Fundamentals of Nursing- Lecture

INFECTION CONTROL
Infection control
According to centers for disease control and prevention infection control prevents or stops the
spread of infections in health care settings this includes how infection spreads ways to prevent the spread
of infection and more detailed recommendation by type of healthcare settings

How infections spread?

So germs are part of everyday life and are found in our air soil water and in and on our bodies
some germs are helpful others are harmful many germs live in and on our bodies without causing harm
and some even helps us to stay healthy so only a small portion of germs are known to cause infection
Infection is the invasion and multiplication of microorganisms in body tissues which may be an apparent
or the result of local cellular injury caused by competitive metabolism toxins intracellular replication or
antigen antibody response
Invasion of the susceptible host by pathogens or microorganisms, resulting in disease.
An infection occurs when germs enter the body increase in number and cause a reaction of the
body.
Three things are necessary for an infection to occur:
1. Source these are the places where infectious agents or the germs live like seeing surfaces human
skin
2. Susceptible person-with a way for germs to enter the body
3. Transmission- this is a way germs are moved to the susceptible person
Chain of infection
1. An infectious agent or pathogen(Source)
 A source is an infectious agent or germ and refers to a virus bacteria or other microbe
 In healthcare settings germs are found in many places.
 People are one source of germs including patient’s healthcare workers visitors and household
members. People can be sick with symptoms of an infection or colonize with germs. This means
that not having any symptoms of an infection but able to pass the germs to others
 So germs are also found in the healthcare environment example is environmental sources of
germs include dry surfaces in patient care areas like the bed rails medical equipment counter
tops and tables
1. Wet surfaces- moist environments and biofilms. Example: cooling towers faucets and sinks okay
and other equipment such as ventilators
2. Dwelling- medical devices like your catheters and iv tubes or iv lines
3. Dust or decaying debris- from construction dust or wet materials from water leaks
2. Reservoir of infection source of pathogen growth
 Is any person animal plant soil or substance in which an infectious agent normally lives and
multiplies
  The reservoir typically harbors the infectious agent without injury to itself and serves as a
source from which other individuals can be infected
 The infectious agent primarily depends on the reservoir for its survival it is from the reservoir
that the infective substance is transmitted to a human or another susceptible host
3. Portal of exit
 The path which a pathogen leaves its host
 The portal of exit usually corresponds to the site where the pathogen is localized
For example: influenza viruses and mycobacterium tuberculosis exits the respiratory tract. Schistosomes
through urine; cholera vibros in feces; sarcophyte scuba and scabby skin lesions; And enterovirus 70 a
cause of hemorrhagic conjunctivitis in conjunctival secretions
 Some blood-borne agents can exit by crossing the placenta from mother to fetus like your rubella
or syphilis or toxoplasmosis while others exit through the cuts or needles in the skin like the
hepatitis b or blood sucking arthropods or malaria
4. Modes of transmission
An infectious agent may be transmitted from its natural reservoir to a susceptible hose in different
ways
Classifications for modes of transmission
1. Direct
a. Direct contact
o Direct contact occurs through skin to skin contact like kissing in sexual intercourse

o Refers to contact with soil or vegetation harboring infectious organisms thus infectious mono
nucleuses- kissing disease and gonorrhea so this is spread from person to person by their contact we
also have hookworm this is spread by direct contact with contaminated soil
b. Droplet spread
o This refers to spray with relatively large short-range aerosols produced by sneezing coughing or even
talking
o Classified as direct because transmission is by direct spray or over a few feet before the droplets fall
to the ground pertussis and meningococcal infection are examples of diseases transmitted from an
infectious patient to a susceptible hose by droplet spread
2. Indirect
o This we have airborne vehicle airborne or vehicle born and vector born (mechanical or biologic)

o Refers to the transfer of infectious agent from a reservoir to a host by suspended air particles,
inanimate objects which is the vehicles and animate intermediaries which is the vectors
a. Airborne transmission
o Occurs when infectious agents are carried by dust or droplet nuclei suspended in air

o Airborne dust includes material that has settled on surfaces and become suspended by air currents as
well as infectious particles blown from the soil by the wind
o Droplet nuclei are dried residue of less than 5 microns in size in contrast to droplets that fall to the
ground within a few feet droplet nuclei may remain suspended in the air for long periods of time and
 may be blown over great distances. Measles for example has occurred in children who came into
opposition's office after a child with measles had left because the measles virus remains suspended in
the air
b. Vehicles
o So vehicles may indirectly transmit an infectious agent includes food water biologic products like your
blood and fomites
o For example handkerchiefs bedding or surgical sculptures

o A vehicle may passively carry a pathogen as food or water may carry hepatitis a virus

o Alternatively the vehicle may provide an environment in which the agent grows multiplies or produce
toxin as improperly canned foods provide an environment that supports production of botulinum toxin
by clostridium botulinum
c. Vectors
o Vectors such as mosquitoes fleas and ticks may carry an infectious agent through purely mechanical
means or may support growth or changes in the agent
o Examples of mechanical transmissions are flies carrying shigella under appendages and fleas carrying
your senior pestis the causative agent of plague in their gut
o In biologic transmission the positive agent of malaria or guinea worm disease undergoes maturation in
an intermediate host before it can be transmitted to humans
5. Portal of entry
 Refers to the manner in which a pathogen enters a susceptible host
 must provide access to tissues in which the pathogen can multiply or a toxin can act often
infectious agents use the same portal to enter a new host that they use in exit the source host
 Example influenza virus exits the respiratory tract of the source hose and enters the respiratory
tract of the new host in contrast many pathogens that cause gastroenteritis follow a so-called
pickled oral route
 Because they exit the source host in feces then carried on inadequately wash hands to a vehicle
such as food water or utensils and enter a new host through the mouth
Other portals
 Include the skin this is for the hookworm we have mucus membranes for syphilis and blood for
hepatitis b or hiv for human immunodeficiency virus

