DISTANCE LEARNING CENTRE

AHMADU BELLO UNIVERSITY

ZARIA, NIGERIA

COURSE MATERIAL

FOR

Course Code & Title: NURS 203

(FOUNDATION OF NURSING I)

Programme Title: Bachelor in Nursing Sciences (BNSc.)

1
 ACKNOWLEDGEMENT
We acknowledge the use of the Courseware of the National Open University of
Nigeria (NOUN) as the primary resource. Internal reviewers in the Ahmadu Bello
University who extensively reviewed and enhanced the material have been duly
listed as members of the Courseware development team.

2
 COPYRIGHT PAGE
© 2018 Ahmadu Bello University (ABU) Zaria, Nigeria

All rights reserved. No part of this publication may be reproduced in any form or by any
means, electronic, mechanical, photocopying, recording or otherwise without the prior
permission of the Ahmadu Bello University, Zaria, Nigeria.

First published 2018 in Nigeria.

ISBN:

Ahmadu Bello University e-Learning project,

Ahmadu Bello University
Zaria, Nigeria.

Tel: +234

E-mail:

3
 COURSE WRITERS/DEVELOPMENT TEAM

Salihu Abdulrahman Kombo

Balarabe Fatima Subject Matter Reviewers
Enegoloinu Adakole Language Reviewer
Dr. Fatima Kabir Instructional Designers/Graphics
Prof. Adamu Z. Hassan Editor

4
 CONTENTS
Title Page…………………………………………………………….……?
Acknowledgement Page…………………………………………… ……?
Copyright Page………………………………………………………..……?
Course Writers/Development Team………………………………………?
Table of Content………………………………..……………………………?

COURSE STUDY GUIDE ?

i. Course Information ?
ii. Course Introduction and Description ?
iii. Course Prerequisites ?
iv. Course Learning Resources ?
v. Course Objectives and Outcomes ?
vi. Activities to Meet Course Objectives ?
vii. Time (To complete Syllabus/Course) ?
viii. Grading Criteria and Scale ?
ix. OER Resources ?
x. ABU DLC Academic Calendar ?
xi. Course Structure and Outline ?
xii. STUDY MODULES ?
Module 1: Health and human needs
Study Session 1: Health and Human Needs I AND II
Study Session 2: Concept of Health and Illness
Study Session 3: Promoting Health and primary Health Care -Introduction,
Principles and Elements
Study Session 4: Assessing Health

Module 2:

5
 Study Session 1: Assessing Health II (Vital Signs)
Study Session 2: Assessing Health III (History Taking and Physical
examination)
Study Session 3: Diagnostic Measures in Patients Care
Study Session 4: Providing Safety and Comfort I

Module 3:
Study Session 1: Providing Safety and Comfort II (Pain Management
Study Session 2a: Infection Control, Sexuality and Gender Issues
Study Session 2b: Sexuality and Gender Issues
Study Session 3a: Ethical and Legal Issues in Nursing I
Study Session 3b: Legal Aspects of Professional Nursing I
Study Session 3c: Legal Aspects of Professional Nursing II
Study Session 4a: Stress and Adaptation, Nursing and Society
Study Session 4b: Nursing and Society
Study Session 5: Health Education

XIII. Glossary ?

6
 i. COURSE INFORMATION
Course Code : NURS 203
Course Title: Foundation of Nursing 1
Credit Units: 2
Year of Study: Second
Semester: First

ii. COURSE INTRODUCTION AND DESCRIPTION

Introduction:
The course provides a broad base understanding of the facts that the concepts of
disease, health needs and health promotion that exist in a sociocultural,
institutional and political vacuum do reflect the values, beliefs, knowledge and
practices shared by the people, professionals and other influential groups. It
therefore identifies the various health needs of the people and adapted the three (3)
levels of health promotion be it primary, secondary and tertiary to differentiate
between the conceptions of disease prevention and health promotion.

The ability to assess the patient is one of the most important skills of the nurse
regardless of the practice setting. All settings where nurses provide care, eliciting a
complete history and using appropriate assessment skills are critical to identifying
physical and psycho- emotional problems concern experienced by the patient.
Patient assessment include the five (5) steps in nursing process and is necessary to
obtain data that will enable the nurse to make a nursing diagnosis, identifying and
implementing nursing intervention and assess their effectiveness.

7
Description:
The course looks at the individual and his health care utilizing the holistic
approach, cultural diversity, safety and comfort of care, sexuality and gender issues
as well as the ethical issues in relation to nursing practice. It also identifies the
legal responsibilities and their implications for nursing practice and impact on the
nursing profession.

iii. COURSE PREREQUISITES

You should note that although this course has no subject pre-requisite, you are
expected to have:
1. Satisfactory level of English proficiency
2. Basic Computer Operations proficiency
3. Online interaction proficiency
4. Web 2.0 and Social media interactive skills

iv.COURSE LEARNING RESOURCES

i. Course Textbooks
Cox, C.L. (2010). Health and Human Needs. In H. B. M. Heath (Ed.).
Potters and Perry’s Foundations in Nursing Theory and Practice. Italy:
Mosby, An Imprint of Times Mirror International
Coy, J. (2008). Comfort and Sleep. In S. C. Delaune & P.K. Ladner, (Eds.).
Fundamentals of Nursing, Standard and Practice. Albany: Delmar
Publishers.
Furest, et al (2004). Fundamentals of Nursing, J.B. Lippincott Co.,

8
Philadelphia.
Kozier, B., Erb, G., Berman, A.U. & Burke, K. (Eds.). (2007). Health,
Wellness and Illness. Fundamental of Nursing: Concepts Process and
Practice (6th Ed.). New Jersey: Prentice Hall, Inc.

v. COURSE OUTCOMES
After studying this course, you should be able to:
(must be quantifiable and measurable)
1. Achieve the aims set out above, the course sets the overall objective.
2. In addition, each unit has specific objectives stated at the beginning of a
unit. Learners are advised to read them carefully before going through the
unit. You will have to refer to them during the course of your study to
monitor your progress. You are encouraged to always refer to the Unit
objectives after completing a Unit. This is the way you can be certain that
you have done what was required of you in the unit.
3. The wider objectives of the course are set below. By meeting these
objectives, you should have achieved the aims of the course as a whole.

vi. ACTIVITIES TO MEET COURSE OBJECTIVES

Specifically, this course shall comprise of the following activities:
1. Studying courseware
2. Listening to course audios
3. Watching relevant course videos
4. Field activities, industrial attachment or internship, laboratory or
studio work (whichever is applicable)
5. Course assignments (individual and group)

9
 6. Forum discussion participation
7. Tutorials (optional)
8. Semester examinations (CBT and essay based).

vii. TIME (TO COMPLETE SYLABUS/COURSE)

To cope with this course, you would be expected to commit a minimum of 3 hours
daily for the Course.

viii. GRADING CRITERIA AND SCALE

Grading Criteria
A. Formative assessment
Grades will be based on the following:
Individual assignments/test (CA 1,2 etc) 20
Group assignments (GCA 1, 2 etc) 10
Discussions/Quizzes/Out of class engagements etc 10

B. Summative assessment (Semester examination)

CBT based 30
Essay based 30
TOTAL 100%

C. Grading Scale
A = 70-100
B = 60 – 69
C = 50 - 59
D = 45-49

10
F = 0-44

D. Feedback
Courseware based:
1. In-text questions and answers (answers preceding references)
2. Self-assessment questions and answers (answers preceding references)

Tutor based:
1. Discussion Forum tutor input
2. Graded Continuous assessments

Student based:
1. Online programme assessment (administration, learning resource,
deployment, and assessment).

IX LINKS TO OPEN EDUCATION RESOURCES

OSS Watch provides tips for selecting open source, or for procuring free or open
software.
SchoolForge and SourceForge are good places to find, create, and publish open
software. SourceForge, for one, has millions of downloads each day.
Open Source Education Foundation and Open Source Initiative, and other
organisation like these, help disseminate knowledge.
Creative Commons has a number of open projects from Khan
Academy to Curriki where teachers and parents can find educational materials for
children or learn about Creative Commons licenses. Also, they recently launched
the School of Open that offers courses on the meaning, application, and impact of
"openness."
Numerous open or open educational resource databases and search engines
exist. Some examples include:

11
• OEDb: over 10,000 free courses from universities as well as reviews of colleges
and rankings of college degree programmes
• Open Tapestry: over 100,000 open licensed online learning resources for an
academic and general audience
• OER Commons: over 40,000 open educational resources from elementary school
through to higher education; many of the elementary, middle, and high school
resources are aligned to the Common Core State Standards
• Open Content: a blog, definition, and game of open source as well as a friendly
search engine for open educational resources from MIT, Stanford, and other
universities with subject and description listings
• Academic Earth: over 1,500 video lectures from MIT, Stanford, Berkeley,
Harvard, Princeton, and Yale
• JISC: Joint Information Systems Committee works on behalf of UK higher
education and is involved in many open resources and open projects including
digitising British newspapers from 1620-1900!
Other sources for open education resources
Universities
• The University of Cambridge's guide on Open Educational Resources for Teacher
Education (ORBIT)
• OpenLearn from Open University in the UK
Global
• Unesco's searchable open database is a portal to worldwide courses and research
initiatives
• African Virtual University (http://oer.avu.org/) has numerous modules on subjects
in English, French, and Portuguese
• https://code.google.com/p/course-builder/ is Google's open source software that is
designed to let anyone create online education courses
• Global Voices (http://globalvoicesonline.org/) is an international community of
bloggers who report on blogs and citizen media from around the world, including
on open source and open educational resources
Individuals (which include OERs)
• Librarian Chick: everything from books to quizzes and videos here, includes
directories on open source and open educational resources
• K-12 Tech Tools: OERs, from art to special education

12
• Web 2.0: Cool Tools for Schools: audio and video tools
• Web 2.0 Guru: animation and various collections of free open source software
• Livebinders: search, create, or organise digital information binders by age, grade,
or subject (why re-invent the wheel?)

13
 X. ABU DLC ACADEMIC CALENDAR/PLANNER

PERIOD
Semester Semester 1 Semester 2 Semester 3
Activity JAN FEB MAR APR MAY JUN JUL AUG SEPT OCT NOV DEC
Registration

Resumption

Late Registn.

Facilitation

Revision/
Consolidation
Semester
Examination

N.B: - All Sessions commence in January

- 1 Week break between Semesters and 6 Weeks vocation at end of session.
- Semester 3 is OPTIONAL (Fast-tracking, making up carry-overs & deferments)

14
 XI. COURSE STRUCTURE AND OUTLINE
Course Structure
WEEK/DAYS MODULE STUDY SESSION ACTIVITY
1. Read Courseware for the corresponding Study Session.
Study Session 1: 2. View the Video(s) on this Study Session
Title: Health and 3. Listen to the Audio on this Study Session
Human Needs I and II 4. View any other Video/U-tube
(https://www.youtube.com/watch?v=JHcQXMghylo
1 https://www.youtube.com/watch?v=47LbJMaJ8Uk
https://www.youtube.com/watch?v=9zyrxyv4vGk
https://www.youtube.com/watch?v=hhwfoNjEzrg)
1. Read Courseware for the corresponding Study Session.
Study Session 2 2. View the Video(s) on this Study Session
Title: Concept of 3. Listen to the Audio on this Study Session
Health and Illness 4. View any other Video/U-tube
(https://www.youtube.com/watch?v=jcMCDzo7khY
STUDY https://www.youtube.com/watch?v=pQbnmi5fTZY
MODULE 1 https://www.youtube.com/watch?v=jXcUaLPivVU
https://www.youtube.com/watch?v=rwmCQ2kFLQQ)

Study Session 3 1. Read Courseware for the corresponding Study Session.

