell phones
(ICE)
▪ Smoke alarms operable and
appropriately located
▪ Batteries in smoke alarms
changed annually on a special
day
▪ Family "fire drills"
▪ Fire extinguishers available
and in working order
▪ Close windows and doors, if
possible
▪ Cover mouth and nose with
damp cloth
▪ Assume bent position with
head as close to floor as
possible
5) Carbon Monoxide Poisoning
o Prolonged exposure can lead to
unconsciousness, brain damage, or
death.
o All gasoline-powered vehicles, lawn
mowers, kerosene stoves, barbecues,
and burning wood emit CO.
o Detectors available for the home
6) Poisoning
o Teach parents to "childproof" the
environment
o Provide information and counseling
about insect or snake bites and drugs
used for recreational purposes
o Safeguard the environment and
monitor underlying problems to
prevent accidental ingestion of toxic
substances
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7) Excessive Noise
o Minimize noise in hospital setting
o Protect hearing as much as possible
o Physiological effects of noise:
▪ Increased heart and
respiratory rate
▪ Increased muscular activity
▪ Nausea
▪ Hearing loss
o Methods of minimizing noise:
▪ Acoustic tiles on ceilings,
walls, floors
▪ Drapes and carpeting
▪ Background music
8) Electrical Hazards
o Electric shock - current travels
through body to ground rather than
through electric wiring
o Equipment must be properly
grounded.
o Faulty equipment means a danger of
electrical shock or fire.
o Client may sustain superficial or deep
burns, muscle contractions, and
cardiac and respiratory arrest.
o Use machines in good repair
o Wear shoes with rubber soles
o Stand on a nonconductive floor
o Use nonconductive gloves
o Do not touch victim until electrical
current turned off or victim removed
from contact
9) Firearms
o Store all guns in sturdy locked
cabinets without glass
o Make sure keys are inaccessible to
children
o Store bullets in separate location
o Tell children never to touch a gun or
stay in a friend's house where a gun is
accessible
o Teach children never to point the
barrel of a gun at anyone
o Ensure the firearm is unloaded and
the action open when handing it to
someone
o Don't handle firearms while affected
by alcohol or drugs of any kind,
including pharmaceuticals
SYHV | BSN 1-E
o When cleaning or dry firing a firearm,
move all ammunition to another room
o Double-check the firearm when
entering the room used to clean the
firearm
o Inspection of regularly used firearms
at least every 2 years
10) Radiation
o Limit time near source
o Provide as much distance as possible
from source
o Use shielding devices
o Be familiar with agency protocols
11) Disasters
o Mitigation, preparedness, response,
and recovery
Procedure and Equipment Related
Accidents:
- Important aspect of risk assessment
- Agency protocols to prevent accidents
- Consult written guidelines
- Incident report
Restraining Clients:
• Restraints - protective devices used to limit
the physical activity of client or body part
• 2 Reasons for Restraining:
o Avoid and/or prevent purposeful or
accidental harm to resident/client
o To do what is required to provide
medically necessary treatment that
could not be provided any other way
• May be used to prevent client from harming
others
• Physical restraint - any manual or physical
or mechanical device, material, or equipment
attached to client's body
• Chemical restraint - medications used to
control socially disruptive behavior
• Legal Implications of Restraints:
o Restraints restrict the individual's
freedom
o Orders renewed daily
o Order must state reason and time
period.
o PRN order prohibited
o Nurses must document that need for
restraints was made clear both to
client and family.
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• Selecting a Restraint:
o Nurses need to understand its
purpose.
o 5 criteria for restraint:
▪ Restricts client's movement as
little as possible
▪ Is safe for the particular client
▪ Does not interfere with client's
treatment or health problem
▪ Is readily changeable
▪ Is as discreet as possible

EVALUATING PHASE
• Nurse's role largely educational
• Desired outcomes reflect:
o Acquired knowledge about hazards
o Behaviors that incorporate safety
practices
o Skills to perform in event of
emergency
• Desired outcomes involve client being able
to:
o Describe methods to prevent hazards
o Report use of home safety measures
o Alter home environment to reduce risk
of injury
o Describe emergency procedures for
poisoning and fire