6. Host
 Final link in the chain of infection
 Susceptibility of a host depends on genetic or constitutional factors specific immunity and non-
specific factors that affect an individual's ability to resist infection or to limit pathogenicity
 An individual's genetic makeup may either increase or decrease susceptibility
 Example: persons with sickle cell trait seem to be at least partially protected from a particular
type of malaria
  Specific immunity refers to protective antibodies that are directed against a specific agent such
antibodies may develop in response to infection vaccine or toxoid or may be acquired by trans-
placental transfer from mother to fetus or by injection of antitoxin or immune globulin
 Non-specific factors that defend against infection includes the skin mucous membranes
gastric acidity cilia in the respiratory tract, the cough reflex and non-specific immune response
Factors that may increase susceptibility to infection by disrupting host defenses
1. Malnutrition
2. Alcoholism
3. Disease or therapy that impairs the non-specific immune response
Break the chain of infection
 Knowledge of the portals of exit and entry and modes of transmission provides a basis for
determining appropriate control measures in general control measures are usually directed against
the segment in the infection chain that is most susceptible to intervention unless practical issues
dictate otherwise
Interventions are directed at:
 Controlling or eliminating agent at source of transmission
 Protecting portals of entry and increasing host defenses
 For some diseases the most appropriate intervention may be directed at controlling or eliminating
the agent at its source
 A patient sick with communicable disease may be treated with antibiotics to eliminate the infection
and a symptomatic but infected person may be treated both to clear the infection and to reduce
the risk of transmission to others
 In the community, soil may be decontaminated or covered to prevent escape of the agent
 Some interventions are directed at the mode of transmission
 Interruption of direct transmission may be accomplished by isolation of someone with infection or
counseling persons to avoid the specific type of contact associated with transmission
Vehicle borne transmission may be interrupted by elimination or decontamination of the vehicle to
prevent fecal oral transmission efforts often focus on rearranging the environment to reduce the risk of
contamination in the future an unchanging behavior such as promoting hand washing.
Airborne diseases strategies may be directed at modifying ventilation or air pressure and filtering or
treating the air.
To interrupt vector-borne transmission measures may be directed toward controlling the vector
population such as spraying to reduce the mosquito population.
Some strategies that protect portals of entry are simple and effective for example bed nets are used for
protecting sleeping persons from being beaten by mosquitoes that may transmit malaria or dengue
A dentist masks or gloves are intended to protect the dentist from patient's blood secretion and droplets as
well as to protect the patient from the dentist
Wearing of long pants and sleeves to use of insect repellent are recommended to reduce that infection
caused by different kinds of insects for example filariasis, malaria dengue
Some interventions aim to increase host defenses
  Vaccinations promote development of specific antibodies that protect against infection so like now
 On the other hand prophylactic use of anti-malarial drugs are recommended for visitors to malaria
endemic areas like one
 Doing your hand hygiene or hand washing because this will not only prevent spread of infection
but will ensure that all of us will be clean and avoid any kinds of germs replicating in our body
 Portable alcohol or a sanitizer
Nursing knowledge
1. Asepsis
 Absence of pathogenic or disease-producing microorganism
 Absence of disease or infection
2. Aseptic
 Technique which refers to practices or procedures that help reduce the risk of infection
Medical asepsis or clean technique
 Includes procedures for reducing the number of organism present and preventing the transfer of
organisms
 Hand washing is the most important action to prevent infection
 Five moments for hand hygiene (based on world health organization)
Moments that you have to perform hand washing
1. Before touching the patient
2. Before clean or a septic procedure
3. After body fluid exposure or risk number
4. After touching a patient number
5. After touching patients surroundings like their handrails the doorknob their bag or anything that is
inside the room of the patient
Surgical asepsis
 Absence of all microorganisms within any type of invasive procedure
Sterile field
 an area of microorganisms and prepared to receive sterile procedures