Title: Promoting 2. View the Video(s) on this Study Session
Health and Primary 3. Listen to the Audio on this Study Session
Health Care- 4. View any other Video/U-tube
Introduction, (https://www.youtube.com/watch?v=y9THQTEqMaU
2 Principles and https://www.youtube.com/watch?v=G2quVLcJVBk
Elements https://www.youtube.com/watch?v=ZWIN3EJ98qw
https://www.youtube.com/watch?v=jAbcTT-qRLo)

1. Read Courseware for the corresponding Study Session.

2. View the Video(s) on this Study Session

15
 Study Session 4 3. Listen to the Audio on this Study Session
Title: Assessing 4. View any other Video/U-tube (address/site??????
Health https://www.youtube.com/watch?v=fCUHYMQcWgE
Pp??? https://www.youtube.com/watch?v=zl-gf-G8_P8
https://www.youtube.com/watch?v=gG8kh8MfnGY
https://www.youtube.com/watch?v=AFziK0VlzPY
https://www.youtube.com/watch?v=xE6cAEl-Wnc
https://www.youtube.com/watch?v=73K0hD6hceU)

1. Read Courseware for the corresponding Study Session.

Study Session 1 2. View the Video(s) on this Study Session
Title: Assessing 3. Listen to the Audio on this Study Session
Health II (Vital Signs) 4. View any other Video/U-tube
(https://www.youtube.com/watch?v=JpGuSxDQ8js
3 https://www.youtube.com/watch?v=f9OreW1n0qU
https://www.youtube.com/watch?v=O9eTUIiVNj4
https://www.youtube.com/watch?v=VrgaaxVBLmQ)

1. Read Courseware for the corresponding Study Session.

STUDY Study Session 2 2. View the Video(s) on this Study Session
MODULE 2 Title: Assessing 3. Listen to the Audio on this Study Session
Health III (History 4. View any other Video/U-tube
Taking and Physical (https://www.youtube.com/watch?v=cjwJ7QxaOP0
examination) https://www.youtube.com/watch?v=aMyVDceW8RQ
https://www.youtube.com/watch?v=YPUibwuWjhM)

1. Read Courseware for the corresponding Study Session.

Study Session 3 2. View the Video(s) on this Study Session
Title: Diagnostic 3. Listen to the Audio on this Study Session
Measures in Patients 4. View any other Video/U-tube
Care (https://www.youtube.com/watch?reload=9&v=fStBWT6
fa3E https://www.youtube.com/watch?v=J-mmBBoFmbI
https://www.youtube.com/watch?v=cR1A5wN0_gw

16
4 https://www.youtube.com/watch?v=0qKcTD6qMqE)

1. Read Courseware for the corresponding Study Session.

Study Session 4 2. View the Video(s) on this Study Session
Title: Providing Safety 3. Listen to the Audio on this Study Session
and Comfort I 4. View any other Video/U-tube
(https://www.youtube.com/watch?v=e1Af5m3g7rM
https://www.youtube.com/watch?v=ld5ivhqkgSw
https://www.youtube.com/watch?v=DmXax9Z1LPI
https://www.youtube.com/watch?v=uRPvf3EIBBc)
5. View referred OER (address/site??????)
6. View referred Animation (Address/Site?????)
7. Read Chapter/page of Standard/relevant text.
8. Any additional study material
9. Any out of Class Activity
1. Read Courseware for the corresponding Study Session.
Study Session 1 2. View the Video(s) on this Study Session
Title: Providing Safety 3. Listen to the Audio on this Study Session
and Comfort II (Pain 4. View any other Video/U-tube
Management) (https://www.youtube.com/watch?v=Ssymdf8CFQ4
https://www.youtube.com/watch?v=C_3phB93rvI
5 STUDY https://www.youtube.com/watch?v=A8ozaSn7jHU
https://www.youtube.com/watch?v=r3qBlVfPzXo)
MODULE 3

1. Read Courseware for the corresponding Study Session.

Study Session 2a 2. View the Video(s) on this Study Session
Title: Infection 3. Listen to the Audio on this Study Session
Control, Sexuality and 4. View any other Video/U-tube
Gender Issues (https://www.youtube.com/watch?v=c-yLWHmkZUQ
https://www.youtube.com/watch?v=QgqTW0FjN08
https://www.youtube.com/watch?v=bZheuS4e2ZY
https://www.youtube.com/watch?v=91_BDSa7T5A)

17
 1. Read Courseware for the corresponding Study Session.
Study Session 2b 2. View the Video(s) on this Study Session
Title: Sexuality and 3. Listen to the Audio on this Study Session
Gender Issues 4. View any other Video/U-tube
(https://www.youtube.com/watch?v=c-yLWHmkZUQ
https://www.youtube.com/watch?v=QgqTW0FjN08
https://www.youtube.com/watch?v=bZheuS4e2ZY
https://www.youtube.com/watch?v=91_BDSa7T5A)

1. Read Courseware for the corresponding Study Session.

Study Session 3a 2. View the Video(s) on this Study Session
Title: Ethical and 3. Listen to the Audio on this Study Session
Legal Issues in 4. View any other Video/U-tube (
Nursing I https://www.youtube.com/watch?v=8PZNl6vix8Q
https://www.youtube.com/watch?v=xUOw5QGE1oM
6 https://www.youtube.com/watch?v=M7cpV8k4Id4
https://www.youtube.com/watch?v=jSNhGv7OsDQ)

Study Session 3b 1. Read Courseware for the corresponding Study Session.

Title: Legal 2. View the Video(s) on this Study Session
Aspects of Professional 3. Listen to the Audio on this Study Session
Nursing I

Study Session 3c 1. Read Courseware for the corresponding Study Session.

Title: Legal Aspects of 2. View the Video(s) on this Study Session
Professional Nursing 3. Listen to the Audio on this Study Session
II 4. View any other Video/U-tube (
https://www.youtube.com/watch?v=8PZNl6vix8Q
https://www.youtube.com/watch?v=xUOw5QGE1oM
https://www.youtube.com/watch?v=M7cpV8k4Id4
https://www.youtube.com/watch?v=jSNhGv7OsDQ)

18
 Study Session 4a 1. Read Courseware for the corresponding Study Session.
Title: Stress and 2. View the Video(s) on this Study Session
Adaptation, Nursing 3. Listen to the Audio on this Study Session
and Society 4. View any other Video/U-tube
(https://www.youtube.com/watch?v=-QSVsb0wlLw
https://www.youtube.com/watch?v=XADIs-A1iiM
https://www.youtube.com/watch?v=O6MLMAZeHwI
https://www.youtube.com/watch?v=BF0Qjvp4Pjg)

7 Study Session 4b 1. Read Courseware for the corresponding Study Session.

Title: Nursing and 2. View the Video(s) on this Study Session
Society 3. Listen to the Audio on this Study Session
4. View any other Video/U-tube
(https://www.youtube.com/watch?v=-QSVsb0wlLw
https://www.youtube.com/watch?v=XADIs-A1iiM
https://www.youtube.com/watch?v=O6MLMAZeHwI
https://www.youtube.com/watch?v=BF0Qjvp4Pjg)

1. Read Courseware for the corresponding Study Session.

Study Session 5 2. View the Video(s) on this Study Session
Title: Health 3. Listen to the Audio on this Study Session
Education 4. View any other Video/U-tube
(https://www.youtube.com/watch?v=ErBECLCWNOk
https://www.youtube.com/watch?v=A48_CmLeM_Y
https://www.youtube.com/watch?v=RUbELIFLFWA
https://www.youtube.com/watch?v=iVPrGalChJo)

Week 13 REVISION/TUTORIALS (On Campus or Online) & CONSOLIDATION

WEEK

Week 14 & 15 SEMESTER EXAMINATION

19
20
Course Outline
MODULE 1:
Study Session 1: Health and Human Needs I AND II
Study Session 2: Concept of Health and Illness
Study Session 3: Promoting Health and primary Health Care -Introduction,
Principles and Elements
Study Session 4: Assessing Health

MODULE 2:
Study Session 1: Assessing Health II (Vital Signs)
Study Session 2: Assessing Health III (History Taking and Physical
examination)
Study Session 3: Diagnostic Measures in Patients Care
Study Session 4: Providing Safety and Comfort I

MODULE 3:
Study Session 1: Providing Safety and Comfort II (Pain Management
Study Session 2a: Infection Control, Sexuality and Gender Issues
Study Session 2b: Sexuality and Gender Issues
Study Session 3a: Ethical and Legal Issues in Nursing I
Study Session 3b: Legal Aspects of Professional Nursing I
Study Session 3c: Legal Aspects of Professional Nursing II
Study Session 4a: Stress and Adaptation, Nursing and Society
Study Session 4b: Nursing and Society
Study Session 5: Health Education

21
 12.0 STUDY MODULES
MODULE 1: Health and Human Needs
Contents:
Study Session 1: Health and Human Needs I and II
Study Session 2: Concept of Health and Illness
Study Session 3: Promoting Health
Study Session 4: Assessing Health

STUDY SESSION 1
Health and Human Needs I and II
Section and Subsection Headings:
Introduction
1.0 Learning Outcomes
2.0 Main Content
2.1- Esteem and Self-Esteem Needs
2.2- Self Actualization Needs
2.3- Theories of Human Needs
2.4- Criticisms of Maslow’s Theory of Needs
2.5- Application of Basic Needs Theory
3.0 Tutor Marked Assignments (Individual or Group assignments)
4.0 Study Session Summary and Conclusion
5.0 Self-Assessment Questions
6.0 Additional Activities (Videos, Animations & Out of Class activities)
7.0 References/Further Readings

Introduction:
The preceding unit opens the discussion on the universality of needs and the
relationship between health and human needs but fail to address all aspects of

22
this all-important issue. The present unit is therefore a continuation of that
discourse. The unit particularly examines esteem needs, self-actualization needs,
Maslow hierarchy of human needs and other theories of human needs.

1.0 Study Session Learning Outcomes

After studying this session, I expect you to be able to:
1. Differentiate between the esteem needs and self-actualization needs
2. Discuss the Maslow hierarchy of needs
3. Describe what is meant by hierarchy of needs
4. Discuss Maslow Hierarchy of Needs and other Needs Theories
5. Examine the flaws of Maslow Hierarchy of Needs
6. Discuss the clinical and other applicability of Basic Needs theory.

2.0 Main Content

2.1 Esteem and Self-Esteem Needs
The term self-esteem (self-image, self-respect, self -worth) is related to the
person’s perception of self / personal feeling of self-worth and recognition or
respect from others. All people in every society (with a few pathological
exceptions) have a need or desire for a stable, firmly based (i.e. soundly based
upon real capacity), usually high evaluation of themselves, for self-respect, or
self-esteem, and for the esteem of others. This is because self-respect and
dignity are essential to the psychological well-being of individuals who have
reached some degree of satisfaction in the first three levels of human needs.
Cox (2010) declared that a change in roles whether anticipated (for instance
retirement), or sudden such as injury, may threaten self-esteem. Similarly,
changes in body image whether obvious like amputation or hidden (e.g.
hysterectomy) may also influence self-esteem. Cox (2010) stressed further that
it is not the magnitude of the change or role that affects self-esteem, but rather

23
how the person perceives the self after the change.
Esteem and Self-Esteem needs are met when the person thinks well of himself
or herself (achievement, adequacy, competence, confidence) and is well
thought of by others (recognition, status awards, prestige) (Rosdahl 2009).
When both of these needs are met, a person feels self- confident and useful but
thwarting of these needs produces feelings of inferiority, of weakness and of
helplessness. These feelings in turn give rise to either basic discouragement or
else compensatory or neurotic trends (Maslow, 1970). Consequently
indications of unmet needs for self-esteem include a feeling of
helplessness/hopelessness/inferiority complex and becoming self-critical or
unusually lethargic or apathetic about anything involving self, including
appearance. Cox (2010) stated that, a person feeling the lack of esteem of other
people may test others by making such statements that call for their approval or
praise, or may act in a way that prevents such approval if little self-esteem is
present and the person is certain of failure.
Nursing intervention in cases of low self-esteem begins right from admission
or first contact with the client/patient. The nurse can assist client/patient to
regain positive self-esteem by conveying a feeling of acceptance and respect,
employing a non-judgmental approach in handling the values and beliefs of the
client/patient, encouraging independence, rewarding progress, allowing the
client/patient to do as much self-care as possible, and tailoring specific nursing
actions towards the root cause of the altered self-concept. But if patients’ self-
esteem is so low that they fail to care for themselves, the nurse assumes total
responsibility for meeting those other needs while taking steps to increase self-
esteem (Rosdahl 2009; Cox, 2010).

