Fundamentals of Nursing Practice - RLE
Points to Remember on Becoming a Student Nurse
• Know that you are needed and wanted in this
work
• When you desired to do your best, you will
always have pride in your work. This in turn,
makes the dull moments less frequent
• Understand what your assignment is; ask about
if it is not clear
• Make a work plan. Write down or think through
what you have to do and how much time you
have to do it. Decide in what order it will be
best to take care of a patient and to do the
other task assigned to you
• Be willing to accept changes in work load and
assignment when necessary. Be ready to make
adjustments and help a co-student if needed
• Report to the nurse or C.I. the following:
• A patient’s request or complaint which
calls for a professional nurse’s decision
• Some changes in patient’s condition or
something which seems unusual to you
• A problem or question about your work
✓ As nursing student, you are called upon to be
dependable. This means:
• Being on the job and being there
on time;
• Doing an assigned task and
finishing it on time; and
• Keeping promises after telling
anyone, particularly a patient, that
you will do something.
✓ As nursing student, you are called upon to be
trustworthy. This means that:
• When accidents occur or errors are
made, you must report them at once;
• When personal experiences are shared
you, keep these in confidence. It is an
honor that the person has trusted you
especially if the person is a patient. Do
not disappoint him; and
• When using supplies and equipment,
avoid careless waste of materials and
senseless abuse of equipment.
✓ Try to be mindful of the feelings of others and
try to show consideration by controlling your
own emotion.
✓ Nursing is an important job. It calls for persons
who want to grow in the process of caring for
others.
Role of a Nurse
NURSING
• To assist the individual, sick or well, in the
performance of those activities contributing to
health that he would perform unaided if he had
the necessary strength, will, or knowledge.
Nursing as an Art
• Concerned with skills that require proficiency
and dexterity
Nursing as a Science
• Requires the systematic application of scientific
knowledge
Characteristics of Nursing
a. Nursing is caring
b. Involves close, personal contact with the
recipient of care
c. Concerned with services that considers man as
a multifaceted being
d. Committed to promoting individual, family,
community, and national health goals in the
best manner possible
e. Committed to involvement in ethical, legal, and
political issues in the delivery of health care
f. Utilizes research to improve quality of human
life
Role of the Nurse
THERAPEUTIC ROLE
• A.k.a “healing” or “curative”
• A nurse may use appropriate techniques which
help the natural process of healing
CARING ROLE
• A.k.a “comforting”
• Caring – includes those activities which provides
support while preserving client’s dignity
i.e. assistance in the performance of ADL
 Fundamentals of Nursing Practice - RLE
COMMUNICATING ROLE COUNSELOR ROLE

• Utilize to identify client’s needs and them • A process which help client to recognize and
communicate these to other members of the cope with problems
healthcare team
LEADERSHIP ROLE
• Quality of nurse’s communication is important
in nursing care • A nurse influences others to work together to
accomplish a specific goal
TEACHING ROLE

• Imparting information and reinforcing change in Levels:

behavior of client o Clientele
o Colleagues
Include:
o Community
a. Assessing learning needs and readiness
ADMINISTRATIVE ROLE
b. Set learning goals’
c. Enacts learning strategies • A nurse must see to it that nursing services are
d. Measures learning organized, coordinated, and dispensed
appropriately
PLANNING ROLE
Maintaining a Good Personal Health and Hygiene
• Used during the entire phase of nursing care What is Health? (World Health Organization, 1948)
• A nurse plans with patients, their families, and
with the members of the healthcare team • It is a state of complete physical, mental, and
social well being, and not merely the absence of
COORDINATION ROLE disease or infirmity.
• Needed to achieve high-quality care What is Hygiene?
• Prevents unnecessary duplications and gaps in
services • Hygiene is the self care by which people attend
to such functions such as bathing, toileting, and
PROTECTING ROLE general body hygiene
• Safety of patients General Body Hygiene Involves the Care of:
i.e. falls, transmission-based precautions, ✓ Skin
adverse reaction, etcetera ✓ Hair
REHABILITATING ROLE ✓ Nails
✓ Teeth
• Any activities which maximizes patient’s ✓ Oral and Nasal Cavities
remaining potentials or capabilities ✓ Eyes
i.e. teaching the use of assistive devices ✓ Ears
✓ Perineal-genital area
SOCIALIZING ROLE
How to Maintain Good Personal Health and
• Pertains to engagement of enjoyable, carefree Hygiene?
conversation 1. Accept your responsibility to yourself and
• Offers distraction and respite from the focus on others to keep as healthy as possible especially
illness in dealing with sick people
2. Keeping in good health requires daily attention
to health needs
 Fundamentals of Nursing Practice - RLE
Eating Well Balanced Meals
Proteins
− Meats, fish, poultry, nuts, beans, milk;
− Body uses to grow and make repairs
Carbohydrate
− Such as bread, cereal, rice, potatoes, sugar
Fats
− Such as butter, cream, oils, fatty meats
(hamburger and bacon)
Fiber
− Contained in whole grains (whole grain
cereals and breads), and in salads, fresh
vegetables, and fruits
Obtaining enough sleep and rest (6-8 hours)
3. Remember the foods that are essential for good
health
4. Have sufficient water about 6-8 glasses daily
5. If overweight/underweight, consult the problem
with your health care provider or to your family
doctor
6. Bathe daily for health and social reasons
✓ Use soap and water generously to
cleanse the skin of perspiration and
bacteria
7. Facial care is important, making use of mild
soap and skin cleanser
8. Have a daily mouth care at least three times a
day
9. Shampoo hair regularly and frequently
10. Give special attention to the hands
✓ Use a good lotion or cream especially if
hands are chapped
11. Wash hands thoroughly throughout the day
12. Keep fingernails clean and trimmed
13. Take excellent care of your feet
✓ When bathing, wash carefully 5hing,
wash carefully but thoroughly and dry
✓ Trim toenails straight across (prevent
painful ingrown nails)
✓ Well-fitting and rubber soled shoes
must be worn
✓ If necessary, alternate two pairs of
shoes
14. Check your posture; if there seems to be a
problem, consult with health care provider
15. Try to keep an even, keen emotion
16. Become interested in some type of sports or
hobby that gives you pleasure
17. Keep an open mind always
Communication in Healthcare Setting
Definition of Communication
• Any means of exchanging information or
feelings between two or more people
o It is a basic component of human
relationship
• Main purposes: influence others and obtain
information
Modes and Channels of Communication
• Modes of communication – Is defined as way
communication is expressed, or the method of
communicating, and here are the different
modes:
o Verbal - words that the patients,
clients, and significant others conveys
o Non-verbal – patient’s responses aside
from the verbal cues
Essential Components of Communication
SOURCE/SPEAKER
• A person or group who wishes to convey a
message to another; source-encoder
• Encoding is the use of signs/symbols such as
language, words to use, how to arrange the
words, tone of voice, gestures to use
• Nurses must cope with 2 language levels:
a. The layman’s
b. The health professionals
MESSAGE
• What is actually said or written and sent by the
sender
 Fundamentals of Nursing Practice - RLE
CHANNEL
• Medium through which a message is
transmitted
• Example:
o Visual (sight, observation, perception) “
I can see how sad you are” “you look
busy today”
o Auditory (hearing, listening) “tell me
where it hurts now baby” “sounds like it
really is terrible”
o Kinesthetic (procedural touch, caring
touch)
RECEIVER OR DECODER
• The person who must listen, observe, and
attend and interprets the sender’s message
• To decode means to sort out the meaning of
the message, it depends largely on their
similarity of knowledge, experience, and
sociocultural background
Decoded message – sender’s intent (effective)
Decoded message – sender’s intent (ineffective)
RESPONSE
• The message that the receiver returns to the
sender, it is also called as feedback, it can either
be verbal or nonverbal