Sterile technique
 a set of specific practices and procedures performed to make equipment and areas free from all
microorganisms and to maintain that sterility
 All personnel involved in an aseptic procedure are required to follow the principles and practice set
forth by the association of perioperative registered nurses
 These principles may be strictly applied when performing any aseptic procedures, when assisting
with aseptic procedures and when intervening when the principles of surgical asepsis are breached
  It is the responsibility of all healthcare workers to speak up and protect all patients from infection
Steps in surgical asepsis
1. All objects used in a sterile field must be sterile. So commercially packaged sterile supplies are marked
as sterile other packaging will be identified as sterile according to the agency policy
Check packages for sterility by assessing intactness dryness and expiry date prior to use
Any thorn or previously open or wet packaging or packaging that has been dropped on the floor is
considered non-sterile and may not be used in the sterile field
2. Sterile object becomes non-steady when touched by a non-sterile object because stared objects must
only be touched by sterile equipment or sterile gloves whenever the sterility of an object is questionable
consider it non-sterile.
Fluid flows in the direction of gravity keep the tips of forceps down during a sterile procedure to prevent
fluid traveling over entire forceps and potentially contaminating the sterile field
3. Sterile items that are below the waist level or items held below waist level are considered to be non-
sterile keep all sterile equipment and sterile gloves above waist level table drapes are only sterile at waist
level
4. Sterile fields must always be kept in sight to be considered steady sterile fields must always be kept
inside throughout the entire sterile procedure never turn your back on the sterile field as sterility cannot be
guaranteed
5. When a stirred surface comes in contact with wet contaminated surface the sterile object or field
becomes contaminated by capillary action. Set up sterile trays as close to the time of use as possible stay
organized and complete procedure as soon as possible. So place large items on sterile field using sterile
gloves or sterile transfer forceps
6. Fluid flows in the direction of gravity
7. Edges of a sterile field or container are considered to be contaminated. So place all objects inside the
sterile field and away from the one inch border.
Additional
 Movement around and in the sterile field must not compromise or contaminate the sterile field. So
make sure the keep your hair tied
 Back do not sneeze cough laugh or talk over the sterile field
 Maintain a safe space or margin of safety between steady and non-sterile objects and areas
 Refrain from reaching over the sterile field
 Keep or traffic to a minimum and keep doors closed
 When pouring sterile solution only the lip and inner cup of the pouring container is considered
steady the pouring container must not touch any of the sterile field
 Avoid splashes
Standard precautions
 Used to prevent and control infection and its spread
 Example are wearing of gloves when there is an opportunity to come in contact with blood body
fluid
 Non-intact skin and mucous membranes from all patients
Disinfection and sterilization
Disinfection
 Describes a process that eliminates many or all microorganisms with the exception of bacterial
spores from inanimate objects
Sterilization
 Is the complete elimination or destruction of all microorganisms including sporesso
 Examples of disinfectants: lysol and zonrox, bleach, muriatic acid
 Sterilization is using an autoclave okay steaming your or equipment the bar or gown
Infection prevention and control to reduce reservoirs of infection
1. Bathing
 Use appropriate bathing kits wipes to remove drainage dried secretion or excess perspiration or
sweat
2. Dressing changes
 Change wound dressing okay when it's wet or soiled
3. Contaminated articles
 Place tissues soil dressings or soiled linen in fluid resistant bags for proper disposal usually
infectious are being thrown in a yellow bean or yellow trash can
4. Contaminated sharps
 Place all needles, safety needles and needle less systems into puncture proof containers usually
 If there's no container for sharps, improvise using bottles or white containers but if there's a
container usually it's already labelled okay sharps container
5. Bedside unit
 Keep table surfaces clean and dry
6. Bottled solutions
 Do not leave the bottle solutions open
 Keep solutions tightly cup date bottles when open and discard in 24 hours
7. Surgical wounds
 Keep drainage tubes and collection bags patent to prevent accumulation of serous fluid under
the skin surface
8. Drainage bottles and bags
 Wear gloves and protective eyewear if splashing or spraying with contaminated blood or body
fluid is anticipated
 Empty and dispose the drainage suction bottles according to facility protocol then empty all
drainage system in each ship unless otherwise ordered by physician
 Never raise a drainage system like the urinary drainage bug okay it should be above the level of
sight being drained unless it is clamped off
Fundamentals of Nursing- Lecture
NURSING PROCESS
 Critical thinking can be broadly defined as a complex cognitive process that involves the
development and effective utilization of multiple dimensions of cognition to interpret and analyze a
situation and arrive at end up on an appropriate conclusion or solution
 Critical thinkers demonstrate the ability to ask relevant questions clearly define a problem or
solution and situation use knowledge and previous experience to guide problem solving examine
their own thinking and the thinking of others and arrive at a conclusion that reflects thorough
analysis of all aspects of the situation.
 According to American nurses association (ANA) an essential feature of a professional nursing is the
application of scientific knowledge to the processes of diagnosis and treatment through the use of
judgment and critical thinking
Purposes of nursing process
• To identify a client's health status and actual or potentiall health care problems or needs.
• To establish plans to meet the identified needs
• To deliver specific nursing interventions to meet those needs.
Nursing Process
 is systematic problem solving approach to diagnose and guide treatment for patient responses to
health and illness is considered a critical thinking competency
 Critical thinking is important in all five steps of the Nursing Process
 Synonymous with problem solving approach for discovering the health care and nursing care needs
of the client
The History of Nursing Process
1. Lydia hall
 Who said nursing process is consisting of three steps observation; administration of care and
validation
2. Dorothy Johnson 1959
 She also has three steps which is assessment, decision and the nursing action
3. Ida Jean Orlando 1961
 Has three steps patient behavior, nurse's reaction and nurse’s action during.
4. Yura and walsh 1967
 Four steps: assessment planning, implementing and evaluation this is
5. Knowles 1967
 5ds: discover, delve, decide, do and discriminate
Five Steps of Nursing Process
1. Assessment
  Involves data collection through physical examination and taking a health history accurate
assessment requires skilled observation data verification and differentiation of pertinent from
irrelevant data
 Critical thinking is key to perform complete systematic patient assessments, in recognizing the
nurse's crucial role in identifying and responding to signs of patient deterioration following a
surgery intentioned team of experts nurses develop a clinical algorithm to guide less
experienced nurses in systematic surveillance and management of post-surgical patients
algorithm is based on an expert level approach to patient care providing information on possible
etiologies for clinical changes post-surgery
 Strategies to effectively communicate those changes to the health care team and potentially
helpful interventions it aids nurses in developing critical thinking skills necessary to provide high
quality Patient care
 Where to get the data? The individual, family or the community
 Purpose: is to establish database
 The subsequent steps of the nursing process rely on the accuracy and thoroughness of the data
collected during the assessment step
Two ways of Collection of data
1. Subjective
 Usually the symptoms
 Verbalization from the patient
 This are the things that patients describe only by the person who's experienced it
 Example: vertigo, pain
2. Objective
 These are the signs which is observable
 Those that can be observed and measured example pallor or being pale of the patient,
discoloration of the eyes or the skin, diaphoresis or the excessive sweating and, BP 110 over 80
reddish urine
Methods of collecting data
1. Interview
 Planned purposeful conversation
 There are objectives and my goals when we're conducting an interview
2. Observation
 Use of senses use of units of measures physical assessment techniques lab results
Sources of data
1. Primary source- Patient. Important data
2. Secondary from family members related literatures charts significant others healthcare team
members.
  2 Approaches of interview
- Directive interview (Nurse): interview highly stuctuctured and directly ask questions
-Non directive interview (Patient):  rapport building interview
Stages of Interview
1. Opening/introduction
2. Body/development
3. Closing
3. Examination:
- Physical examination is a systemic data collection method to detects health problems 
- IAPERPA  

2, Nursing diagnosis
 Is the step during which the nurse summarizes the assessment data and formulates a statement
about the patient's need for nursing care
 Requires a critical analysis of assessment data in order to make an accurate clinical judgment about
a patient's response to a current or potential physical psychological or emotional stressors
NANDA
- A clinical judgment concerning human response to health conditions, life processes, or vulnerability for
the response in individual, family,group or community
Status of the Nursing Diagnosis
1. Actual dx.
- Present in the time of the Nursing assessment
2. Health promotion dx.
- Preparedness to improve their health condition
3. Risk nursing dx.
- Clinical judgment
- Potential problem
- Presence of risk factors
Components of NANDA Nursing Dx.
1. Problem statement: Client's health Problem
2. Etiology: Causes of health problem
3. Defining characteristics: cluster of s/sx that indicate a presence of health Problem
Formulating Diagnostic Statement
P-Problem: Statement of client's health problem (NANDA label)
E-Etiology: causes of the health Problem
S-S/Sx: characteristics manifested by the client
Example: Post appendectomy P- Risk for Infection
P-Pain E-post appendectomy
E- Surgery S- Post surgery incision
S- Pain scale, discomfort of patient Nursing Dx: Risk for Infection related to post-
surgical incision secondary to post appendectomy
Nursing Dx: acute Pain r/t abdominal surgery as
evidenced by patient discomfort and pain scale of
7