In-text Question 1 (A short question requiring a single sentence answer for quick reflection
over the read topic): What is the positive link of esteem and self-esteem needs?

Answer A person feels self-confident and useful to himself and community.

24
2.2. Need for Self Actualisation
This term, first coined by Kurt Goldstein refers to the desire for self- fulfillment,
namely, to the tendency for him to become actualized in what he is potentially.
This tendency might be phrased as the desire to become more and more what
one is, to become everything that one is capable of becoming. They are more
ego oriented in nature and frequently express themselves in highly independent
behaviors. However, the clear emergence of these needs rests upon prior
satisfaction of the physiological, safety, love and esteem needs. That is, even if
all aforementioned needs are satisfied, we may still often (if not always) expect
that a new discontent and restlessness will soon develop, unless the individual is
doing what he is fitted for. A musician must make music; an artist must paint, a
poet must write, if he is to be ultimately happy. What a man can be, he must be
(Maslow, 1943). It must however be stressed that the specific form that these
needs will take, will of course vary greatly from person to person. In one
individual it may take the form of the desire to be an ideal mother, in another it
may be expressed athletically, and in still another it may be expressed in
painting pictures or in inventions. It is not necessarily a creative urge although
in people who have any capacities for creation it will take this form.

Present needs, environment, and stressors influence how well people meet their
need for self-actualization. As a matter of fact, many psychologists believe that
people continue striving to reach this level in life and very few people believe
that they are self-actualized. Self- actualized individuals have mature
multidimensional personality, frequently they are able to assume and complete
multiple tasks, and the achieve fulfillment from the pleasure of a job well done.
They do not totally depend on opinions of others about appearance, quality of
work, or problem-solving methods. While it is true that they may have failings
and doubts, they generally deal with them realistically (Cox, 2010). However,

25
self-actualizers may focus on the fulfillment of this highest need to such an
extent that they consciously or unconsciously make sacrifices in the fulfillment
of the lower level needs.

Illness, injury, loss of loved one, change in role, and change in status can
threaten or disturb self-actualization sometimes manifesting in behavioral
changes. The gal of nursing care is to assist individuals to reach their fullest
potential. As such nursing care is planned to encourage individual to make
decisions when possible, particularly those that concern his health. Because the
self-actualized person tend to be creative, nursing care should give room for
expression of creativity as well as encouraging the individual to continue with
specific projects. And since the healthy self-actualized person generally has a
strong need for privacy, the patient’s need for privacy must be respected (Cox,
2010).

2.3 Theories of Human Needs

Quite a number of theories have been propounded on human needs but
prominent among them are the Maslow Hierarchy of Needs and the Alderfer's
Existence/Relatedness/Growth (ERG) Theory of Needs.
(a) Abraham Harold Maslow
Abraham Harold Maslow was a renowned psychologist and philosopher who
lived between April 1, 1908 and June 8, 1970. He was a scholar and was
referred to as the father of humanistic psychology. In 1943, Abraham H.
Maslow observed and concluded that:
i. Needs are hierarchical in nature. That is, each need has a specific ranking
or order of obtainment.
ii. The need network for most people is very complex, with a number of
needs affecting the behaviors of each person at any point in time.

26
iii. People respond to these needs in a progressive manner from simple
physiological needs (survival needs) to more complex (aesthetic) needs;
and that they do so as whole and integrated beings.
iv. When one set of needs is satisfied, it seizes to be a motivator.
v. Lower level need must be satisfied in general, before higher level needs
are activated sufficiently to drive behavior.
vi. There are more ways to satisfy higher level needs than there are for lower
level needs

Consequently, he identified various needs that motivate behavior and place

them in sequential hierarchy or graded order according to their significance to
human survival i.e. in ascending order from lowest to the highest needs. He
posited that that the basic needs of all people regardless of age, sex, creed,
social class, or state of health (sick or well) could be categorized into five
levels:
i. Physiological: hunger, thirst, bodily comforts, etc.;
ii. Safety/Security: the need for structure, predictability, out of danger, free
from harm, feel safe and secure;
iii. Belongings and Love: the need to be accepted by others and to have
strong personal ties with one's family, friends, and identity groups;
iv. Esteem: the need to achieve, be competent, gain approval and
recognition; and
v. Self-Actualization: the need to find self-fulfillment and reach one's
potential in all areas of life;

Maslow's needs pyramid starts with the basic items of food, water, and shelter.
These are followed by the need for safety and security, then belonging or love,
self-esteem, and finally, personal fulfillment (Self- Actualization). According to
him, the first level needs, which are physiologic, occupying the bottom of the

27
pyramid/ladder, are the most important as they are activities needed to sustain
life such as breathing and eating.
Fig 3 – 1 Schematic Representation of Maslow Hierarchy of
Needs

Source: Adapted from Dr. C. George Boeree (2004) Abraham

Maslow. Available on
http://www.ship.edu/cgboeree/maslow.htm

Each higher level represents one of lesser importance to human existence than
the one previous to it. Maslow believed that it is when a particular physiological
need is met with relative degree of satisfaction that other needs of lesser
importance to human existence take precedence. However by progressively
satisfying needs at each subsequent level, people can realize their
maximum potential for health and well-being (Timby, 1996).

(b) Alderfer's Existence/Relatedness/Growth (ERG) Theory of Needs

The ERG Theory of Clayton P. Alderfer is a model that appeared in 1969 in a
Psychological Review article entitled "An Empirical Test of a New Theory of
Human Need". In a reaction to Maslow's famous Hierarchy of Needs, Alderfer,
an American Psychologist, postulated that there are three groups of human

28
needs that influence workers’ behavior; existence, relatedness, and growth.
These three needs categories are:
i. Existence - This group of needs is concerned with providing the basic
requirements for material existence, such as physiological and safety
needs. (Maslow‘s first two levels). This need is satisfied by money earned
in a job so that one may buy food, shelter, clothing, etc.
ii. Relationships - This group of needs center upon the desire to establish
and maintain interpersonal relationships i.e. social and external esteem
(involvement with family, friends, co-workers and employers) (Maslow's
third and fourth levels.
iii. Growth – This encompasses internal esteem and self- actualization
(desires to be creative, productive and to complete meaningful tasks)
(Maslow's fourth and fifth levels). These needs are met by personal
development. A person's job, career, or profession provides significant
satisfaction of growth needs.
Contrarily to Maslow's idea that access to the higher levels of his pyramid
required satisfaction in the lower level needs, Alderfer declared that the three
ERG areas are not stepped in any way. ERG Theory recognizes that the order of
importance of the three Categories may vary for each individual. Managers
must recognize that an employee has multiple needs to satisfy simultaneously.
According to the ERG theory, focusing exclusively on one need at a time will
not effectively motivate. In addition, the ERG theory acknowledges that if a
higher-level need remains unfulfilled, the person may regress to lower level
needs that appear easier to satisfy. That is, if the gratification of a higher-level
need is frustrated, the desire to satisfy a lower level need will increase. Alderfer
identifies this phenomenon as the "frustration & shy aggression dimension."
This frustration-regression dimension affects workplace motivation. For
example, if growth opportunities are not provided to employees, they may

29
regress to relatedness needs, and socialize more with co-workers. The relevance
of this on the job is that even when the Upper-level needs are frustrated, the
job still provides for the basic physiological needs upon which one would then
be focused. If, at that point, something happens to threaten the job, the person’s
basic needs are significantly threatened. If there are not factors present to relieve
the pressure, the person may become desperate and panicky (Alderfer, 1969).
Fig 3 – 2 Schematic Presentation of Alderfer's ERG Theory of Needs

ERG Theory – Clayton P. Alderfer

Relatedness
Needs

Existenc Growth
e Needs Needs

Satisfaction / Progression

Frustration / Regression

Satisfaction / Strengthening
Source: Adapted from
http://www.valuebasedmangement.net/methods_alderfer_erg_theory.html

Other Theories of Needs: A Summary

Huitt (2004) in what looks like a review of literature captures other scholars’
contribution to ‘Need Theory’ as follows:
“Contrary to Maslow’s categorization of needs, James (1892/1962)
hypothesized that there are three levels of needs namely: material
(physiological, safety), social (belongingness, esteem), and spiritual. Mathes
(1981) while agreeing with the three-tier categorization of needs proposed that

30
the three levels were physiological, belongingness, and self-actualization; he
considered security and self-esteem as unwarranted. Ryan & Deci (2000) also
suggest three needs, although they are not necessarily arranged hierarchically:
the need for a u t o n o m y , the need for competence, and the need for
relatedness. Thompson, Grace and Cohen (2001) submitted that the most
important needs for children are connection, recognition, and power. Nohria,
Lawrence, and Wilson (2001) provide evidence from a sociobiology theory of
motivation that humans have four basic needs: (1) acquire objects and
experiences; (2) bond with others in long-term relationships of mutual care and
commitment; (3) learn and make sense of the world and of ourselves; and (4) to
defend ourselves, our loved ones, beliefs and resources from harm. The Institute
for Management Excellence (2001) suggests there are nine basic human needs:
(1) security, (2) adventure, (3) freedom, (4) exchange, (5) power, (6) expansion,
(7) acceptance, (8) community, and (9) expression”.

As rightly noted by Huitt (2004), a common trait or regular feature of all these
theories however is bonding and relatedness. Notice that there do not seem to be
any other that are mentioned by all theorists. Franken (2001) suggests this lack
of accord may be a result of different philosophies of researchers rather than
differences among human beings. In addition, he reviews research that shows a
person's explanatory or attributional style will modify the list of basic needs.
This possibly explains why Huitt (2004) concluded that it will seem appropriate
to ask people what they want and how their needs could be met rather than
relying on an unsupported theory.

2.4 Criticisms of Maslow’s Theory of Needs

Maslow concept of needs had been subjected to considerable research. For
example, in their extensive review of research that is dependent on Maslow's

31
theory, Wabha and Bridwell (1976) found little evidence for the ranking of
needs that Maslow described or even for the existence of a definite hierarchy at
all but rather are sought simultaneously in an intense and relentless manner.
Other needs theorists have perceived human needs in a different way -- as an
emergent collection of human development essentials (Marker, 2003). Some
have contend that Maslow does not mention time period between various needs
and that people do not necessarily satisfy higher order needs through their jobs
or occupations. Besides, the concept of self-actualization is considered vague
and psychobabble by some behaviourist psychologists. They asserted that the
concept is based on an Aristotelian notion of human nature that assumes we
have an optimum role or purpose. In their words, ‘self-actualization is a difficult
construct for researchers to operationalize, and this in turn makes it difficult to
test Maslow's theory. Even if self-actualization is a useful concept, there is no
proof that every individual has this capacity or even the goal to achieve it’.
Other counter positions suggest that satisfaction which Maslow viewed as major
motivator has been found not to be directly related to production which is main
goal of the manager

2.5 Application of the Theory of Need

Huitt (2004) citing the works of Norwood (1999) submitted that Maslow
Hierarchy of needs could be used to describe the kinds of information that
individual's seek at different levels. For example, individuals at the lowest level
seek coping information in order to meet their basic needs. Information that is
not directly connected to helping a person meet his or her needs in a very short
time span is simply left unattended. Individuals at the safety level need helping
information. They seek to be assisted in seeing how they can be safe and secure.
Enlightening information is sought by individuals seeking to meet their
belongingness needs. Quite often this can be found in books or other materials

32
on relationship development. Empowering information is sought by people at
the esteem level. They are looking for information on how their ego can be
developed. Finally, people in the growth levels of cognitive, aesthetic, and self-
actualization seek edifying information.