Approaches to Patient Care
ADMISSION
• The administrative process that covers the
period from the time the patient enters the
institution door to the time the patient the
patient is settled
DISCHARGE
• The official procedure for helping patients to
leave the health care institution, including
teaching them how to care for themselves at
home. It is the termination of care from a
health care agency
Types of Admission
1. Elective Admission
✓ The admission itself may be delayed
until a time is convenient for the client
and the doctor
2. Emergency Admission
✓ This occurs through the emergency
department. The client may be
admitted to a floor, a specialized unit,
or a holding (observation) unit
3. Same-day Surgery or Our Patient Procedure
✓ The doctor will schedule a procedure
that will be performed at the hospital
4. Direct Admission
✓ The client does not feel well, goes
directly to the hospital and was advised
to be admitted or has spoken to or seen
the doctor, who feels the need that the
client should be admitted
Hospital Team
1. Medical staff
o Doctors/specialist, medical students
(interns, clerks)
o House Case – affiliated doctor
o Private Case – preferred physician
2. Nursing staff
o Nurses, nursing aides
3. Social services
o Social worker, financial help
4. Ancillary services
o Laboratory, radiology, pharmacy,
rehabilitation, nutrition, maintenance
5. Spiritual services
o Chaplain, nuns/sisters
Helping patients adjust to a healthcare facility
A. Every patient admitted to a healthcare facility
is nervous, even if it is not a first admission
➢ The strange surroundings
➢ The busy nursing staffs
➢ The sight of other patients may add to
the patient’s feelings of helplessness
➢ If this is a first admission, the patient
will not know what to expect
 Fundamentals of Nursing Practice - RLE
B. Admission to a health care facility may be:
TEMPORARY
o Patients are hospitalized for surgery or
treatment of an acute illness
PERMANENT
o Patients are n longer able to take care
of themselves. Whether temporary or
permanent, admission to a healthcare
facility causes many changes in their
lifestyle
• Confusion and disorientation often occur when
patients are first admitted because they have
lefty friends, family, and everything familiar
behind.
• They may feel they no longer have control over
their lives
• They may be physically powerless and almost
completely dependent on strangers for
everyday care
C. Greeting the Patient
• The patient’s first impression of the
facility will depend on how he/she is
• greeted
• Greet each patient in a friendly,
cheerful manner
• Introduce yourself, and take the patient
to their room
• If the patient has a friend or relative
with him/her, invite them to
accompany you to the room
Admission Procedure
• It depends on the policy of the healthcare
facility; in some healthcare facilities the patient
is take directly to the room and the actual
admission process begins
• In larger facilities however, the admission
process starts in the admitting office
1. A preliminary interview of the patient is
done to obtain the necessary medical and
financial information
2. It is important for the family to remain with
the patient for this interview
3. If an ID bracelet is used, it may be placed on
the patient’s wrist at this time
4. Complete the admission checklist
5. Fill in the date and time of admission
6. Method of admission – the way the patient
came into the room
7. Observation or unusual conditions noted
8. Chief complaint of the patient
9. Be brief but complete, and write legibly
Admission Procedure – Client’s Unit
A. Before a patient is admitted, make sure the
room is ready for his/her arrival
Check necessary equipment:
✓ Admission checklist
✓ Pen or pencil
✓ Patient’s gown or pajamas (if the
patient is to be put to bed)
✓ Portable scale
✓ Thermometer
✓ Sphygmomanometer
✓ Stethoscope
✓ Envelope for the patient’s valuables
Admission Units
Intensive Care Unit
• Generally reserved for the sickest people,
those who require close nursing supervision, or
those who require a ventilator to help them
breathe
Coronary Care Unit
• Like the ICU, but reserved for people with heart
problem
Pediatric Intensive Care Unit
• For children
Neonatal Intensive Car Unit
• For newborns
Surgery Floor
• A general floor for people who need surgery
Medical Floor
• A general floor for medical care
 Fundamentals of Nursing Practice - RLE
H. Records taken during admission should be
thorough with as much pertinent information
Neurological or Neurosurgery Unit
about the patient as possible
• People who have suffered a stroke I. In acute care hospitals, the patient must
provide a urine specimen
Oncology Unit ✓ Assist the patient to the bathroom, or
• People with cancer offer the bedpan or urinal as needed
✓ Collect the urine specimen from the
Orthopedic Unit patient, and replace the cap.
✓ Label the specimen with the patient’s
• People with fracture, etc.
name, doctor’s name, and room
B. Help the patient become familiar with the new
number, and send it to the laboratory
surroundings
along with the requisition for the
✓ Explain the facility’s policy on visitors. Tell
admission urine test