Diff. Bet. Nursing dx from medical dx

Nursing dx Medical dx

Nursing Judgment ( education, experience, and Physician

expertise 

Human response to an illness  Disease Process

change client's response  remains the same for as long as the disease is
present 

Ineffective Breathing pattern Asthma 

activity intolerance  CVA

acute Pain  Appendicitis

Following eight aspects of critical thinking in nursing diagnostic process

1. Scientific and technical knowledge- evidence-based nursing as presented in a literature
2. Analysis- research and evaluation of a clinical situation to understand it holistically
3. Logical reasoning is the nurse's perception of the situation
4. Clinical experience - how the nurse responded in a similar situations in the past
5. Knowledge of the patient- this is the awareness of the patient's physical emotional social and
spiritual status
6. Discernment this is how the assessment data are judged to arrive at a decision
7. Applying patterns- use of information in the literature to assist with identification evaluation and
grouping of data
8. Contextual perspective- this is the view of the clinical situation as a whole
Format for nursing diagnosis
PRS R- related factors or related to
P- problem S- signs and symptoms
PES E- etiology
P- problems S- signs and symptoms
 do not use medical terms or medical diagnosis
 For example the patient has a chronic obstructive pulmonary disease; for nurses we're going to use
ineffective breathing pattern related to and then look for the related factors and then what is the
observable signs and symptoms. diagnosis from nanda which is nursing diagnosis like ineffective
breathing pattern acute pain or chronic pain
3. Planning
 involves an essential link between nursing diagnosis and implementation of patient care
interventions
 Involves identifying short and long term patient goals and desired outcomes prioritizing nursing
diagnosis identifying appropriate nursing interventions for each diagnosis and using goal-directed
critical thinking to develop a plan for applying interventions including a plan for providing patient
education
 Plan should be smart; what is smart, specific measurable, attainable, realistic and time
bounded
TYPES OF PLANNING
1.  Initial planning: after initial assessment
2.  Ongoing planning: continuous planning 
3.  Discharge planning: planning for needs after discharge 
PLANNING PROCESS
1.  Setting Priorities
- The nurse begin planning by deciding w/c nursing dx requires attention.
- Maslow hierarchy of needs  
2.  Establishing clients goal/ desired out come
- After establishing priorities, the nurse set goals for each nursing dx.  (SHORTERM OR LONG
TERM)
3. Selecting nursing intervention
4.  Writing individualized nursing interventions on care plans 

4. Implementation
 This is a step during which the plan for nursing intervention is carried out through the provision of
direct patient care as the nurse provides direct patient care critical thinking is necessary in order to
identify appropriate health promoting actions designate specific personnel to provide patient care
monitor the patient's response to actions and interventions and monitor the risk and benefits of
interventions and actions
 Putting nursing care plan into action something that is not written is considered as not done
 That's why documentation is very important
  It consists of knowledge technical skills communication skills and therapeutic use of self
Process of implementation
- implementing of nursing Intervention
- documenting of nursing Activities
Nursing Interventions
- Is any treatment, that nurse performs to improve patients health
Three types
1. Independent nursing intervention
a. These are the interventions or actions that nurses can do without the help of the physician
2. Dependent nursing intervention
a. These are the actions that we need to do but with guidance and approval of the physician
for example we cannot prescribe a medication but we need a medication for the patient so
that the illness or the corresponding sciences symptoms should be eliminated
3. Interdependent nursing intervention
a. Collaborative intervention meaning we need the help of other departments from the hospital
for example we need to refer the patient to a pedia or refer the patient to the radiology or
oncology department or nutritionist
Writing Individualized nursing interventions
- After choosing the appropriate nursing intervention, the nurse writes them on the care plan
- NCP is written computerized information about the Client's care

5. Evaluation
 Final step of the nursing process
 Involves analyzing the plan of care and adjusting it as needed to meet the patient's continued
health needs
 The nurse critically analyzed the patient's response to interventions and determines whether goals
were achieved or the plans require modification
You will write:
1. Goal was completely met
2. Goal was partially met
3. Completely at unmet
4. New problems or nursing diagnosis have developed
 We have to become knowledgeable about the effects of critical thinking on the nursing process and
competent patient care so you can appreciate the importance of evaluating and promoting critical
thinking competence among nurses
A nurse is one who opens the eyes of a newborn and gently closes the eyes of the dying man. It is indeed
a high blessing to be the first and last to witness the beginning and end of life.
Fundamentals of Nursing- Lecture HADCAN, BSN 1-D
DOCUMENTATION
 Clear accurate and accessible documentation is an essential element of safe quality evidence-based
nursing practice
 Nurses practice across setting at position levels from the bedside to the administrative office the
registered nurse and the advanced
 Practice registered nurse are responsible and accountable for the nursing documentation and
reporting that is used throughout an Organization
What is documentation?
Written evidence of:
1. Interaction between and among health care professionals clients and their families and health care
organizations
2. Administration of tests procedures treatments and client education
3. Result of or clients respond to diagnostic tests and interventions
 Documentation of nurses work is critical as well for effective communication with each other and
with other disciplines
 It is how nurses create a record of their services for use by the legal system, government agencies
accrediting bodies researchers and other groups and individuals directly or indirectly involved with
health care
 It also provides a basis for demonstrating and understanding nursing contributions both to patients
care outcomes and to the viability and effectiveness of the organizations that provide and support
quality patient care
 Documentation is sometimes viewed as burdensome and even as a distraction from patient care
high quality documentation however is unnecessary and integral aspect of the work of a registered
nurse in all roles and settings
 This requires providing nurses with sufficient time and resources to support documentation
activities
 At a time when assessing, generating and sharing information in healthcare is rapidly changing it is
particularly important to articulate and reinforce principles that are basic to effective documentation
of nursing service
Purposes of the documentation
Could be for:
1. Professional responsibility 5. Research purposes
2. Accountability 6. Reimbursement
3. For good communication 7. Satisfaction of legal and practice
standards
4. Education
8. Documentation as Communication
  Nurses document their work and outcomes for a number of reasons
 The most important is for communicating within the healthcare team and providing information for
other professionals primarily for individuals and groups involved with accreditation legal regulatory
and legislative reimbursement research and quality activities