Maslow’s theory of human needs has also gain a universal application in

nursing care of patients/clients of all ages. It wide applicability in nursing is
predicated upon the fact that illness often disrupt patients the ability to meet
needs on different levels, hence patients/clients come up with many needs. It
should however be noted that Maslow’s hierarchy is a generalization about the
need priorities of most but not all people. As such when the nurse applies this
theory in practice, the focus should be on the needs of the individual rather than
rigid adherence to Maslow’s hierarchy. In all cases, an emergency physiological
need takes precedence over a higher-level need. However the need for self-
esteem may be a higher priority than a long-term nutritional need for one
patient/client, whereas for another person, the reverse may be the case.
Furthermore, although the hierarchy of needs suggests that one should be met
before the other, nursing care often addresses two or more at the same time. As
Cox (2010) suggests the provision of most effective nursing care therefore
entails an understanding on the part of the nurse, the relationship among
different needs for the individual. Indeed in some nursing situations, it is
unrealistic to expect a patient’s/clients basic needs to be fulfilled in the fixed
hierarchical order. The example given by Cox (2010) of a person who possibly
enters the health care system as a result of chronic respiratory infection but
presents with multiple related unmet needs for nutrition, sleep, e.t.c. aptly
buttress this assertion. Nursing care in this situation will not simply be directed
at meeting the respiratory needs but will be directed at resolving the

33
pressing/life threatening needs while simultaneously addressing the higher level
needs.

In-text Question 1 (A short question requiring a single sentence answer for quick reflection
over the read topic) Sketch a diagrammatic representation of Abraham Maslow’s Hierarchy
of needs.

Answer Show your representation to your colleague.

3.0 Tutor Marked Assignments (Individual or Group)

1. Critically analyze Maslow’s Hierarchy of needs?

4.0 Conclusion/Summary
It should also be noted that for different individuals, needs on different levels
may be related in different ways. Some people may give sexual need a higher
priority than the need for love, whereas for others, sexual need is deferred until
the need for love is met. Similarly, people with unmet needs for self-esteem
may be unable to seek fulfillment of the need for love if their self- esteem is so
low that they feel inferior and fear rejection. In these and many other ways,
needs on different level may be closely related for individuals. When assessing
needs and planning care, the nurse must not assume that lower–level need
always takes priority. As with all other aspects of providing care, the nurse
individualizes the nursing care plan to provide for the unique needs and desires
of the patient / client (Cox, 2010). Factors influencing need priorities include:
(a) A person’s personality and mood. For instance a depressed person may react
negatively to a suggestion for an activity that could increase self-esteem,
although in another mood the person might respond with enthusiasm. Thus,
when providing care to help meet several needs, the nurse can adjust the care
plan to correspond most effectively to the patients/client’s personality and
mood. (b) The health status of the client/patient. A frail looking anaemic patient
for example, should not be encouraged to resume physical activities related to

34
need for self-esteem until need for physical safety and security have been met.
(c) Socio-economic status and cultural background – this affects a person’s
perception of needs. To make any meaningful impact in meeting the hydra-
headed needs of clients/patients, the nurse must therefore take into consideration
all the aforementioned factors. In addition, in view of the interrelatedness of
needs (e.g. if nutritional needs are not met for a long time, the person not only
begins to grow lean and malnourished but also become deficient in meeting
safety, love and self-esteem needs.

The unit is a follow up of the discussion on health and human needs. It

discusses the esteem and self-actualization needs with particular reference to
how nurses could assist patients/clients to meet these needs. The unit also
incorporates a comprehensive discourse of the Maslow hierarchy of needs with
its flaws/ weaknesses and other need theories. The unit acknowledges that
Maslow hierarchy of needs is a theoretical representation of the need priorities
of most people and not all people and therefore cautioned that when the nurse
applies this theory in practice, the focus should be on the needs of the individual
rather than rigid adherence to Maslow’s hierarchy.

5.0 Self-Assessment Questions

1. Write an essay on Maslow’s Hierarchy of needs. Discuss the
application of Maslow’s Hierarchy of Needs in a clinical setting.
2. What is its criticism?

6.0 References/Further Readings

Alderfer, C. P. (1969). Existence, Relatedness, and Growth; Human Needs in
Organizational Settings. Retrieved from,
http://www.valuebasedmangement.net/methods_alderfer_erg_the

35
 ory.html
Boeree, C. George (2004). Abraham Maslow. Available on
http://www.ship.edu/cgboeree/maslow.htm
Cox, C.L. (2010). Health and Human Needs. In H. B. M. Heath (ed.) Potters
and Perry’s Foundations in Nursing Theory and Practice. Italy: Mosby,
An Imprint of Times Mirror International.
Huitt, W. (2004). Maslow's Hierarchy of Needs. Educational Psychology
Interactive. Valdosta, GA: Valdosta State University. Retrieved from,
http://chiron.valdosta.edu/whuitt/col/regsys/maslow.html.
Marker, S. (2003). What Human Needs Are. In Beyond Intractability. Available
on http://www.beyondintratability.org/m/human_needs.jsp
Maslow, A. H. (1943). A Theory of Human Motivation. Psychological Review,
50, 370-396. Retrieved August 2000, from
http://psychclassics.yorku.ca/Maslow/motivation.htm
Maslow, A.H. (1970). Motivation and Personality (2nd Ed). New York: Harper
& Row.
Norwood, G. (1999). Maslow's Hierarchy of Needs. The Truth Vectors (Part I).
Retrieved May 2002, from http://www.deepermind.com/20maslow.htm.
Rosdahl, C. B. (Ed.). (1995). Optimum Health for All People; Textbook of
Basic Nursing. Philadelphia: J.B. Lippincott Company.
Timby, B.K. (Ed.). (1996). Health and Illness. Fundamental Skills and Concepts
in Patient Care (6th Ed.). Philadelphia: Lippincott.
Wahba, M. A. & Bridwell, L.G. (1976). Maslow Reconsidered: A Review of
Research on the Need Hierarchy Theory. Organisational Behavior and
Performance, 15: 21 – 240.

36
 STUDY SESSION 2
Concept of Health and Illness
Section and Subsection Headings:
Introduction
1.0 Learning Outcomes
2.0 Main Content
2.1- What is Health?
2.2- Conceptions of Wellness
2.3- Illnesses and Disease
2.4- Etiology of Illnesses and Diseases
2.5- Classification of Illnesses and Diseases
2.6- Theoretical perspectives of health and wellness
2.7- The Health-Illness Continuum
3.0 Tutor Marked Assignments (Individual or Group assignments)
4.0 Study Session Summary and Conclusion
5.0 Self-Assessment Questions
6.0 Additional Activities (Videos, Animations & Out of Class activities)
7.0 References/Further Readings

Introduction:
To many people, health and illness virtually means the same thing or as
accompanying one another. In fact most individuals and societies in the past
have viewed good health or wellness as synonymous to absence of illness. This
limited view overlooks the complex interrelationships between the
physiological, emotional, intellectual, socio-cultural, developmental and
spiritual dimensions of health and illness (Cox, 2010) However like Kozier,
Erb, Berman and Burke (2000) rightly noted, health may not always accompany
well-being as a person with terminal illness may have a sense of well-being

37
while somebody else may lack a sense of well-being yet be in good health. As
nurses we therefore need a comprehensive and robust understanding of health
and illness as this go a long way to affect scope and nature of nursing practice.
To this end, this unit employs a comprehensive and integrated approach of
health, wellness and illness. It particularly examined illness behaviour, models
of health and wellness, as well as the health-illness continuum.

1.0 Study Session Learning Outcomes

After studying this session, I expect you to be able to:
1. differentiate health, wellness and illness
2. describe five dimensions of wellness
3. differentiate between acute, chronic and terminal illnesses; primary and
secondary illnesses; and hereditary, congenital, and idiopathic illnesses.
4. distinguish between the terms illness and disease
5. Outline the etiology of illnesses and diseases
6. describe health.

2.0 Main Content

2.1 What is Health?
The term ‘health’ is so common a vocabulary in every culture; race or creed that
one is often tempted to assume that it would have a homogeneous meaning.
This is however not so. How each person perceives and defines health varies,
and it is important to respect these individual differences rather than impose
standards that may be personally unrealistic (Timby, 1996). In Watinson (2002)
words ‘Health’ is a slippery concept to grasp in comparison with ill-health,
which seems so solid and tangible.
Nonetheless, the World Health Organization (WHO) asserts in the preamble of
its constitutions that the enjoyment of the highest attainable standard of health is

38
one of the fundamental rights of every human being regardless of race, religion,
political belief, economic, or social conditions. According to WHO, health ‘is a
state of complete physical, mental and social well-being and not merely the
absence of disease on infirmity’. By this definition, health is much more than
physical well- being. It means more than not having a physical disease but to be
in harmony. The question that quickly comes to mind however is harmony with
what and how? To answer this question, there is need to explore cosmological
framework to show how physical and social component of the society helps to
explain or determine the notion of health and illness. Conception of health is
therefore ultimately based on the perception of the original and intended fashion
of humanity. As a result, the body becomes an extension of moral perception.
Kozier, Erb, Berman and Burke (2000) in what looks like a critical review of
the WHO definition submitted that the WHO definition:
i. Reflects concern for the individual as a total person functioning
physically, psychologically, and socially. They noted that mental
processes determine people’s relationship with their physical and social
surroundings, their attitudes about life, and their interaction with others.
ii. Places health in the context of environment. It takes cognizance of the
fact that people’s live, and therefore their health, are
iii. affected by everything they interact with – not only environmental
influences such as climate and the availability of nutritious food,
comfortable shelter, clean air to breathe and pure water to drink – but also
other people, including family, lovers, employers, coworkers, friends, and
associates of various kinds.
iv. Equates health with productive and creative living. According to them it
focuses on the living state rather than on categories of disease that may
cause illness or death.
v. Health therefore in its global/broadest sense encompasses:

39
 vi. Physical health – physical fitness, the body fixing at its best.
vii. Emotional health – feelings and attitudes that make one comfortable with
oneself.
viii. Mental health – a mind that grows and adjusts; in control, free of serious
stress.
ix. Social health – a sense of responsibility and caring for health and welfare
of others.
x. Spiritual health – inner peace and security, comfort with ones higher
power, as one perceives it.
One cannot but agree with Delaune & Ladner, (1998) and Kozier, Erb, Berman
& Burke, (2000) that the concept of health encompasses such things as
emotional and mental stability, spiritual well-being and social usefulness. And
while it is very true that health is the fundamental right of every individual, it is
also a limited resource as well as a personal responsibility. It is considered a
resource and personal responsibility because it is valuable; has no substitute;
and requires continuous personal effort. Health however is not an absolute
entity; rather there may be fluctuations along a continuum from time to time.
Health is not a condition, it is an adjustment; it is not a state, it is a process
(President’s commission, 1953). Delaune and Ladner (1998) definition of health
as a process through which the person seeks to maintain equilibrium that
promotes stability and comfort aptly corroborate this fact. In other words health
is a dynamic process that varies according to the individual’s perception of well-
being.