the patient when meals are served
✓ Always wash your hands after handling
✓ Answer any questions he/she has about
urine specimens
daily routine
J. Make the patient comfortable
✓ Demonstrate how to use:
✓ If the patient is ambulatory, he/she may
➢ Intercom and signal cord system
wish to sit up and visit the family
➢ Remote-control for television
members
➢ Automatic bed control
✓ In an acute care hospital, the patient is
C. Screen or curtain off the bed or close the door
put to bed
to a private room
✓ Raise the side rails if the nursing
✓ Ask the patient to put on a hospital
supervisor orders it, and it also ensures
gown, or a gown or pajamas brought
the safety of the patient admitted – side
from home
rails may be needed if the patient
✓ Assist the patient as needed
cannot or should not get out of bed
✓ If the patient wants a family member to
unassisted, or if the patient’s bed is not
be present, invite the person in
in the lowest position
D. Assess the patient’s general physical condition,
✓ Give the patient water if it is allowed
appearance, and behavior as the admission
✓ Make sure the patient can reach the
process is continued
signal cord and anything else he/she
✓ Observe the patient for unusual
might need while you are not in the
conditions:
room
➢ Cuts or bruises
✓ Remove the screen or curtains
➢ Loss of function
surrounding the patient, or open the
➢ Signs of weakness
door so others will know you are
➢ Any prosthesis
finished
➢ Other physical complains the
✓ Tell family members they may return to
patient may have
the patient’s room
E. Record vital signs and note for any unusualities
from the baseline VS and refer
F. Ask about previous hospitalizations, allergies,
or diseases other than the one for which the
patient is being admitted
G. Record all information and observations on the
admissions checklist
 Fundamentals of Nursing Practice - RLE
Patient’s Chart 7. Vital Signs Sheet/Page
• A database, a body of knowledge about the • Done by the nurse/aide
patient, the one source that has everything the ✓ Recording of the patient’s BP,
healthcare team needs to return the patient to PR, RR, CR (if the patient is for
daily activities of life hourly VS and I/O, there is a
• It contains information describing the patient’s separate sheet for that, this is
previous and current medical conditions and common in the ICU)
healthcare that the patient received and will 8. Medical Order Page
receive from the healthcare team • Doctor’s page
• It is used to document and to communicate the ✓ Nurse can write the order:
patient’s medical condition and treatment telephone, verbal made by the
among the healthcare team doctor
1. Clinical Case Record ✓ Countersign by the doctor asap
2. Patient’s Data Sheet/Page 9. Intravenous Fluid Sheet/Page
• Authorization for examination and • Filled up the nurse
admission ✓ Information about the IVF
• Against Medical Advice (in case of AMA, administered to the patient:
there is a sheet that is signed by the start, follow-up, incorporation,
patient for this) termination
3. Clinical History Page 10. Medication Sheet/Page
• To be filled up by the medical • Nurse (use pen according to the time of
resident/intern/clerk duty)
✓ Present complaint ✓ RED – NOC shift
✓ Family history ✓ BLACK – AM shift
✓ Past history ✓ BLUE – PM shift
✓ Present illness 11. Nurses’ Notes
✓ Physical examination • Recordings of the nurse on the course
✓ Impression/tentative diagnosis of the patient’s stay throughout his
✓ Examiner’s signature hospitalization by shift
4. Admitting Notes Page 12. Discharge Summary Page (Clinical Summary)
• To be filled up by the • Done by resident/intern/clerk
resident/intern/clerk ✓ Physical examination
✓ Chief complaint ✓ Treatment
✓ Brief clinical history ✓ Course in the ward
5. Laboratory Results Page ✓ Final diagnosis
• All lab results will be pasted in this page ✓ Recommendation/discharge
(serial, hgb, hct. Platelet, protime instructions
monitoring) ✓ Signature
6. Graphic Chart Page 13. Intake and Output Sheet
• To be filled up by the nurse/nursing 14. Insulin Sheet
aide • Filled up by the nurse (if the patient is
✓ Contains the record of the diabetic and needs glucose monitoring)
patient’s TPR, weight, activity, • Records HGT results, and medications
diet, urine, stool form the day given
of admission
 Fundamentals of Nursing Practice - RLE
ADD-ONS
✓ Consultation report page done
by resident/intern/clerk
✓ Patient is referred to another
doctor for evaluation
✓ Patient must sign the consent
for referral
• Consent for
surgery/minor
• Consent for admission
to ICU
✓ Signatory provides 3 samples
of signature
✓ Pre-operative preparation
slip/checklist
Nurse has to sign after
each procedure is done
✓ Consent for restrain
applications
✓ DNR order form
15. Doctor’s Fee Charge Slip/Summary of Services
• Nurse’s responsibility to write the
name(s) of the patient’s doctor(s)
Transferring the Patient
✓ Discharging a patient from one unit or agency
and admitting him or her to another without
going home during the process
✓ A patient may be transferred from one room to
another within the same healthcare facility for
several reasons:
1. Sometimes, the transfer is made at the
patient’s request
2. At times, the medical staff may request it
Circumstances wherein Medical Staff request the
patient transfer:
1. The physician may request the patient to be
transferred from one level of nursing care to
another because of a change in the patient’s
condition that might require more or less
specialized care
2. Transfer onto a regular medical floor when
his/her condition improves
3. Sometimes, the nursing staff will transfer a
patient closer to the nursing station where the
patient’s condition can be supervised more
closely
4. The patient may also be transferred if the room
location or equipment in the room is needed for
a more critically ill patient
Nurse’s Responsibilities
An organized and efficient transfer may help prevent
fear and anxiety of the patient
RESPONSIBILITIES
✓ Agency policy must be followed during any
transfer. Transfer based on medical condition
should have a written order
✓ Reason for transfer must be explained to the
patient and family by the appropriate personnel
✓ Coordinate with the personnel of the receiving
unit/ward regarding the transfer. New
room/unit must be ready to receive the patient
✓ Make sure that all patient’s belongings are
transferred with him/her
➢ Collect the belongings and any
equipment that will be moved
➢ Check with the nursing supervisor
before moving any equipment to
another floor
➢ Check drawers, closets, tables,
windowsills, the bathrooms, and the
bed covers for any articles that might
be forgotten
✓ The nurse will collect the patient’s charts and
medicines
✓ Arrange for the transport of patient
✓ The ward clerk will make the necessary changes
in the patient’s records, billing charges and
other forms
✓ Post the transfer on the patient’s chart:
➢ Time of transfer
➢ Room numbers transferred from and to
➢ The reason for the transfer
➢ The patient’s attitude toward the move
should also be charted
 Fundamentals of Nursing Practice - RLE
Discharging the Patient
PATIENT DISCHARGE
✓ Termination of care from a health care agency
✓ The doctor plans the discharge with the patient
and leaves a written order on the patient’s
chart
PURPOSES
✓ To facilitate the person to return to a state of
independence
✓ To determine the patient and family’s
preparedness for discharge
✓ To promote continued care outside the
institution through linkages to community
resources
✓ To avoid legal and moral impediments for the
health care practitioners, patients, and family
members after discharge
WHO/WHAT ARE INVOLVED IN A PLANNED
DISCHARGE
• Physician’s order
• Care provider
• Safekeeping
• Patient
• Nurse
− Explains discharge instructions to
family/care giver
• Unit secretary
− Calls for transport, copies chart/orders
• RN or social worker
• Extended care facility
NURSE’S RESPONSIBILITIES
• The nurse must ensure that the discharge order
has been written by the doctor
• The nurse will then make the necessary
arrangements with other departments to
prepare for the patient’s discharge
• The nurse will also make sure the patient has
been given instructions by the doctor for home
care understands the instructions
• Determine the availability of community
resources necessary for client’s continuous care
such as health clinics, rehabilitation centers
• Verify availability of therapeutic
equipment/assistive devices necessary for
home care such as walker/crutches,
wheelchairs, oxygen set, suction machine,
nebulizer, etc.
• If possible, the nurse will give the patient a
written copy of the instructions, such as a copy
of the diet or an appointment card for a return
visit to the doctor
• Carry out medical orders or termination of
therapeutics before discharge (i.e
discontinuation of IVF, catheters, etc.)
• Facilitate billing procedures. Instruct patient
and significant others about the proceedings
• The family must be notified of the patient’s
discharge time so they can make arrangements
for transportation
• The family must also be informed of the check-
out time to avoid being billed for an extra day
• Assist the client to change hospital gown to
street clothes and pack up belongings
• Wheel the patient to hospital exit according to
institutional discharge protocol
• Go back to the unit and strip patient’s bed
sheets following standard precautionary
measures, facilitate general cleaning of
patient’s room by the housekeeping personnel.
Wash hands
• Chart the patient’s discharge
✓ The date and time the patient was
discharged
✓ The way the patient left the healthcare
facility
✓ Any special instructions, diet, or
medications that the patient has to
continue after discharge
✓ Notations should be made on the chart
that the patient’s personal belongings
were sent with the patient
• Completing the discharge summary
Against Medical Advice (AMA)
• The patient leaves prior to obtaining a written
order for discharge
• Nurse will request patient to sign in the AMA
form
 Fundamentals of Nursing Practice - RLE
• If refused, the nurse must let the patient leave 3. Base of Support
but must note refusal to sign AMA in chart. ✓ The part that makes contact with the
supporting surface
DISCHARGE PLANNING: METHOD