 Communication within the healthcare team nurses and other healthcare providers aim to share
information about patients and organizational functions that is accurate timely concise thorough
organized and confidential
 Information is communicated verbally and in written and electronic formats across all settings
 Written and electronic documentation are formats that provide durable records
 For most of such electronic documentation is the electronic health record it provides an integrated
real-time method of informing the healthcare team about the patient's status
 Types of information should be made and maintained in patients EHR or electronic health record to
support the ability of the healthcare team to ensure informed decisions and high quality care in the
continuity of patient care.
 it has the following like assessment, clinical problems, communications with other healthcare,
professionals regarding the patient, medication records, order acknowledgement, implementation
and management, plans of care patients response and Outcomes and patient clinical parameters
 An effective piece of documentation tells the story and the purpose of an event experience or
development
 It is a product that draws others into the experience evidence or artifacts that describe a situation,
tells a story of the patient and help the healthcare providers to understand the purpose of the
action
Documentation as education
 The medical record can be used by healthcare students as a teaching tool
 It is main source of data for clinical research
 Patient's chart because it includes different sheets inside the medication record physician's order
nurse's notes
Documentation and research
 This method refers to the analysis of the documents that contains information about the patient or
the intervention or the event under consideration
 It is used to investigate categorize and analyze physical sources most commonly written documents
in the social public or digital world in or out of the hospital
Legal and practice standards
 Nurses are responsible for assessing and documenting that the client has an understanding of
treatment prior to intervention because as nurses we have ethical values that are essential for any
healthcare provider
 Ethical values are universal rules of conduct that provide a practical basis for identifying what kinds
of action interventions and motives are valued
 In ethics there are moral principles that govern how the person or a group will behave or conduct
themselves
  The focus pertains to the right and wrong of actions and encompasses the decision-making process
of determining the ultimate consequences of those actions
 Each person has their own set of personal ethics and morales
 Ethics within healthcare are important because workers must recognize healthcare dilemmas make
good judgments and decisions based on their values while keeping within the laws that govern
them
 To practice competently with integrity nurses like all health care professionals must have regulation
and guidance within the profession some of the ethical
 Values are autonomy, beneficence, justice veracity and non-maleficence
Two indicators of documentation
1. Informed consent
 It is a process of communication between you and your health care provider that often leads to
agreement or permission of care treatment or services
 Every patient has the right to get information and ask questions before any kinds of procedure and
treatments
 Based on the moral and legal premise of patient autonomy
 Patient have the right to make decisions about your own health and medical conditions
 Must give your voluntary informed consent for treatment and for most medical tests and
procedures the legal term for failing to obtain informed consent before performing a test or
procedure on a patient is called battery this is a form of assault
 Example physical exam with your doctor implied consent is assumed
 For more invasive tests or for those tests or treatments with significant risk or alternatives you will
be asked to give explicit written consent
 Under certain circumstances there are exceptions to the informed consent rule the most common
exemptions are an emergency in which medical care is needed immediately to prevent serious or
irreversible harm
 Incompetence in which someone is unable to give permission or to refuse permission for testing or
treatment. When the patient refuse you have to give waiver.
Four components of informed consent
1. Decision Capacity
2. Documentation Of Consent
3. Disclosure
4. Competency
There are four principles of informed consent
1. Must have the capacity or ability to make decision
2. The medical provider must disclose information on the treatment test or procedure
3. Must comprehend the relevant information
4. Must voluntarily grant consent without coercion or jures
 2. Advance directives and leaving wheels
 Are documents that you can complete before an emergency occurs these legal documents direct
doctors and other health care providers as to what specific treatments you want or do not want
Most common types of advanced directives
1. Living wheel
2. Durable power of attorney for health care sometimes known as the medical power of attorney
Advanced directive formats
1. Forms outline in state laws
2. Created by lawyers or even the patients themselves
3. State laws and court decides whether these documents are valid
Living will
 is a legal document used to state certain future health care decisions only when a person becomes
unable to make a decision and choices on their own
 The living will is only used at the end of life if a person is terminally ill or cannot be cured or
permanently unconscious
 Describes the type of medical treatment the person would want or not want to receive in these
kinds of situations
 It can describe under what conditions an attempt to prolong life should be started or stopped
 This applies to treatments including but not limited to dialysis tube feedings or actual life support,
breathing machines ventilator
 So before your healthcare team use uses your living will to guide the medical decisions two
physicians must confirm that you are unable to make your own medical decisions and you are in a
medical condition that is specified by your state law as terminal illness or permanent
unconsciousness
Things to remember in writing a living will
1. Use of equipment such as dialysis machines mcd machines or ventilators that could help you keep
breathing
2. Do not resuscitate orders
3. Fluid or liquid usually ivs tube feeding
4. Add if you want to if you want to be a donator or if you want to donate organs or body tissues
after deat
5. So you may end or take back a living will at any time

Medical power of attorney for health care

 A legal document in which you name a person to be proxy or agent to make all your health care
decisions if you become unable to do so before a medical power of attorney can be used to guide
 medical decisions a person's physician ust certify that the person is unable to make their own
medical decisions
 Person you name as proxy or agent
 Should be someone who knows you very well and someone you trust, you trust to carry out all
your wishes your proxy or agent should understand how you would make decisions if you were able
and should be comfortable asking questions and advocating to your health care team on your
behalf, be sure to discuss your wishes in detail with that person
 You may also choose to name a back-up person in case your first choice becomes unable or
unwilling to act on your behalf
 Durable power of attorney laws vary from state to state
Additional information
 So we have physician orders for life sustaining treatment or p-o-l-s-t
 Has to be signed by a qualified member of your health care team such as your doctor emergency
personnel like the paramedics, Emts. They cannot use an advanced directive but they can use p-o-
l-s-t form.
 Emergency personnel are required to provide every possible treatment to help keep you alive
 Sometimes we have dnr or do not resuscitate; so resuscitation means medical staff will try to
restart your heart and breathing using methods such as cpr or cardiopulmonary resuscitation and
aed meaning automated external defibrillator. In some cases they may also use life sustaining
devices such as breathing machines
 DNR that means you will not perform those treatments
Documentation and Reimbursement
 Accreditation and reimbursement agencies required to accurate and total documentation of the
nursing care rendered and clients response to intervention
 For example: insurance like field health medicare, maxi care value care
Principles of effective documentation
Elements of nursing process needed to be made evident in documentation include:
1. Assessment
2. Nursing diagnosis
3. Planning and outcome
4. Identification
5. Implementation
6. Evaluation
7. Revision of planned care
Remember that documentation has their own characteristic
1. Accessible 4. Consistent
2. Accurate 5. Clear
3. Relevant 6. Concise complete
 7. It should be thoughtful 9. And sequential
8. Timely 10. It should also reflective of the nursing
process