40
Dubo (1978) views health as a creative process. In his words, individuals are
actively and continually adapting to their environments. He stressed that
individuals must however have sufficient knowledge to make informed choices
about his or her health and also income and resources to act on choices. Pike
and Forster (1995) compliments Dubo’s statement by arguing that it is
important to take into account people’s own perceptions and views on health
and that different people will see and express these in different ways.
Individuals as they continuously adapt to their environment therefore are at
different stages/level of wellness.
It is also noteworthy that man responds to the environment in which he find
himself as an integrated whole. This brings us to the concept of holism. Holism
is a philosophy that views the “whole person”. The person is seen as a complete
unit that cannot be reduced to the sum of its parts. Health in holistic sense
therefore is total wellness – wellness of mind, spirit as well as body (Timby,
1996). But in view of the fact that it is virtually impossible for someone to be
well and stay well, or get well and remain well forever, nurses are expected to
assists people in the prevention of illness and restoration of health through
holistic health care i.e. comprehensive and total care of a person.
In-text Question 1 (A short question requiring a single sentence answer for quick reflection
over the read topic) List the five (5) factors that contribute to wellness?

Answer Physical 2. Social 3. Emotion 4. Intellectual 5. Spiritual.

41
2.2 Concepts of Wellness
Simply put, wellness is a state of well-being. Kozier, Erb, Berman & Burke,
(2000) drawing on the work of Leddy and Pepper (1998) contend that people do
confuse the process of health with the status of well- being. Well-being they
declared is a subjective perception of vitality and feeling well. It is a state that
can be described objectively and can be plotted on a continuum. A more lucid
definition however is the one given by Carroll and Miller (1991) which states
that term wellness connotes good physical self-care, using one’s mind
constructively, expressing ones emotion effectively, interacting creatively with
others and being concerned about one’s physical and psychological
environment. Akin to this, is the definition by Travis and Ryan (1988) which
states that wellness is a choice; a process; efficient handling of energy;
integration of body, mind, and spirit; and loving acceptance of self. In synopsis,
wellness can be interpreted as full and balanced integration of physical,
emotional, social and spiritual health i.e. the condition in which an individual
functions at optimal level.
According to Kozier, Erb, Berman & Burke (2000), the basic conceptions of
wellness include self-responsibility; an ultimate goal; a dynamic, growing
process; daily decision making in areas of nutrition, stress management,
physical fitness, preventive health care, emotional health, and other aspects of
health; and most importantly, the whole being of the individual. Using the
works of Anspaugh, Hamrick, & Rosata (1991) as the basis, they declared
further that there are five dimensions to wellness and for people to realize
optimal health and wellness, individuals must take cognizance of the factors
within each dimension. See figure 2 – 1.

42
 Fig 2 – 1 the Dimensions of Wellness

Physical

Spiritual

Social
Wellness

Intellectual
Emotional

Source: Adapted from Kozier, Erb, Berman and Burke

2000 Fundamentals of Nursing: Conceptions, Process and Practice.

Let us examine these factors one by one:

i. Physical – The ability to carry out daily tasks, achieve fitness, maintain
adequate nutrition and proper body fat, avoid abusing drugs and alcohol
or using tobacco products, and generally to practice positive lifestyle
habits.
ii. Social – The ability to interact successfully with people and within the
environment of which each person is a part, to develop and maintain
intimacy with significant others, and to develop respect and tolerance for
those with opinions and beliefs.

43
iii. Emotional – The ability to manage stress and to express emotions
appropriately. It encompasses the ability to recognize, accept, and express
feelings and to accept one’s limitations.

iv. for personal, family, and career development. It includes striving for
continued growth and learning to deal with new challenges effectively.
v. Spiritual – The belief in some force (nature, science, religion, or a higher
power) that serves to unite human beings and provide meaning and
purpose to life. It includes a person’s own morals, values, and ethics.
vi. Intellectual – The ability to learn and use information effectively
In conclusion, they noted that the five components overlap to some extent, and
factors in one component often directly affect another but nonetheless wellness
involves working on all aspects of the model.

2.3 Illness and Disease

The term illness and disease to the layman means the same thing and no wonder
they are used interchangeably in everyday language. However the two terms are
not synonymous even though they may or may not be related. Hence the need to
differentiate between the two terms. Any deviation from the accepted standard
of well-being is regarded as illness. To Kozier, Erb, Berman & Burke (2000)
illness is highly personal state in which the person’s physical, emotional,
intellectual, social, developmental, or spiritual functioning is thought to be
diminished. For instance an individual may have a disease, say hypertension and
not feel ill. By the same token a person can feel ill, that is feeling
uncomfortable, yet have no discernible disease. By extension, illness may or
may not be orchestrated by pathological abnormality. Therefore illness can be
described as a situation in which somebody fails to perform his/her normal roles
in the society.

44
Disease on the other hand is a biological parameter of non-health a pathological
abnormality that is indicated by a set of signs and symptoms. It could also be
defined as a state of discomfort that results when a person’s health becomes
impaired through disease, stress or an accident or injury. Implicit in the above
statement is that this state of discomfort or abnormality may be the aftermath of
one organism invading another with predictable negatively valued outcomes or
consequences on the host. It could also be a result of breakdown of anatomic
structures of an organism or a result of stress that the body cannot cope with. It
may even not be organic phenomenon interfering with body function but the
fabric of antisocial behaviour. For instance among the Yoruba ethnic group
of western Nigeria, distasteful behaviour are labeled as sickness as this has
something to do with the state of mind. In other words such behaviour tends to
exhibit the relationship between the mind and the body thus reflecting the state
of disharmony between the mind and the body. Perhaps it is good to mention at
this juncture that disease may not necessarily be symptom manifesting as many
forms of diseases are hidden and allow the carrier or victim to go about their
normal business.

2.4 Etiology of Illnesses and Diseases

In the dark ages before the advent of science, diseases were thought to be
consequences of running foul to the laws of the gods/deity i.e. a punishment
inflicted on man by demons or evil spirits secondary to offending the deity. This
explains why the first line of action when somebody falls sick then is to appease
the gods. This was later replaced by the single causation theory. Today we
however know that multiple factors are considered to be instrumental to causing
disease. Outlined below therefore are some of the etiological agents of the
various diseases confronting man:
i. Inherited genetic defects

45
 ii. Developmental defects/Congenital malformations. Example – Atria
Septal Defect
iii. Biological agents or toxins
iv. Physical agents such as temperature extremes, chemicals, or radiations
v. Generalized response of tissues to injury or irritation
vi. Physiological and psychological reactions to various stressors
vii. Biochemical imbalances within the body.
It should however be mentioned as noted by Stephen (1992) that though many
of these factors are interrelated, the causes of many diseases are still unknown.

2.5 Classification of Illnesses and Diseases

Illness may be classified as acute, chronic or terminal. Could also be classified

as Primary (1o) or Secondary (2 o). Let’s quickly see what these means.
An acute illness is one that comes on suddenly and last a relatively short time.
Example: Bacterial conjunctivitis, Gastroenteritis to mention a few. Acute
illnesses are usually severe but curable; some however lead to long-term
problems because of their sequelae. Sequelae are ill effects that result from
permanent or progressive organ damaged cause by a disease or its treatment. A
chronic illness on the other hand, is one that is gradual in onset and last a
relatively long time. Stephen (1992) paraphrasing the work of Zindler-Wernet
and Weiss on Health Locus of Control and Preventive Health Behaviour
submitted that chronic illnesses are illnesses that lead to at least some of the
following characteristics: (1) permanent impairment or deviation from normal,
(2) irreversible pathological changes, (3) a residual disability, (4) special
rehabilitation, and (5) long term medical and/or nursing management. Examples
include Arthritis, Chronic renal failure [CRF], Hypertension, and Diabetes
Mellitus. A terminal illness is one in which there is no known cure. The
terminal stage of an illness is one in which death has become inevitable.

46
A 1o illness is one that has developed independently of any other disease. Any
subsequent disorder that develops from a pre-existing condition is referred to as

2o illness Example - Hypertension leading to Congestive Cardiac Failure

(CCF). Furthermore, illness could be classified according to their etiological
factors as follows: Hereditary, Congenital and Idiopathic.
Hereditary – A hereditary condition is one that is transmittable down the
family tree i.e. from parent to their offspring through their genetic code. A
common example in our environment is sickle cell anaemia. Hereditary illnesses
may be manifested immediately after birth or develop at some time later.
Congenital – Congenital disorders are those that are present at birth and are
products of faulty embryonic development especially during the first three
month of intrauterine life otherwise referred to as period of organogenesis.
Example includes Tetralogy of Fallot.
Idiopathic – An idiopathic illness is one that for which there is no known cause.
Treatment is usually palliative (directed at relieving symptoms alone). A typical
example is cancer.

2.7 The Health – Illness Continuum

A continuum is defined as a continuous whole. Our health is in a dynamic state
of continuity and change constantly being challenged, stressed, abused and even
enhanced by our genetic make-up and lifestyle, and by our wider ecological
environment (Watkinson, 2002). Consequently, fluctuations of health and
illness can be illustrated on a health-illness continuum. See figure 2 – 2 below.

47
 Fig 4 – 2 Illness–Wellness Continuum

Wellness axis

Premature High-level
Death *Critical **Illness Normal *Good wellness
illness health health

Illness axis
Excellent health

Source: Adapted from Rosdal, 1995: Textbook of Basic Nursing & Kozier,
Erb, Berman and Burke 2000: Fundamentals of Nursing: Conceptions,
Process and Practice.

People do not tend to be totally healthy or totally ill at any given time.
Individual’s state of health however falls somewhere on a continuum from high-
level wellness to death. There is no exact point at which health ends and illness
begins. Both are relative in nature, and for each individual there is range and
latitude in which he may be considered ill or well (Fuerst, Wolff & Weitzel,
1974). When needs are blocked or threatened, one moves towards the “illness”
end of the continuum and vice versa. The body adapts to change in an attempt to
maintain homeostasis but high-level wellness is optimum. Nursing actions
involving health promotion and illness prevention assist the patient/client not
only in maintaining and increasing the existing level of health but also in
achieving an optimal health (Heath, 1995). However to assist the patient/client
in health maintenance and promotion, illness prevention, and adaptation to the

48
changes that illness produces in every dimension of functioning, the nurse must
understand all the aforementioned dimensions.
In-text Question 1 (A short question requiring a single sentence answer for quick reflection
over the read topic) List the two main classification of illness?

Answer Acute (primary) 2.chronic (secondary).

3.0 Tutor Marked Assignments (Individual or Group)

1. Discuss the classification of disease/illness?

4.0 Conclusion/Summary
It can thus be concluded that concept of health, illness and wellness has been
thoroughly discussed thereby establishing various and true meaning of health,
wellness and illness. To this end, this unit has employed a comprehensive and
integrated approach of health, wellness and illness. It particularly examined
illness behavior, models of health and wellness, as well as the health-illness
continuum. As nurses we now have a comprehensive and robust understanding
of health and illness as this will go a long way to affect scope and nature of
nursing practice.

This study session has shown that health is a dynamic state and its
conception/perception is highly varied. There however seems to be a consensus
that it involves the whole person – mind, body and spirit – functioning at
optimal level. And contrary to the traditional view of illness, it has been shown
to be a highly personal state in which a person feels unhealthy or ill. Though
usually associated with disease may occur independently of disease. To
provide effective nursing care and assist clients/patients in regaining and
maintaining high-level wellness, nurses must therefore understand
patients/clients conception of health as this influences their health belief and
health practices.

49
This unit examined the concept of health and illness. The unit employed a
comprehensive and integrated approach to health, wellness and illness. It also
examined the health-illness continuum. Nursing as a holistic and humanistic
discipline is therefore concerned with promotion, maintenance and recovery of
health. The subsequent chapter expatiates on how this is achieved.