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C. HYGIENE SKIN
- Protects underlying tissue
INTRODUCTION: - Regulates body temperature
• Hygiene - science of health and its - Secretes sebum
maintenance. It is a highly personal matter o Oily substance that softens and
determined by individual and cultural lubricates hair and skin
practices. o Maintains moisture
• Personal hygiene includes: o Bactericidal action
o Hair o Transmits sensation
o Eyes - Produces and absorbs vitamin D
o Ears
o Perineal-genital area • Sudoriferous (sweat) glands - All surfaces
except lips and parts of the genitals
HYGIENIC CARE • Apocrine glands - Axillae, anogenital areas.
Begin to function at puberty
• Morning Care
o Usually after breakfast • Eccrine glands - Palms of hands, soles of
o Elimination feet, forehead. Cool the body through
evaporation
o Bath or shower
o Perineal care
o Back massage ASSESSING & DIAGNOSING THE SKIN
o Oral, nail, and hair care
Assessment Nursing Diagnosis
• Hours of sleep or PM care Nursing history Examples
o Elimination • Determine the client’s Altered self-care (bathing)
o Washing face and hands skin care practices
o Oral care • Self-care abilities Altered self-care (dressing)
(Client’s functional, Altered self-care (toileting)
o Back massage cognitive levels, and Altered self-care (feeding)
• As-needed (prn) care - As required by motivation)
client need • Past or current skin
problems
o More frequent bathing • Physical Assessment
o Changes of clothes
PLANNING FOR THE SKIN
FACTORS INFLUENCING INDIVIDUAL • Nurse and, if appropriate, client and/or family
HYGIENIC PRACTICES set outcomes for each nursing diagnosis.
1) Culture • Nurse performs nursing interventions and
o Some cultures place a high value on
activities to achieve client outcomes.
cleanliness.
o Body odor is offensive in some cultures • Planning for Home Care:
1) Religion o Client's and family's abilities to provide
o Ceremonial washing are practiced self-care/care
2) Environment o Need for referrals and home health
o Financial capability can influence services
bathing practices o Learning needs
3) Developmental level
o Children learn hygiene in home EVALUATION FOR THE SKIN
4) Health & Energy • Functional ability for self-care
o Individuals who are ill may not have the • Efficacy of instructions and assistive devices
motivation or energy to attend to • Client status
hygiene • Need for analgesics
5) Personal Preference • Tissue integrity
o Prefers shower/tub bath
• Nutrition adequate to support skin integrity

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HAIR ▪ If client taking anticoagulant,

- Reflects person's feeling or self-concept, well- use an electric shaver
being, state of health
- Developmental Variations EVALUATION OF THE HAIR
o Lanugo - Use data collected
o Fine hair on body of fetus - Judge whether desired outcomes have been
- Puberty achieved
o Pubic hair o If not, explore why
o Sebaceous glands - Modify care plan if needed
- Thinning hair in older adults
o Alopecia SUPPORTING A HYGIENIC ENVIRONMENT
- Holistic
ASSESSMENT OF THE HAIR - Bed-making as preparation of a healing space
• In Nursing history, determine: - Room temperature
o Usual hair care o Between 68–74 degrees for most
o Self-care abilities - Ventilation
o History of hair or scalp problems o Odors can be offensive to people.
o Conditions known to affect the hair - Noise
▪ Alopecia (hair loss) o Staff communication, hallways
▪ Dandruff o Sleep disturbance
▪ Pediculosis (infestation of the o Increased perception of pain
hairy parts of the body or
clothing with the eggs, larvae,
or adults of lice)
▪ Hirsutism (condition in
women that results in
excessive growth of dark or
coarse hair in a male like
pattern)

IMPLEMENTING HAIR
• Brushing and combing hair
o Hair needs to be brushed or combed
daily.
o Long hair may present a problem.
o Dark-skinned people often have
thicker, drier, curlier hair than light-
skinned people.
▪ Some may have it
straightened or have naturally
straight hair.
• Shampooing the hair
o Shower or sink for clients who are
able
o "Head bath"
▪ Shower cap that contains
shampoo and conditioner
o Bed shampoo
• Beard and mustache care
o Most important aspect to keep clean
o Grooming may be requested.
o Shaving
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D. COMMUNICATION MODES OF COMMUNICATION

Verbal Non-verbal Electronic
INTRODUCTION Use spoken or Uses gestures, Use of technology
• Communication written word facial expressions,
o Any means of exchanging information touch, and other
forms
or feelings between two or more Makes up majority Email, social media,
individuals. of communication chatbox
o Intent: to obtain a response.
o Purposes: VERBAL COMMUNICATION PROCESS
▪ To influence others • Pace and intonation
▪ To gain information • Simplicity
o Nurses who communicate
• Clarity and brevity
effectively are better able to:
• Timing and relevance
▪ Collect assessment data
• Adaptability
▪ Provide nursing interventions
▪ Evaluate outcomes • Credibility
▪ Promote health • Humor
▪ Prevent legal problems o Consider client's perceptions

NON-VERBAL COMMUNICATION PROCESS

• Personal appearance
• Posture and gait
• Facial expression
• Gestures
o Consider cultural differences