Elements of effective documentation

1. Use a common vocabulary
2. Write legibly and neatly
3. Use only authorized abbreviations and symbols
4. Employ factual and time sequence organization
5. Document accurately and completely including any errors
6. It should be retrievable and permanent basis in a nursing specific manner
The different methods of documentation
1. Narrative charting
 This traditional method of nursing documentation takes the form of a story written in
paragraphs
 Before the advent of flowsheets this was the only method for documenting care
 This is the most familiar method of documenting nursing care
 It is a diary or story format in chronological order
 It is used to document the patient's status care events treatments interventions and patients
response to the intervention
2. Source Oriented Charting
 A narrative recording by each member or what we call the source of the health care team on
separate records
DISADVANTAGES
 it documents all the findings makes it difficult to separate the pertinent from irrelevant information
 It requires extensive charting time by the staff discourages precision and other healthy members
from reading all parts of the Chart
ADVANTAGES
 Information are in chronological order documents patients baseline condition for each shift
indicates aspect of all steps of the nursing process

3. Problem oriented charting

 Focuses on the client's problem and employs structured logical format called soap charting
 Soap s for subjective data o for objective data a for assessment and p for plan
ADVANTAGES
 Documents care by focusing on patients problems promotes
  Problem-solving approach to care
 Allows easy auditing of patients record
 Improves continuity of care
 And communication by keeping relevant data in all one place
DISADVANTAGE
 Result in loss in chronological charting and then it is fragmented and difficult to see the status of
the patient
4. The Pie Charting
o P for problem identification

o I for interventions

o E for evaluation

o It follows the nursing process and uses nursing diagnoses while placing a plan of care