5.0 Self-Assessment Questions

1. Is health static or changing? Explain with particular reference to the
health-illness continuum.

6.0 References/Further Readings

Anspaugh, D. J., Hamrick, M. H. & Rosata, F. D. (1991). Wellness:
Conceptions and Applications. St. Louis: Mosby-Year Book.
Carroll, C. & Miller, D. (1991). The Science of Human Adaptation.
Cox, C.L. (1995). Health and Illness. In H. B. M. Heath (Ed.). Potters and
Perry’s Foundations in Nursing Theory and Practice. Italy: Mosby, An
Imprint of Times Mirror International.
Delaune, S. C. & Ladner, P.K. (Eds.). (1998). the Individual, Health and
Holism. Fundamentals of Nursing, Standards and Practice. Albany:
Delmar Publishers.
Dubos, R. (1978). Health and Creative Adaptation. Human Nature, 74(1), Entire
Issue.
Fuerst, E.V.; Wolff, L.U. & Weitzel, M. H. (eds.) (1974). Fundamentals of

Nursing (5th Ed.). Toronto: J. B Lippincott Company.

Kozier, B.; Erb, G.; Berman, A.U. & Burke, K. (eds.) (2000). Health, Wellness

and Illness. Fundamental of Nursing: Concepts Process and Practice (6th

Ed.). New Jersey: Prentice Hall, Inc.
Leddy, S. & Pepper, J. M. (1998). Conceptual Bases of Professional Nursing

50
 (4th Ed.). Philadelphia: Lippincott.
Pike, S. & Forster, D. (eds.) (1995). Health Promotion for All. London:
Churchill Livingstone.
President’s Commission on Health Needs of the Nation (1953). Building
Americans’ Health. Vol. 2. Washington, DC: U.S Government Printing
Press.
Rosdahl, C. B. (Ed.). (2009). Optimum Health for All People; Textbook of Basic
Nursing. Philadelphia: J.B. Lippincott Company.
Stephen, P. P. (1992). Experience of Health and Illness. In S. M. Lewis and I.
C. Collier (Eds.). Medical-Surgical Nursing; Assessment and

Management of Clinical Problems (3rd Ed.). St Louis: Mosby- Year

Book, Inc.
Timby, B.K. (Ed.). (1996). Health and Illness. Fundamental Skills and

Conceptions in Patient Care (6th Ed.). Philadelphia: Lippincott.

Travis, J. W., & Ryan, R. S. (1988). Wellness Workbook (2nd Ed.) Berkeley,
CA: Ten Speed Press.
Watinson, G. (2002). Promoting Health. In R. Hogston & P. M. Simpson

(Eds.). Foundations of Nursing Practice; Making the Difference (2nd

Ed.). New York: Palgrave Macmillan.

51
 STUDY SESSION 3
Promoting Health
Section and Subsection Headings:
Introduction
1.0 Learning Outcomes
2.0 Main Content
2.1- Factors/Variables Affecting Health
2.2- Defining Health Promotion and Illness Prevention
2.3- Health Promotion Goals
2.4- Behaviours that Promote Health (Healthy Habits)
2.5- Nurses Role in Health Promotion and Illness Prevention
2.6- Primary Health Care -Introduction, Principles and Elements
3.0 Tutor Marked Assignments (Individual or Group assignments)
4.0 Study Session Summary and Conclusion
5.0 Self-Assessment Questions
6.0 Additional Activities (Videos, Animations & Out of Class activities)
7.0 References/Further Readings

Introduction:
The popular axiom – prevention is not only better than cure but also cheaper
than cure – cannot be more relevant than in today’s world. This is because the
recent past had witnessed more natural disasters than ever recorded. Emerging
infectious diseases had been on the rampage with the resurgence of those
hitherto eradicated communicable diseases, that have not only become more
virulent but resistant to the simple therapeutic agents. All these coupled with the
global economic recession and depreciation of currencies in many African states
had compounded the already precarious level of people in the African nation.

52
Therefore, health promotion becomes a veritable weapon to stem the all-time
high morbidity and mortality rate that has been trailing the African nation.
Interestingly health promotion is an important component of nursing practice.
Health Promotion as Kozier, Erb, Berman, & Burke (2000) puts it ‘as a way of
thinking that revolves around a philosophy of wholeness, wellness, and well-
being.’ Implicit in the above statement is that there is a level of commitment
that should be displayed by the individual, community, organization, and the
government if the goal of health promotion is ever to be achieved. The role of
each of this player and how the nurse can assist in health promotion therefore
forms the focus of this.

1.0 Study Session Learning Outcomes

After studying this session, I expect you to be able to:
1. Identify variables affecting health and explain the relationship between
such and health
2. Define health promotion and distinguish it from illness prevention
3. Enumerate health promotion goals and discuss the levels of preventive
care
4. Describe the behaviours that promote health
5. Discuss theoretical models of health and illness together with their
assumptions
6. Differentiate health preventive or protective care from health promotion
7. Discusses the nurses’ role in health promotion and illness prevention.

2.0 Main Content

2.1 What Affects Health?
Health status of individuals in any community depends to a large extent on their
level of awareness of factors that enhance and/or militate against their health.

53
White (1998) contends that a great many things affect health. She groped them
into four broad categories namely:
1. Genetic/Human Biology – It is not uncommon to hear that certain
diseases run in families or have familial tendency. This is because human
traits are transmissible from parents to offspring via the genes. Hence an
individual genetic make-up to a large extent affects his state of health.
2. Personal Lifestyle/Behaviour – This is the area that exerts the most
influence on health and well-being, and it is controlled entirely by the
individual. As such it is the individual’s decision whether these factors
will promote health or lead to ill health. Although an increasing number
of people are becoming aware of the relationship between health, lifestyle
and illness, and are already developing health-promoting habits, but a
sizeable proportion of the population are still naïve of this relationship.
Simply put health promoting habits encompasses such things as: Diet,
Exercise, Personal Care, Safe sex and Control sex, Tobacco and Drug
use, Alcohol Consumption, and safety.
3. Environmental Influences – The aggregate of people, things, conditions,
or influences surrounding man is what is referred to as the environment.
It could be physical, biological or social. Man and his environment are
constantly interacting. The environment influences man and man
influences his environment at all times i.e. the relationship is never static
but always changing. Interestingly, health and the quality of life are
greatly affected by this interaction.
4. Human beings enjoy optimum functioning when the air they breathe, the
food they eat, the houses they live in, indeed the neighbourhood in which
they stay is of good quality. If they are bad, they tend to promote disease,
disability and discontent. For instance in metropolitan cities where
domestic and industrial pollution is high, tarry particles, which contain

54
 cancer-producing chemicals, may exist. As such irritation to the eye and
respiratory tissue may be rampant. In addition, overcrowding secondary
to rural-urban migration and problems of population control enhances the
spread of communicable diseases such as droplet infections. Besides, bad
housing, lack of adequate facilities for the storage, preparation, and
cooking of food are also intricately related to the development of
malnutrition, poor growth and low immunity among people. Poor
sanitation as well as lack of provision of drinkable water will also
promote the spread of water borne disease with adverse consequences on
healthy living.
5. It is also worth mentioning that technological advancement and
industrialization with its attendant problems has placed new stresses on
man such as transport difficulties, noise, and loneliness. All these factors
are associated with greater incidence of hypertension, mental disorder and
suicide. Noise can produce alteration in respiration and circulation, in the
basal metabolic rate as the environment. It could be physical, biological
or social. Man and his environment are constantly interacting. The
environment influences
man and man influences
his environment at all
times i.e. the relationship
is never static but always
changing. Interestingly,
health and the quality of
life are greatly affected by this interaction.

Human beings enjoy optimum functioning when the air they breathe, the
food they eat, the houses they live in, indeed the neighbor-hood in which

55
 they stay is of good quality. If they are bad, they tend to promote
disease, disability and discontent. For instance in metropolitan cities
where domestic and industrial pollution is high, tarry particles, which
contain cancer-producing chemicals, may exist. As such irritation to the
eye and respiratory tissue may be rampant. In addition, overcrowding
secondary to rural-urban migration and problems of population control
enhances the spread of communicable diseases such as droplet
infections. Besides, bad housing, lack of adequate facilities for the
storage, preparation, and cooking of food are also intricately related to
the development of malnutrition, poor growth and low immunity among
people. Poor sanitation as well as lack of provision of drinkable water
will also promote the spread of water borne disease with adverse
consequences on healthy living.
It is also worth mentioning that technological advancement and
industrialization with its attendant problems has placed new stresses on
man such as transport difficulties, noise, and loneliness. All these factors
are associated with greater incidence of hypertension, mental disorder
and suicide. Noise can produce alteration in respiration and circulation,
in the basal metabolic rate, and in muscular tension. Even the fetus is
affected by certain factors in the mothers’ environment. For instance the
baby’s well-being to a large extent depends on her mother’s capability
and knowledge of standard of hygiene, good nutrition, and avoidance of
harmful substances e.g. some drugs.
6. Health Care – This encompasses such things as immunization, regular
examinations and screening tests, prophylactic medications, to mention a few
that man undertakes to prevent invasion of disease causing organisms and
prevent the body from breaking down. Failure to undergo such treatment
could spell doom for the body with serious adverse consequences on healthy
living.

56
In-text Question 1 (A short question requiring a single sentence answer for quick reflection
over the read topic) What affects health?

Answer Genetic, personal life style, Environment, Technological advancement.

2.2. Defining Health Promotion

The concepts of health promotion, self-care and community participation
emerged during 1970s, primarily out of concerns about the limitation of
professional health. Since then there have been rapid growth in these areas in
the developed world, and there is evidence of effectiveness of such
interventions states system although these areas are still in infancy in the
developing countries (Bhuyan, 2004). The Ottawa charter, an important
milestone in Health Promotion practice worldwide, defines Health Promotion as
the process of enabling people to increase control over, and to improve, their
health. To reach a state of complete physical, mental and social well-being, an
individual or group must be able to identify and to realize aspirations, to satisfy
needs, and to change or cope with the environment. Health is, therefore, seen as
a resource for everyday life, not the objective of living. Health is a positive
concept emphasizing social and personal resources, as well as physical
capacities. Therefore, health promotion is not just the responsibility of the
health sector, but goes beyond healthy lifestyles to well-being (WHO Ottawa
charter for health promotion, 1986). Consequently, the Ottawa charter noted that
five key strategies for Health Promotion action are building healthy public
policy, creating supportive environments, strengthening community action,
developing personal skills and reorienting health services). This no doubt,
settles any storm about the genesis of Health Promotion but has not addressed
what Health Promotion is all about and how it is different from illness
prevention.

57
Health promotion and illness prevention are closely related concepts, and in
practice, overlap to some extent. Activities for health promotion help the
patients/clients maintain or enhance their present levels of health while
activities for illness prevention protect patients/clients from actual or potential
threats to health. Both types of activities are future orientated. The difference
between them involves motivations and goals. Health promotion activities
motivate people to act positively to reach the goals of more stable levels of
health. Illness prevention activities motivate people to avoid declines in health
and functional states (Cox, 2010).

Health promotion activities can be passive or active. With passive strategies of

health promotion, individuals gain from the activities of others without doing
anything themselves. The fluoridation of municipal drinking water, the
fortification of salt with iodine and milk with vitamin D are common examples
of passive health promotion strategies. The active health promotion strategies on
the other hand, involves active participation of individuals i.e. individuals are
motivated to adopt specific health programs. For instance the weight reduction
and smoking cessation programs require the patient/client to be actively
involved in measures to improve their present and future levels of wellness
while decreasing the risk of disease. Some health promotion and illness
prevention programs are operated by health care agencies. Others are
independently operated. Whichever, the point to be made is that health

58
promotion and illness prevention activities are important to both the consumer
and the health care provider (Cox, 2010).