✓ Medication
✓ Environment’
✓ Treatment
✓ Health teaching
✓ Outpatient referral
diet

BODY MECHANICS
What is Body Mechanics?

• Coordinated use of the boy parts to produce ANATOMICAL POSITION

motion and maintain their equilibrium in
relation to the skeletal, muscular, and visceral
systems and their neurological association
• A term used to describe the efficient,
coordinated, and safe use of the body to move
objects and carry out the activities of daily living
PURPOSES:
1. To maintain good body posture
2. To promote good physiological functions of the
body
3. To use the body correctly and to maintain its
effectiveness
4. To prevent injury or limitation of movement of
the musculoskeletal system
EQUILIBRIUM
• A state of balance
• An equal distribution of weight to be able to
stay upright and steady
PRINCIPLE OF BALANCE
• Balance is maintained if the line gravity passes
through the center of gravity and the base of
support
1. Line of Gravity
✓ Imaginary vertical line drawn through the
body’s center of gravity
2. Center of Gravity
✓ The point at which all body mass is centered
• The balanced upright position
• Standard Anatomical Position: fleet flat with
toes pointing forward, torso and back straight,
arms hang loosely at the sides, palms facing
forward
Principles of Body Mechanics
1. The wider the base of support, the greater the
stability of the nurse.
2. The lower the center of gravity, the greater the
stability of the nurse.
3. The equilibrium of an object is maintained as long as
the line of gravity passes through its base of support
4. Facing the direction of movement prevents abnormal
twisting of the spine.
5. Dividing balanced activity between arms and legs
reduces the risk of back injury.
6. Leverage, rolling, turning or pivoting requires less
work than lifting
7. When friction is reduced between the object to be
moved and the surface on which it is moved, less force
is required to move it.
8. Reducing the force of work reduces the risk of injury.
9. Maintaining good body mechanics reduces fatigue of
the muscle groups.
10. Alternating periods of rest and activity helps to
reduce fatigue.
 Fundamentals of Nursing Practice - RLE
11. Pulling action requires less effort than pushing or
lifting.
12. Get help whenever possible
TIPS:
1. Work as close to your center of gravity as
possible.
2. Flex hips and knees slightly in preparation for
lifting.
3. Bend from your hips and knees, never your
back.
4. Hold objects to be lifted as close as possible to
your body’s center of gravity.
Application of Body Mechanics
✓ Standing
✓ Sitting
✓ Body Movement
STANDING
• Stand erect with head upright, face forward,
shoulders squared, back straight, abdominal
muscles tucked in, arms straight at sides with
palms forward.
• Keep feet 3 – 4 inches apart for a wide base of
support. Pace equal weight on both legs to
minimize strain on weight–bearing joints.
SITTING
• Position the buttocks against the back of the
chair. Hips and knees are flexed at right angle to
the trunk.
• Keep trunk and head as in standing position.
• Place feet flat on the floor at a 900 angle to the
lower legs.
• If the chair has arms, flex the elbows and place
the forearms on the armrest to avoid shoulder
strain.
BODY MOVEMENT
1. Start any body movement with proper alignment and
balance.
2. Adjust the working area to waist level and keep your
body close to the area.
3. Face in the direction of the task.
4. When moving a heavy object, keep your center of
gravity as low as possible and centered over your base
of support.
5. Avoid working against gravity whenever possible.
6. Tighten the gluteal and abdominal muscles before
lifting any object. Often referred to as “putting on the
internal girdle.”
7. Carry object close to the body and to the base of
support.
8. Use the palmar grip when grasping and lifting object.
9. When lifting heavy objects, squat rather than stoop.
10. Use the body’s weight to pull or push objects.
11. Make your body movements smooth and rhythmic.
Procedures on Transferring Clients
Moving Up In Bed
• Changing the position or moving a semi-helpless
or immobilized patient up in bed
• Nurse Alert! Avoid dragging the patient up in
bed. This can cause bedsores or pressure sores.
Turning to Lateral or Prone Position in Bed
• Movement to lateral position may be necessary
when:
✓ Placing a bedpan underneath the
buttocks
✓ Changing the bed linen
✓ Repositioning the client
Logrolling
• Turning a patient whose body must be kept in
straight alignment at all times, like a log
• Equipment needed:
✓ Pillows
✓ Drawsheet or full sheet folded in half
✓ Wedge
✓ Extra linen, as needed
Transferring from Bed to Chair/Wheelchair
• Enables the patient to have a change in
surroundings and increase opportunities for
socialization
• Nurse Alert! This requires the assistance of the
patient and should not be attempted if the
patient is unable to help or understand the
nurse’s instructions
 Fundamentals of Nursing Practice - RLE
Transferring from Bed to Stretcher
Therapeutic Communication Techniques
• A collection of techniques that prioritize the
physical, mental, and emotional well-being of
patients
• Promotes understanding and can help establish
a constructive relationship between the nurse
and client
• A therapeutic helping relationship is client and
goal-directed
*Nurses need to respond not only to the content of a
client’s verbal message but also to the feeling
expressed*
USING OPEN-ENDED QUESTIONS
• Asking broad questions that lead or invite the
client to explore thoughts and feelings
✓ “tell me more about that”
✓ “what is your opinion?”
✓ “I’d like to hear about that”
✓ “how do you feel now?”
OFFERING SELF
• Suggesting one’s presence, interest, or wish to
understand the client without making any
demands or attaching conditions that the client
must comply with to receive the nurse’s
attention
✓ “I’ll help you with that”
✓ “I’ll be here until feel better”
✓ “we can sit here quietly for a while; we
don’t need to talk unless you would like
to”
GIVING INFORMAYION
• Providing information in a simple and direct
manner, specific factual information the client
may or may not request. When information is
not known, the nurse states this and indicates
who has it and when the nurse will obtain it
✓ “your surgery scheduled at 11 am tom”
✓ “you will feel a slight sensation when
the tube is removed”
✓ “I’m not sure about that information
but I’ll ask your doctor regarding this”
PROVIDING GENERAL LEADS
• Using statements or questions that encourage
the client to verbalize, choose a topic of
conversation, and facilitate continued
verbalization
✓ “can you tell me how it is for you?”
✓ “and then what happened?”
✓ “perhaps, you would like to talk
about…”
ACKNOWLEDGING
• Giving recognition in a nonjudgmental way, of a
change in behavior, an effort the client has
made or a contribution to communication.
Acknowledging may be with or without
understanding, verbal or nonverbal
✓ “I noticed you keep squinting your eyes.
Are you having difficulty seeing?”
✓ “I notice that you are really afraid of
that”
 Fundamentals of Nursing Practice - RLE
Responding to Patient’s Call 2. Do not send or create any text messages while
Patient’s Call
on duty or in the classroom
1. Keep alert for patient’s call or bell 3. Answer only emergency calls and never on
2. Go immediately to patient’s beside
3. Do the thing the patient asks if you are SURE it bedside. Limit the duration for 3 minutes
is RIGHT and SAFE for the patient Asepsis and Hand Hygiene
4. Go at once to the CI or Head Nurse if the
MICROORGANISMS
request is something that you cannot do
5. Place signal cord within reach • It can be anywhere
6. Leave the patient comfortable and satisfied • Nurse, making the environment biologically safe
• Good bacteria (mostly seen in intestines) have
HOW TO ANSWER PHONE CALLS: certain benefits like for absorption of food or
production of vitamins
When receiving, state the following: • Most are harmless; some may be beneficial
• Some are resident
1. Hospital
✓ Resident flora or Normal flora
2. Ward ✓ E.coli can also cause urinary tract infection
3. Name due to improper hygeine
4. Position • Varied characteristics incudes
5. “May I help you” ✓ Virulence
- harmful
When someone is looking for somebody:
✓ Severity of disease they produce
✓ Degree of communicability
“Who’s calling please? … Just a minute”
- how communicable?
- incubation period
When the person concerned is out:
RESIDENT FLORA
“Sorry he’s not in, would you like to leave a 1. Staphylococcus epidermidis
message?” 2. Proprionibacterium acnes
3. Staphylococcus aureus
When terminating, say thank you and goodbye
4. Streptococcus pneumoniae
POINTS TO REMEMBER WHEN USING THE HOSPITAL 5. Lactobacillus
6. Fusobacterium
PHONE: 7. Clostridium
1. Length of call 8. Candida albicans