5. Focus charting
 A documentation method that uses a column format to chart data action and response or the d-a-r
ADVANTAGES
 Compatible with the use of nursing process
 Shortens charting time because of the many flowsheets and checklists
DISADVANTAGE
 If the database is insufficient patient problems missed and does it adhere to charting with the focus
on nursing diagnosis and expected outcomes
6. Charting by exception
 A documentation method that requires the nurse to document only deviations from pre-
established norms
GOALS
 Eliminating lengthy and repetitive notes
 Eliminate poorly organized information
 Eliminate possibility of overlooking the really important things
7. Computerized documentation
 Electronic health record computerized record of the patient's history and care across all facilities
and admissions
 C-p-o-e or the computerized provider order entry
 Which provides efficient workflow and automatically routes orders to appropriate clinical areas
 Could decrease documentation time
ADVANTAGES
 It is clear and concise in words it can increase legibility
  Enhance implementation of the nursing process
 Enhance decision making and it is multi-disciplinary networking
DISADVANTAGE
 Initial costs are considerable
 Implementation can take a long time
 Significant cost and time to train staff to use the system
 It is sophisticated security system needed to prevent and authorize personnel from accessing the
record
8. CRITICAL PATHWAYS
 Is a comprehensive standard plan of care for specific case situations
 The pathway is monitored to ensure that interventions are performed on time and client outcomes
are achieved on time
FORMS FOR RECORDING DATA
1. Kardex
2. Flow sheets
3. Nurses progress notes
4. Discharge summary
KARDEX
 Is used as a summary worksheet reference of basic information that traditionally
 Is not part of the record usually contains the client's data like the name age marital status religious
preference physician and family contact
 It also includes medical diagnosis, the patient's allergies, medical orders like the diet iv therapy and
activities that is permitted
 Use pencil in writing in the kardex because usually we write here the most common orders that is
being changed in a short period of time
FLOWSHEETS
 This is vertical or horizontal columns for recording dates and times and related assessment and
intervention information
 Included are notes on client teaching use of special equipment and iv therapy
 It depends on the institution if ever they would or would not have kardex in the station anymore
 It depends on the institution if they change the name of the sheets inside the chart
NURSES PROGRESS NOTES
 This is used to document clients condition problems and complaints some interventions and clients
response to the interventions and of course the achievement of the outcomes
DISCHARGE SUMMARY
 It highlights clients illness and course of care
Includes:
 The client status at admission and discharge
 Brief summary of the client's care
 Intervention and education outcomes
 Resolved problems and continuing care needs
 Clients instructions regarding medications diet food drug interactions activity treatments
 When to follow up or go back to the clinic
 Usually the nurse is the one who's going to explain to the client before discharge the different
medications that he or she would take at home
Trends in documentation
Nursing minimum data set
 The element that should be contained in clinical records and abstracted for studies on the
effectiveness and cost of nursing care should focus on the demographics service and nursing care
Nursing diagnosis
 Clinical judgment about individual family or community responses to the actual or potential health
problems or life processes is what we call the nursing diagnosis usually we use nanda
Nursing intervention classification
 A comprehensive standardized language of nursing interventions organized in a three-level
taxonomy so we always prioritize our interventions
Independent.
Interventions are the interventions or actions that can be done by the nurse alone.
Dependent.
Wherein we need the help of the physician like giving medications which is prescribed by the
physician.
Collaboration.
Which we need other team in the medical health professions like we need the help of the
laboratory technicians or we need the med techs the rad techs or we need nutritionists, we need an obgyn
physician or when we need to refer the client to an outside physician that is more specialized in the
managing of the treatment care plan
Nursing Outcomes Classification
 That comprises a 190 outcome labels and corresponding definitions measures indicators and
references here we state the different outcomes or things that the patient have received or the
status of the client whether we need to re-evaluate or reassess the client
Summary reports
 The outlining of information pertinent to the client's needs as identified by the nursing process or
pie
 Commonly given at the end of shift
Walking rounds
  A reporting method used when the members of the care team walk to each client's room and
discuss care and progress with each other and with the client so usually
 Morning rounds(ward)
 Endorsement on the bedside,
Telephone reports and orders
 This is a way of nurses to report transfers communicate referrals obtain clients data solve problems
 Also we receive telephone order; has countersign and classify to the doctor
 When it comes to telephone reports it should be complete always say the complete name of the
patient in room number physician, the cc or chief complain and other status like vital signs
Incident reports
 The documentation of any unusual occurrence or accident in the delivery of client care such as
false or medication error
 For example: you are recapping which is not advisable anymore but accidentally you forgot and
you have the cap the syringe within the cup of the needle and then you puncture yourself
 So afterwards you will report the incident to the proper office and then you will now write an
incident report
 Incident report usually has a format which this varies from different institution. There are
institutions that
 Will require you to create a letter or a narrative form or an essay explaining what happened then
some institutional man they already have a specific form or a template wherein you just have to
check all the specific items or information given
 So usually this form must be completed within the first 24 hours of the incident.
Fundamentals of Nursing- Lecture
BODY MECHANICS
 Body mechanics
 Used to describe the ways we move as we go about our daily lives it includes how we hold our
bodies when we sit stand lift carry bend and sleep
 Poor body mechanics are often the cause of back problems
 When we don't move correctly and safely the spine is subjected to abnormal stresses that over time
can lead to the generation of spinal structures like discs and joints injury and unnecessary wear
and tear
 It is important to learn the principles of proper body mechanics
Good body mechanics means:
 Using the body strength to the best mechanical advantage to do a task efficiently and without
injury
 A task does not have to be heavy or seem difficult to put us at risk for injury because many
injuries occur because of
 The wear and tear of poor body mechanics on our bodies over time
 Proper body mechanics are very vital so that means it's very significant for keeping your spine
healthy and it is easy to incorporate these principles to our daily life so by doing this it will now
promote musculoskeletal function reduce required energy promotes balance and promotes safety
for patient and healthcare worker
Alignment
 Alignment means having parts in proper relationship to each other so that means your cervical
should be aligned with your thoracic lumbar and socrochixogel
 Refers to how the head shoulders spine hips knees and ankles relate and line up with each other
 By doing this the body puts less stress on the spine and helps you have a good posture
Keep proper alignment avoid the following positions or movement:
1. Slump 2. Head forward postur
Achieve body alignment by:
 Placing one body part in line with another body part in a vertical or horizontal line
 Correct alignment contributes to body balance and decreases strain on muscle skeletal structures.
Without this balance
 There is a false and injuries increase
In the language of body mechanics
 The center of gravity is the center of the weight of an object or person
 A lower center of gravity increases stability
 This can be achieved by bending the knees and bringing the center of gravity closer to the base of
support
  Keeping the back straight a wide base of support is a foundation for stability
 Wide base of support is achieved by placing feet shoulder width distance apart when a vertical line
falls from the
 Center of gravity through the wide base of support body balance is achieved
 If the vertical line moves outside the base of support the body will lose its balance
Terms
Gravity- This is the force that pulls object towards
Center of the earth- Center of gravity this is an area on which mass of object is centered
Line of gravity. This is the vertical line that passes through the center of gravity
Center of gravity and balance. For an object or person to be in a stable position the center of gravity
must be above the base of support
Good posture. The spine is in neutral position not too rounded forward and not too arch back too far.
Good body mechanics are based on good posture
Neutral postures. Avoid awkward postures that cause injuries try to keep the body close to neutral or
normal position while working and in daily tasks
 Straight spine with center of gravity being within person's base of support we move in and out of
neutral posture all the time like walking reaching
 The idea is to be as close to neutral as much as possible
 Do not use heavy forces like pushing pulling or lifting when outside of your base support
Proper posture
 Pull buttocks in and hold abdomen in this helps in keeping your back straight and then hold chest
up and slightly forward and also you can hold head erect with face forward and chin slightly
Body at Work
 Use longest and strongest muscles like your legs to provide energy
 You can also use your internal girdle and make a long midriff to protect abdominal muscles
 You should keep your feet apart for a wide base support and push pull or roll objects when possible
 Bend at the knees and hips use leg muscles and keep back straight when lifting
 Rest between periods of exertion
Concepts of moving a patient or object
Friction. This is the force that opposes motion
Force. This is the energy required to accomplish movement
Inertia. This is the tendency of an object at rest to stay at rest and an object in motion to remain in
motion
Muscle. Which produces force that moves levers
Fulcrum. A fixed point about which a level moves. Example the elbow
Lever. So any one bone or associated joint that acts as a simple machine so that force applied to one end
tends to rotate the bone in an opposite direction
Principles of body mechanics
 Assess the environment. Assess the weight of the load before lifting and determining if assistance
is required
 You have to plan the move. Gather all supplies and clear the area of obstacles
 You have to avoid stretching and twisting or reaching which may place the line of gravity outside
the base of support
 Ensure proper body stance, stance is the feet okay so the feet. Shoulder width apart then tighten
your abdominal muscles through gluteal and leg muscles in the anticipation of the move then stand
up straight. To protect the back and provide balance
 You can stand close to the object being moved okay. You can place the weight of the object. Being
moved close to your center of gravity for balance. Then equilibrium is maintained as long as the
line of gravity passes through the base of support.
 Face direction of the movement.
 Facing the direction prevents abdominal twisting of the spine you should avoid lifting turning rolling
pivoting and leverage requires less work than lifting
 Do not leave if possible use mechanical liftsas required encourage the patient to help as much as
possible then work at waist level
 Keep all work at waist level to avoid stooping
 You can also raise the height of the bed or object if possible
 Do not bend at the waist
 You can reduce friction between surfaces and then you can bend the knees. Bending the knees
maintains your center of gravity and lets the strong muscles of your leg do the lifting.
 You can push the object- rather than pull it and maintain continuous movement
 It is easier to push an object than pull it. Less energy is required to keep an object moving than it
is to stop and start it
 You can use assistive devices. Like gate belts slider boards mechanical lifts okay as required to
position patients and transfer them from one surface to another
 Work with others. The person with the heaviest load should coordinate all the effort of others
involved in the Handling technique.
 All of this is according to berman and cinder 2016 and perry at al 2014 worksafe bc 2013.
Fundamentals of Nursing- Lecture
HANDWASHING
ACCORDING TO THE WORLD HEALTH ORGANIZATION. Hand cleansing practices are established in
the first 10 years of a person’s life. And this imprinting affects the individual’s attitude about hand
cleansing throughout a person’s life. And this is called inherent Hand washing.