The avian influenza (bird flu) that recently broke out in certain parts of Nigeria
presents an excellent picture of the how there could be an interplay of actions
among the major actors in the health sector. The avian influenza epidemics,
being a deadly disease that can be transmitted to man, arouse the society
concern about the disease. Being a communicable disease and one that affect
poultry farming, it also arouses the interest of commercial organizations and
agriculture. Besides it also has a political element, with potential global
repercussions. The jobs and livelihood of some farmers and those within the
food industry particularly the fast food centers are at stake. There is of course,
the possibility of widespread trans-species infection. We can then appreciate the
concerted efforts of the individuals, the organization, the environment, the
society, and the government (political). One cannot but therefore agreed with
Kelly et al. (1993) that health cannot be effectively be promoted unless the
organizational, social, individual, and environmental aspects are combined in an
integrated approach.

2.3 Health Promotion Goals

Delaune & Ladner (1998) submitted the following as health promotion goals:
i. Respect and support clients right to make decisions.
ii. Identify and use clients’ strengths and assets.
iii. Empower clients to promote own health or healing.

Levels of Preventive Care

The three levels of prevention are:

59
 i. Primary Prevention – This is true prevention; it precedes disease or
dysfunction and is applied to patients/clients that are considered
physically and emotionally healthy (Cox, 2010). The goal is to decrease
person’s vulnerability to disease. It includes such activities as health
education, immunization/vaccination, personal and environmental
hygiene, good nutrition, good housing/avoidance of overcrowding,
quarantine of suspects, and chemoprophylaxis.
ii. Secondary Prevention – Focuses on individuals who are experiencing
health problems or illness or who are at risk of developing complications
or worsening conditions. Activities are directed at diagnosis and prompt
treatment, thereby reducing the severity and enabling the patient/client
to return to normal health at the earliest possible time (Edelman &
Mandle, 1990; Cox, 2010). Secondary prevention includes screening
techniques and treatment of early stages of disease to limit disability or
delay the consequences of advanced disease (Cox, 2010; Delaune &
Ladner, 1998).
iii. Tertiary Prevention – Instituted when a defect or disability is permanent
and irreversible. It involves minimizing the effect of a disease or
disability through such activities as rehabilitative nursing care for clients
with permanent defect like blindness, to avert further disability or
reduced function. The focus is to help clients reach and maintain their
optimum level of functioning (Delaune & Ladner, 1998).

2.4 Behaviors that Promote Health (Healthy Habits)

Have you heard such phrase like habit is stronger than information? When we
say something has become habitual, we mean it has become one’s second
nature; a regular way of behaving; a reflex action or instinctive response to a
stimulus. Good health habits help to prevent disorder and/or enhance total

60
wellness. On the contrary poor health habits will almost always adversely affect
health status and individual's capability and efficiency. What then can we
consider as healthy habits? The answer to this is obvious as practicing healthy
habits cut across practically all aspects of our life viz:
Exercise: It’s important for everyone to exercise, and we should all find the
preventive maintenance fitness program best suited for us. There is no
alternative, nor substitute that increases the potential for a happier, healthier and
improved quality of life. “If exercise could be packed into a pill, it would be the
single most widely prescribed, and beneficial medicine in the nation,” says
Robert N. Butler, MD, director of the National Institute on Aging (DiMartino,
1999). Exercise is necessary to maintain muscle tone, to stimulate circulation
and respiration, and to help control body weight. All people need some sort of
exercise daily. A person’s age, occupation and general condition help to
determine the appropriate amount and kind of exercise (Rosdahl, 2009). A
moderate amount of daily exercise is better than occasional sports of strenuous
activity. A study conducted by the Journal of Medical Association (JAMA,
277(16), April 23-30, 1997) included 11,470 women to determine the numerous
benefits that ensues when a sedentary level is increased to merely a normal level
– daily routine movement. The study revealed that the life preserving aspect of
this minor change is huge” (DiMartino, 1999).
Nutrition and Diet: A First Cousin to Exercise. One without the other is like
eating fries without catsup – it just doesn’t work as well. A regular exercise
regime means eating a balanced menu of foods, watching fat intake and
supplementing the diet with nutrients and vitamins. However, when people
exercise regularly, their diet must compensate for the extra calories burned.
Although, individuals’ nutritional needs vary, according to body build, age and
activity, everybody needs certain nutrients to keep the body functioning and in
good repair Eating regular and balanced diet and maintaining one’s weight

61
within the normal range are factors that contribute to wellness. Intake of salt,
sugar, fat and red meat should be limited while liberal intakes of fruits,
vegetables, and grains should be encouraged. Avoid alcohol consumption.
Elimination: The integumentary, respiratory, urinary and digestive systems are
the organs primarily concerned with elimination of wastes from the body.
Moderate intake of fibers in form of roughages (fruits and vegetables) supplies
the bulk that stimulates proper adequate elimination of solids as faecal matter.
Water intakes do assist the kidney in getting rid of liquid wastes. Avoidance of
cigarette smoking and polluted air helps in preserving your lungs and your
cardiovascular system (Rosdahl, 2009).
Sleep and Rest: Rest is soothing to the body. Most people need 7 – 8 hours
sleep per night. Sometimes after a day’s work, rest is needed rather than sleep.
Try lying relaxed and letting your thought drift. Some people find that
meditation or ‘emptying the mind of all thoughts’ is restful (Rosdahl, 2009).
Personal Hygiene: Maintenance of personal hygiene is necessary for comfort,
safety and well-being. Activities of personal hygiene are basic to normal
functioning. Hygiene refers to practices that promote health through personally
cleanliness and it is fostered through activities like bathing, tooth brushing,
cleaning and maintaining fingernails and toenails, and shampooing and
grooming hair. Such activities help to protect the body from infections, make a
good impression on others, and help to promote a positive self-image. For
instance, regular bathing or cleansing removes perspiration oil, and pathogens
from the skin. It also increases circulation and helps maintain muscle tone.
Besides, bathing is refreshing; it can help wake one up in the morning and to
induce sleep at night. Many a people shed their worries along with the day’s
accumulation of dirt by taking baths or showers. Grooming is equally important
to one’s well-being. Nails should be trimmed to comfortable length. Bitten nails
are unsightly and may lead to infection. Shoes should be well fitted and

62
comfortable. Clothes should be clean, well-fitting and comfortable too. They
should be appropriate for the type o f activity being performed. Dental care is
also essential. Teeth to be brushed regularly and regular dental check-up
encouraged. Fluorination of water to lessen tooth decay and consumption of
food rich in calcium, phosphorus, vitamins A, C, and D for healthy and normal
teeth formation and growth is expedient. The cutting down on consumption of
sugary foods that is often overlooked is vital to the prevention of dental caries.
While the eating of soft food is good, continuous eating of such foods affects
the gums and teeth because chewing itself is needed to maintain the tone and
holding power of the gums and the strength of the teeth. Eye care is another
important aspect of personal care that must not be neglected in order to achieve
full health. To this end, eyes examination should be done at least once a year.
Posture and Body Mechanics: Posture is the position of your body, the way its
part line up when you stand, sit, move or lie while body mechanics is the term
that refers to the use of the body as a tool. The way you stand, sit, or move
affects your efficiency and the impression you create. Good posture improves
your health saves your energy and prevents unnecessary muscle strains and back
disorder (Rosdahl, 2009).
Safer Sex: The late twentieth century recorded an astronomical increase in the
emergence and spread of deadly infectious diseases emanating primarily from
unhealthy sexual practices. This informs the gospel of safer sex and the doctrine
of ABC in the prevention of AIDS (Acquired Immune Deficiency Syndrome)
and other sexually transmitted diseases. Safer sex involves carefully choosing
one’s sexual partner, mutual fidelity and the use of condom where in doubt.
Healthy Environment: As earlier stated, man and his environment are
constantly interacting. The environment influences man and man influences his
environment at all times i.e. the relationship is never static but always changing.
Interestingly, health and the quality of life are greatly affected by this

63
interaction. It is suffice to say “it is difficult to have optimum health if the
environment is not safe.”
Note: As beginning health care providers, nursing students are encouraged to
develop their own health-promoting behavior to be better role models for
clients.

2.5 Nurses’ Role in Health Promotion, Health Protection, and Disease

Prevention
It is an open truth that investment in the health sector is rapidly becoming an
amalgam of public and private partnerships. While it is becoming increasingly
glaring that the responsibility for health promotion does not lie with health
sector alone, Watinson (2002) argued that nurses nonetheless have an unequal
contribution to make to alliances created in the pursuit of health. Speaking in
the same vein, Delaune & Ladner (1998) asserted that nurses play a key role in
promoting health and wellness. Therefore there is no doubt about the nurses role
in health promotion and disease prevention however the challenge before us as
nurses is to find ways to motivate clients and families to develop health-
promoting behaviors. This is against the background that health promotion is
not simply something that is done to
the client or patient, as in changing a
dressing, but something that pervades
the entire nursing care ranging from
needs assessment, planning health gain
to evaluating interventions and
strategies for effectiveness and
efficiency (Watkinson, 2002).
Delaune & Ladner (1998) identified health education/health counseling and
motivation as two key components of health promotion strategies employed by

64
nurses. Watkinson (2002) citing the English National Board’s Higher Award
(ENB, 1991) document observed the health promotion stands out as the 6th key
characteristic of that document. Inherent in the said document (highlighted
below), are salient features considered as essential to the performance of health
promotion activities by nurses.
i. Promote understanding of health promotion, preventative care, health
education and healthy living.
ii. Understand and apply the principles and practice of health promotion in
the work setting and create, maintain and take responsibility for a
healthy work environment.
iii. Facilitate responsibility and choice among clients for healthy living, and
their ability to determine their own lifestyles.
iv. Develop and implement strategies for health care based on
understanding of the impact of health trends on resources.
v. Consequently, Watkinson (2002) illustrated the many sided roles of the
nurse in health promotion with this schematic diagram (Fig 3 – 1).

65
 Fig 3.1 The Role of the Nurse in Health Promotion

Evaluati 1 Needs Identification

Students’ identification
of
their own needs
Skills
1 2
8 Practice Based
Outcomes and
Process Structural influences
measurement Empowerment
Monitoring Anti-discriminatio

G d
Implementatio
n
Health 3

Methods
7 of Research

Pl i H lhG i Skills of enquiry

and analysis of

qualitative and
quantitative data
4 Psychosocial issues
Social construction of
health Stress and health
Planni Assessm
5

Choosing the appropriate models and

approaches Educational principles

Source: Watinson (2002) Promoting Health. In R. Hogston & P. M. Simpson

(eds.) Foundations of Nursing Practice; Making the Difference (2nd Ed.)

In-text Question 1 (A short question requiring a single sentence answer for quick reflection
over the read topic) What are the behaviors that promote health habits?

Answer These are activities that help an individual to achieve and maintain a healthy status.
Examples are: elimination, personal hygiene, sleep and rest, posture and body mechanisms.