2. Do not use the telephone for personal use Terminologies

INFECTION
3. Answer ward phone promptly
4. Answer with a well modulated voice and in a
courteous manner
POINTS TO REMEMBER WHEN BRINGING CELL
PHONES:
1. Turn off your mobile phone in order not to
disturb the patients or interfere with the
functioning of equipment
• Invasion by microorganisms to normal cells and
tissues which causes alterations
• Number one indicator is fever
• Microorganisms – infectious agent
✓ Asymptomatic or subclinical stage –
invaded with bacteria or infection
already but not manifesting symptoms;
also called “carrier”
✓ Disease – detectable alteration
 Fundamentals of Nursing Practice - RLE
PATHOGENICITY • 2 classifications
✓ Sterile
• Ability to produce disease ✓ Unsterile
• Pathogen- responsible microorganism that can
cause disease CHAIN OF INFECTION
• Pathogenic
✓ True Pathogen – cause disease to
healthy individual
✓ Opportunistic Pathogen – only in
susceptible individua
• Non-pathogenic
WHAT IS NOSOCOMIAL INFECTION?

• infections that are associated with the delivery

of health care services
• sometimes happen because of nurse’s
negligence
• hospital acquired infection
• it can either develop during a client’s stay in a 1. ETIOLOGIC AGENT
facility or manifest after discharge • Articles are correctly cleaned
• Common sites: disinfection or sterilization
✓ Urinary tract • 3 different types
✓ Respiratory tract ✓ Infective dose
✓ Bloodstream ➢ Amount needed
✓ Wounds capable of causing the
Asepsis and its Types disease
What is asepsis? ➢ Required number of
microorganism in your
• Absence of microorganisms body
What is Aseptic Techniques? ➢ If minimal, cannot
manifest
• Infection control practice used to prevent ✓ Pathogenicity
transmission of pathogens ✓ Invasiveness
➢ Capability to invade to
1. Medical asepsis body tissues
• To confine microorganism 2. RESORVOIR (source)
• To limiting the number, growth, and • Dressings and bandages skin and oral
transmission care, soiled linens fluid containers,
✓ Clean: absence of almost all feces, and urine
microorganisms 3. PORTAL OF EXIT
✓ Dirty: soiled, contaminated. Likely • Talking, coughing, sneezing over open
to have microorganisms that may wounds, cover mouth
be capable of causing infection 4. METHOD OF TRANSMISSION
2. Surgical Asepsis • Hand washing, gowns, soiled materials,
• To free of all microorganisms bedpan handling, mask, eye shields
• To destroy microorganisms including • Direct transmission (face to face; within
spores 3 feet)
• Observed on procedures involving • Indirect transmission (through vectors)
sterile areas of the body • Airborne
 Fundamentals of Nursing Practice - RLE
5. PORTAL OF ENTRY Housekeeping
• Sterile technique, handling open Purpose: to maintain safe, clean, and healthful
wounds, needles, syringes surrounding for the patients, visitors, and staff
6. SUSCEPTIBLE HOST
1. Sweeping – remove dirt from floor area
• Skin mucous membranes, diet,
and precedes all other daily cleaning
immunizations
operations
Handwashing 2. Moping – to rub or wipe the floor with
• Most effective way to help prevent the a mop using soap and water
spread of microorganisms 3. Scrubbing – to remove dirty by rubbing
• Effective handwashing requires at least hard with the use of a brush with or
10 to 30 seconds vigorous washing with without soap and water
plain soap or disinfectant and water 4. Waxing
5. Dusting
EQUIPMENT:
Solid Waste Management
✓ Liquid or bar soap • Refers to all activities pertaining to the control
✓ Hand towel or paper towel of solid waste; and
✓ Sink with running water • It includes all materials from humans, animals,
✓ Trash can and economic activities that are normally solid
✓ Tissue paper and are useless or unwanted
Faucet and its Types SOLID WASTE MANAGEMENT ACT OF 2000
1. Knee-lever faucet
2. Foot-pedal faucet • Emphasizes the proper collection of safe
3. Hand-operated faucet disposal of household garbage, industrial, and
4. Long-lever faucet hospital wastes
• Republic Act 9003 of solid waste management
DISINFECTANT ensures proper segregation, collection,
• Chemical preparation, either phenol or iodine transport, storage, treatment, and disposal of
compounds, used on inanimate objects solid wastes

ANTISEPTIC PRESIDENTIAL DECREE 825

• States the penalty for improper disposal of
• Can be used in the skin
garbage and other forms of uncleanliness
• Can only inhibit growth, but cannot kill
- 5 days to one year imprisonment and/or a fine
• Can control the number of bacteria
ranging from Php 100 to Php 2,000
STERILIZATION