Elective Hand Washing. Attitude of handwashing in situations like delivery of healthcare. Instances
that you should wash hands when delivering care to the patients

Hand Hygiene is the effective basic and effective in preventing and controlling the effect of
infection (WHO).

Why is Hand Hygiene important?

1. Hands are the most common mode of pathogen transmission

2. Reduce the spread of antimicrobial resistance

3. Prevent health-care associated infections

Ex: Surgical Site Infection, CLAB C- central line-associated bloodstream infection, cathether Urinary
Tract Infection;

When to wash the Hands?

1. Before/during/after the procedure.

2. Before eating food or taking medicine.

3. After using the toilet.

4. After touching money.

5. Before/after contact with other, especially visiting patients in the hospital.

6. Before/after caring for someone at home who is sick

7. After cleaning work or dealing with trash

8. After touching blood, tears, nasal mucus, sputum or saliva

9. Before holding a baby, and after changing diapers or cleaning up a child who has used the toilet

10. Before touching your eyes, nose or mouth; after blowing your nose, coughing or sneezing

11. After touching an animal (including own pet), animal feel or animal waste.

Hands Need to Be Cleaned When

 Visibly Dirty.

 After touching contaminated objects with bare hands.

 Before and after patient treatment (before glove placement and after glove treatment).
Handwashing

 It is simply a vigorous, brief, rubbing together of all surfaces of soap-lathered hands followed by
rinsing of the hands under warm/running water for 15 seconds. (Center for Disease Control and
Prevention)

 Fundamental principle behind handwashing is removing microorganisms from the hand and rinsing
with water. Handwashing does not kill microorganisms but simple reduces the number of
microorganisms in the hand.

 Applying Friction When Handwashing. Important to remove the microorganisms.

Hand Hygiene Definitions

Handwashing

 Washing Hands with plain soap and water

 reduce/remove the microorganisms

Antiseptic Hand wash

 Washing hands with water and soap or other detergents containing an antiseptic agent

 antiseptic agent- kills microorganism

Alcohol-based hand rub

 Rubbing hands with an alcohol-containing preparation

 Ethanol based- 60-90% alcohol, most effective on pathogens on the hands.

Surgical Antisepsis

 Handwashing with an antiseptic soap or an alcohol-based hand rub before operation by surgical
personnel before surgery to eliminate transient and reduce resident hand germs

 Contaminated Hand of Healthcare workers- primary source of infection and transmission in

healthcare settings.

 Healthcare workers should have well-manicured nails and not wearing artificial nails to reduce
microorganism transmission.

Efficacy of Hand Hygiene (Preparations in Killing Bacteria)

 Plain Soap- Good

 Antimicrobial Soap- Better

 Alcohol-based Hand rub- Best

Alcohol-based Preparation

Benefits

1. Rapid and effective antimicrobial action. Because presence on ethanol based products.

2. Improved skin condition. Sometimes with moisturizer. Problem with repeatedly handwashing,
removes the natural oil, which makes the skin dry.

3. Most accessible than sinks.

Limitations.

1. Cannot be used if hands are visibly soiled.

2. Store away from high temperatures or flames.

3. Hand softeners and glove powders may build-up.

Special Hand Hygiene Considerations

1. Use hand lotions to prevent skin dryness

2. Consider compatibility of hand care products with gloves (e.g. mineral oils and petroleum bases
may cause early glove failure)

3. Keep fingernails short

4. Avoid artificial nails

5. Avoid hand jewelry that may tear gloves

October 15- Global Hand Washing Day

Purpose of Hand Washing

1. To reduce the number of microorganisms on the hand

2. To reduce the risk of transmission of microorganisms to clients

3. To reduce the risk of cross-contamination among clients

4. To reduce the risk of transmission of infectious organisms to oneself

Equipment in Handwashing

1. Faucet

Materials

1. Soap 3. Disposable or Sanitized towels

2. Warm Running Water

Five Moments of Hand hygiene (WHO)

Defines the key moment for hand hygiene overcoming the misleading language and complicated
description. Presents unified vision and promotes strong sense of ownership. Aligned with evidence based
concerning the spread of healthcare association infections. An interwoven with a natural work of care and
designed to be easy to learn logical and applicable to the wide range of settings.
1. Before touching the patient
2. Before a procedure
3. After body fluid exposure or risk number
4. After touching a patient
5. After touching patients surroundings like their handrails the doorknob their bag or anything that is
inside the room of the patient
Procedures:

1. Stand in front of the sink and do not allow the uniform to touch the sink during the washing
procedure.

2. Remove jewelry if possible and secure it in a safe place and allow plain wedding band to remain in
place.

3. Turn on the faucet then regulate the water flow and use warm water if available. Rinse the hands.

4. Use about 1 teaspoon of liquid soar from dispenser or lather thoroughly with a bar soap (rinse bar
soap before returning to the soap dish)

5. Rub Palms Together

6. Rub the back of the hands

7. Interface fingers and rub hands together

8. Interlock fingers and rub the back of the fingers of both hands

9. Rub thumb in rotating manner followed by the area between the index finger and the thumb for
the both hands

10. Rub fingertips on palms for both hands

11. Rub both wrist in rotating manner.

12. Rinse and dry thoroughly.

13. Keep Hands lower than the elbow. Wash away the dirt and the microorganisms.

14. Pat dry the hands and wrist or elbow with a paper towel or hand towel then turn off the faucet
using the used paper towel or hand towel.

Handwashing is the cheapest and the most accessible way to reduce microorganisms on our hands and
preventing infection.