FACTORS INFLUENCING THE

COMMUNICATION PROCESS
• Values and Perceptions
o Standards that influence behavior
COMMUNICATION PROCESS o Personal view of an event
1) Sender • Personal Space
o Source/encoder - A person or group o Intimate (0 to 1-1/2 feet)
who wishes to communicate a o Personal (1-1/2 to 4 feet)
message to another o Social (4 to 12 feet)
o Encoding - selecting signs, symbols o Public (12 to 15 feet)
to transmit • Territoriality
o Space, things that individual considers
2) Message as belonging to self
o The message itself • Roles and Relationships
o What is said or actually written o Between sender and receiver affect
the communication process.
3) Receiver
• Environment
o The decoder - relating message
o Most effective communication in
perceived to receiver's storehouse to
comfortable environment
sort out the meaning
o Privacy
o The listener
• Congruence
o Verbal and nonverbal aspects of
4) Response
message match
o Feedback - message that receiver
returns to sender • Interpersonal Attitudes
o Caring and warmth

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o Respect
• Interpersonal Attitudes
o Elder speak
▪ Similar to baby talk
▪ Patronizing to older adults
o Acceptance
• Boundaries
o Limits crucial to nurse–client
relationship
o Some indicators that boundaries need
to be addressed:
▪ Gift-giving by the client/nurse
▪ Unprofessional use of social
networking
THERAPEUTIC COMMUNICATION
• Promotes understanding
• Establishes constructive relationships
• Attentive Listening
o Listening actively, mindfully
o Listen for key themes in
communication
• Visibly Tuning In
o Manner of being present to another
o Have good eye contact with the client
THERAPEUTIC COMMUNICATION
TECHNIQUES
1) Using Silence – accepting pauses or silence
that may extend for several seconds/minutes
without interjecting any verbal response.
o Sitting quietly
o Waiting attentively until the client is
able to put thoughts and feelings into
words
2) Being specific & tentative - making
statements that are specific rather general
and tentative rather than absolute.
o Specific - “rate your pain on a scale of
0 to 10”
o General – “are you in pain?”
o Tentative – “ You seem unconcerned
o about your diabetes”
3) Using open-ended questions - asking broad
questions that lead the explain, elaborate,
clarify thoughts/feeling.
o “I’d like to hear more about that”
o “Tell me more”
SYHV | BSN 1-E
o “How have been feeling lately?”
4) Using touch - appropriate form of touch to
reinforce caring feelings.
o Putting an arm over the client’s
shoulder
o Placing hand over the client’s hand.
5) Seeking clarification - making the client’s
broad overall meaning of the message more
understandable.
o “I’m not sure I understand that”
o “I’m sorry that wasn’t very clear. Let
me try to explain it another way.”
6) Summarizing and planning – stating the
main points of discussion
o “During the past half hour, we have
talked about”
o “Tomorrow afternoon, we may explore
this further.”
BARRIERS TO COMMUNICATION
- Need to be recognized when they occur
- Major barriers:
o Failure to listen
o Improperly decoding client's intended
message
o Placing nurse's needs above client's
needs
1) Stereotyping - offering generalized and
oversimplified beliefs about groups of people
o “Men don’t cry”
o “two-year-childen are brats”
2) Agreeing & Disagreeing - Similar to
judgmental responses; Implies that the client
may be right/wrong; Deters client from
thinking through their position and may cause
a client to become defensive.
o Client:“I don’t think that Dr. A is a good
doctor”
o Nurse: “Dr. A is the Head of Surgery
Department, and an excellent doctor”
3) Probing - Asking for information out of
curiosity rather than to assist the client; Asking
“why” places the client in a defensive position.
o “Why were you speeding?”
o “Why didn’t you?”
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4) Unwanted Assurance – using cliches or EVALUATION

comforting statements to reassure the client; • Client communication
Blocks the feelings, fears of the client o Listen actively
o “You’ll feel better soon” ▪ Observe nonverbal cues
o “Don’t worry” o Use therapeutic communication skills
• Nurse communication
COMMUNICATION AND THE NURSING o Use of process recording
PROCESS ▪ A verbatim account of a
- Each phase of the nursing process conversation
- Clarify functions and roles ▪ Analyzed in content and
- Clarify what is expected of client, nurse, and meaning of interaction
primary care provider • Increases awareness
and insight
ASSESSMENT • Identify strengths and
• Impairments to communication need for future skills
o Language deficits development
o Sensory deficits
o Cognitive impairments
o Structural deficits
o Paralysis
• Style of communication
o Verbal
▪ Whether pattern is slow, rapid,
quiet, etc.
▪ Vocabulary of individual
▪ Presence of hostility,
aggression, assertiveness,
reticence, anxiety
▪ Difficulties such as slurring,
stuttering
▪ Refusal or inability to speak
o Nonverbal

DIAGNOSIS
• Impaired Verbal Communication
o Not used when caused by a
psychiatric illness
• Anxiety
• Powerlessness
• Situational Low Self-Esteem
• Social Isolation
• Impaired Social Interaction

IMPLEMENTATION
• Manipulate the environment
• Provide support
• Employ measures to enhance communication
• Educate the client and support persons

SYHV | BSN 1-E 17