• Free from any microorganisms WASTE SEGREGRATION

• 4 commonly used methods
• Black: dry waste, drained IVF bag, non-
✓ Moist Heat
biodegradable
- steam under pressure; autoclave
• Green: wet, left-over food, biodegradable
machine
• Yellow: infectious, syringe, tubing(s), operation
✓ Gas
sponge, cannula
- ethylene oxide
• Red: sharps, needles, ampules, blades, glass
- common gas for heat sensitive items
• Orange: radio-active waste, bottle, vials
✓ Radiation
- for foods and drugs, etc.
 Fundamentals of Nursing Practice - RLE
Bed Making STANDARD EQUIPMENT OF A HOSPITAL BED
The client’s ability to rest and sleep depends on how
comfortable he/she feels in bed. 1. Mattress
• Most have inner springs –
The nurse provides both safe and comfortable bed to provide even support to the
the client. body
• Usually covered with a water
What is Bed Making?
repellent material that resists
• The process of applying or changing bed linens. soiling and can be easily
• A process: cleaned
✓ Is a series of actions
Note: Nurses should note any
✓ Sequence
awkwardness of the mattress
✓ Step by step
surface (broken spring)
Supporting a hygienic environment
2. Siderails/safety sides
• Environment – assess age, severity of illness,
• Supposedly standard to all beds
level of activity
• Used in both hospital beds and
• Room temperature – a temperature of 20-23
stretchers
degrees Celsius is comfortable
3. Hand Cranks
• Ventilation – good ventilation is important to
remove unpleasant odors (odors: urine, • Hospital beds are especially
draining wounds, vomitus) designed to:
1. Raise the head, knee, and feet
Prerequisites: 2. Assist in positioning patients
safely and comfortably
1. Principle of Medical Handwashing
3. The height is adjustable for the
− Basic in all nursing procedures convenience of the staff
2. Principles and Rules of Body Mechanics 4. Wheel Locks
− Must be observed all throughout • Engaged by foot
3. Turning a client on his side
− Occupied bed Purpose:
4. Moving a client toward the head of the bed
✓ Prevent the bed from
5. Knowing the type of hospital bed
moving during the patient
STANDARD HOSPITAL BED care, repositioning and
bedmaking
• 66 cm (26 in) high 5. Client Signal
• 0.9 meters (3 feet) wide • Must be within the easy reach
• 1.9 m (6.6 feet) length of the client
Reasons: • Instruct the client how to use
the signal and when to use it
1. So the nurse can reach the client from the other
side Bed Positions
2. Prevent muscle fatigue to the nurse FLAT POSITION (Supine Position)

Types: • Commonly used mattress is completely

horizontal
1. Standard Hospital Bed
2. Special Hospital Bed
✓ Stryker Wedge Frame Bed
✓ Circ olectric Bed
 Fundamentals of Nursing Practice - RLE
FOWLER’S POSITION • Soiled linen is placed directly in a portable linen
hamper
• Sitting position
− If there is no available hamper, make use
2 kinds of Fowler’s Position: of the soiled pillowcase for dispersal
• When stripping and making a bed, make up one
o Semi-fowler’s Position side as completely as possible before making up
- head part is raised at 15-45 deg. to the other side
o Fowler’s Position − To conserve time and energy
- head and trunk elevated at 90 deg. • Gather all needed linen before starting to strip a
Purpose (fowler’s position) bed
− To avoid unnecessary trips to the linen
▪ Gives the client the relief from lying position supply area
▪ Convenient for eating and reading − To conserve time and energy
▪ Position of choice for patients with difficulty of • Do medical handwashing in making a bed
breathing and with cardiac problems − To prevent transfer of microorganisms
▪ Gravity pulls downward, allowing greater lung by the nurse’s hands
expansion
• Observe proper body mechanics
TRENDELENBURG POSITION − Not for the sake of art, but to avoid
muscle strain
• The head of the bed is lowered and the foot • In making the bed, the linen must be smooth
part of the bed is elevated and wrinkle-free to avoid decubitus ulcer or bed
• Used in postural damage sores
REVERSE TRENDELENBURG POSITION − The safety factor of bedmaking relates
directly to the prevention of pressure
• Straight tilt on the opposite direction ulcer
• The head part is elevated and the foot part is
lowered
• Use: patients with problems arterial circulation
to the leg
HYPEREXTENSION POSITION

• Both the head and the foot part are lowered 15

degree
• Used for clients with fractures
• Use only with specific orders and continuous
nursing assessment of the client
Concepts in Bedmaking
• Linen that have been soiled with secretions and
excretions harbor microorganisms that can be
PRESSURE ULCER/BED SORE/ DECUBITUS ULCER
transmitted to others directly
Note: • It is a localized injury to the skin and other
▪ Nurses should wash hands thoroughly underlying tissue, usually over a bony
after handling the client’s soiled linen prominence as a result of prolonged unrelieved
▪ Hold soiled linen away from the pressure
uniform
• Soiled linen is never shaken in the air
− Shaking can disseminate microorganisms
 Fundamentals of Nursing Practice - RLE
HOW DO BED SORES DEVELOP?

AREAS SUSCEPTIBLE TO ULCERATION:

Types of Bedmaking
Stripping
Folding
▪ Unoccupied Bed
− Open Bed
− Close Bed
▪ Obstetrical Bed
▪ Post-Operative Bed
▪ Occupied Bed