2.6. Primary Health Care

Primary health care may be defined as: Essential Health care based on practical,
scientifically sound, and socially acceptable methods and technology made

66
universally accessible to individuals and families in the community through
their full participation and at a cost that the country and community can afford.
Everyone has the right to a standard of living adequate for the health and
wellbeing of himself and his family. The preamble to the WHO Constitution
also affirms that it is one of the fundamental rights of every human being to
enjoy “The highest attainable standard of health”. Increasing importance has
been given to social justice and equity, recognition of the crucial role of
community participation, changing ideas about the nature of health and
development, the importance of political will called for new approaches to make
medicine more effective in the service of humanity.
Against the above background, the 30th World health Assembly resolved in
May 1977 at Alma Ata , that “the main social target of governments and WHO
in the coming decades should be the attainment by all citizens of the world by
the year 2000 of a level of health that will permit them to lead a socially and
economically productive life”
This culminated in the international objective of HEALTH FOR ALL by the
year 2000 as the social goal of all governments. Bhuyan, (2004).
In the joint WHO – UNICEF international conference in 1978 at Alma – Ata
(USSR), the governments of 134 countries and many voluntary agencies called
for a revolutionary approach to health care. Declaring that “The existing gross
inequality in the health status of people particularly between developed and
developing countries as well as within countries is politically, socially and
economically unacceptable”
Health for all means that health is to be brought within the reach of every one in
a given community. It implies the removal of obstacles to health – that is to say
the elimination of.
i. Malnutrition
ii. Ignorance

67
 iii. Disease
iv. Contaminated water supply
v. Unhygienic housing etc.
It depends on continued progress in medicine and public health. Alma Ata
Declaration called on all governments to formulate national policies, strategies
and plans of action to launch and sustain primary health care as part of a
national health system. It is left to each country to innovate, according to its
own circumstances to provide primary health care. Bhuyan, (2004).
This was followed by the formulation and adoption of the Global Strategy for
Health for all by the 34th World Health Assembly in 1981.
Primary Health care got off to a good start in many countries with the theme
“Health for All by 2000 AD” Primary Health Care is a new approach to health
care, which integrates at the community level all the factors required for
improving the health status of the population.

Concept of Primary Health Care: PHC is for all especially the needy.
Regardless of social and economic status every individual in the nation must
have access to good health care.
The services should be acceptable to the community and there must be active
involvement of the community. The health services must be effective,
preventive, promotive and curative. The services should form an integral part of
the country’s health system. The programme must be efficient, multi- sectorial
because health does not exist in isolation.

Levels of Health Care

There are 3 level of health care service:
1. Primary care level
2. Secondary care level

68
 3. Tertiary care level
Primary care level
First level of contact of individual, family and community with health system. It
is most effective and close to the people and includes: PHC, and Clinics.

Secondary care level

Higher level of care at which more complex problem are dealt with. It includes:
Health centers and Hospitals

Tertiary care level

Specialized health care is provided at tertiary care level. Specific facilities are
available. Specialized health workers are present. It involves
1. Teaching hospitals,
2. Regional hospitals
3. Central hospitals
4. Specializes hospitals

Principles of Primary Health Care

1. Equity
2. Community Participation
3. Intersectoral Coordination
4. Appropriate Technology. Bhuyan, (2004).

Equity/Equitable Distribution
The first key principle in primary health care strategy is equity or equitable
distribution of health services. Health services must be shared equally by all
people irrespective of their ability to pay and all (rich or poor, urban or rural)

69
must have access to health services. Currently health services are mainly in
towns and inaccessibility to majority of population in the developing world.

Community Participation
Overall responsibility is of the State. The involvement of individuals, families,
and communities in promotion of their own health and welfare is an essential
ingredient of primary health care. PHC coverage cannot be achieved without the
involvement of community in planning, implementation and maintenance of
health services.

Intersectoral Coordination
Declaration of Alma –Ata states that PHC involves in addition to the health
sector all related sectors and aspects of national and community development,
in particular education, agriculture, animal husbandry, food, industry, education,
housing, public works and communication. To achieve cooperation, planning at
country level is required to involve all sectors.

Appropriate Technology
Technology that is scientifically sound, adaptable to the local needs, and
acceptable to those who apply it and those for whom it is used and can be
maintained by the people themselves with the resources of the community and
country can afford.

Essential Component / Elements

1. Education concerning prevailing health problems and the methods of
identifying, preventing and controlling them,
2. Promotion of food supply and proper nutrition, an adequate supply of safe
water and basic sanitation

70
 3. Maternal and child health care including family planning
4. Immunization against major infectious diseases
5. Prevention and control of locally endemic diseases
6. Treatment of common diseases and injuries
7. Promotion of mental health
8. Provision of essential drugs

Extended Elements in 21st Century

1. Expanded options of immunizations
2. Reproductive Health Needs
3. Provision of essential technologies for health
4. Health Promotion
5. Prevention and control of non-communicable diseases
6. Food safety and provision of selected food supplements

3.0 Tutor Marked Assignments (Individual or Group)

1. Discuss in detail the role of a nurse in health promotion?

4.0 Conclusion/Summary
For health promotion is an important component of nursing practice and shall be
a veritable weapon to stem the all-time high morbidity and mortality rate that
has been trailing the African nation. This is because the recent past had
witnessed more natural disasters than ever recorded. Emerging infectious
diseases had been on the rampage with the resurgence of those hitherto
eradicated communicable diseases, that have not only become more virulent but
resistant to the simple therapeutic agents. All these coupled with the global
economic recession and depreciation of currencies in many African states had
compounded the already precarious level of people in the African nation. There
is a level of commitment to be displayed by the individual, community,

71
organization, and the government if the goal of health promotion is ever to be
achieved. The role of each of this player and how the nurse can assist in health
promotion is indispensable.
The issue of health promotion is an all-encompassing one. This unit has
demonstrated on one hand the limitations of modern medicine and health care
systems in single handedly improving the health status of the population. On the
other hand it emphasized the role of nurses as a key strategy for improving
health through a holistic approach consisting of not only a medical dimension
but also psychological, social and economic dimensions.
The Ottawa charter, an important milestone in Health Promotion practice
worldwide, defines Health Promotion as the process of enabling people to
increase control over, and to improve, their health. To reach a state of complete
physical, mental and social well-being, an individual or group must be able to
identify and to realize aspirations, to satisfy needs, and to change or cope with
the environment. Therefore health status of individuals in any community
depends to a large extent on their level of awareness of factors that enhance
and/or militate against their health. However, good health habits help to prevent
disorder and/or enhance total wellness. On the contrary poor health habits will
almost always adversely affect health status and individual’s capability and
efficiency. As such nurses play a key role in helping clients to adopt healthy
lifestyles and use approaches such as role modeling and formal teaching to
motivate client change.

5.0 Self-Assessment Questions

1. As a nurse in a remote village, you observed that majority of the
pregnant women becomes anemic during pregnancy with frequent
incidence of malaria in pregnancy, and besides, over 90% are already
genitally mutilated. You initially focus on diet and reduction in malaria

72
 attack. How would you begin to design the program? What resources
do you need?

6.0References/Further Readings
Bhuyan, K. K. (2004). Health Promotion through Self-Care and Community
Participation: Elements of a Proposed Programme in the Developing
Countries. BMC Public Health. 4: 11.
Cox, C.L. (2010). Health and Illness. In H. B. M. Heath (Ed.). Potters and
Perry’s Foundations in Nursing Theory and Practice. Italy: Mosby, An
Imprint of Times Mirror International.
Delaune, S. C. & Ladner, P.K. (Eds.). (1998). The Individual, Health and
Holism. Fundamentals of Nursing, Standards and Practice. Albany:
Delmar Publishers.
Edelman, C. L. & Mandle, C. L. (1990). Health Promotion throughout the Life

Span (2nd Ed.). St Louis: Mosby.

Kelly, M., Charlton, B and Hanlon, P. (1993). The FOUR LEVELS of Health
Promotion: An Integrated Approach. Public Health, 107(5): 320.
Kozier, B.; Erb, G.; Berman, A.U. & Burke, K. (eds.) (2000). Health, Wellness
and Illness. Fundamental of Nursing: Concepts Process and Practice

(6th Ed.). New Jersey: Prentice Hall, Inc.

Rosdahl, C. B. (Ed.). (2009). Optimum Health for All People; Textbook of Basic
Nursing. Philadelphia: J.B. Lippincott Company.
Watkinson, G. (2002). Promoting Health. In R. Hogston & P. M. Simpson (eds.)
Foundations of Nursing Practice; Making the Difference (2nd Ed.).
New York: Palgrave Macmillan.
World Health Organization (1986). Geneva: Ottawa Charter for Health
Promotion.

73
 STUDY SESSION 4
Assessing Health (1) Vital Signs
Section and Subsection Headings:
Introduction
1.0 Learning Outcomes
2.0 Main Content
2.1- What are Vital Signs?
2.2- Times to Assess Vital Signs
2.3- Factors Affecting Body Temperature
2.4- Alterations in Body Temperature
2.5- Assessing Body Temperature
3.0 Tutor Marked Assignments (Individual or Group assignments)
4.0 Study Session Summary and Conclusion
5.0 Self-Assessment Questions
6.0 Additional Activities (Videos, Animations & Out of Class activities)
7.0 References/Further Readings

Introduction:
Health assessment is vital to monitoring the progress made by clients/patients as
well as establishing whether identified needs have been met. Although health
assessment is such a broad area encompassing observation, physical
examination and interviewing/History taking and requiring the use of all senses,
the measurement of vital signs appears to be a regular and essential feature.
Hence this unit is dedicated to discussing vital signs with a view to enhancing
nurses’ technical skills in the art of assessing vital signs as well as deepening
their theoretical/knowledge base. This to our mind, will not only help nurses to
measure the vital signs correctly but will go a long way at assisting them to

74
understand and interpret the values, communicate findings appropriately and
begin interventions as needed.

1.0 Study Session Learning Outcomes

After studying this session, I expect you to be able to:
1. identify the measurements that comprise the vital signs
2. identify when to assess vital signs
3. define body temperature
4. describe the thermoregulatory mechanisms
5. identify the variations in normal body temperature that occur from
infancy to old age
6. discuss factors affecting body temperature
7. describe how to measure body temperature using various routes stating
the advantages and disadvantages associated with each route

2.0 Main Content

2.1 What are Vital Signs?
Donovan, Belsjoe, and Dillon (1968) gave this over-simplified illustration that
beautifully captures what vital signs are. In their words ‘ The healthy person
engaging in his daily activities is relatively unconscious of much chemical
process going on at all times in his body. A never-ending production of energy
in the form of heat is taking place. The fuel we supply to our body as food is
continuously being burned away when it meets the oxygen in the air we breathe.
This process is called oxidation. When conversion of food to energy is occurring
normally, our heart is pumping a steady average amount of blood; our lungs are
taking in a regulated, steady flow of air; and the heat of our body is constant at
an average temperature. These functions are all related and in delicate balance.
When this balance is disturbed by such things as heavy exercise, the rate of heat

75
 production, blood flow, and breathing will vary from normal. This variations in
temperature, pulse, respiration, and blood pressure (otherwise referred to as vital
signs) give nurses and doctors their most important clues to the state of the
body’s functioning.’ Vital signs or cardinal signs as they are sometimes called
could therefore be defined as signs reflecting the body’s physiological state,
which are governed by body’s vital organs (brain, heart, lungs) and necessary for
sustaining life. Consequently, Temperature, Pulse, Respiration, and Blood
pressure are referred to as vital signs because they are indicators of vital
functions of the body that are necessary to sustain life.

In-text Question 1 (A short question requiring a single sentence answer for quick reflection
over the read topic) What are vital signs?

Answer Vital signs can be defined as signs reflecting the body’s physiological state, which
are governed by body’s vital organs (brain, heart, lungs) and necessary for sustaining life.

2.2. Times to Assess Vital Signs

i. On admission to a healthcare agency to obtain baseline data.
ii. When the patient’s/client’s general physical condition changes (as with
loss of consciousness or increased intensity of pain)
iii. Before and after surgery or an invasive diagnostic procedure.

76
iv. Before and/or after administration of certain medication that affect the
cardiovascular, respiratory, and temperature control function.
v. Before and after nursing interventions influencing a vital sign (such as
when a patient/client previously on bed rest ambulates or when a patient
requires tracheal suctioning)
vi. When the patient reports non-specific symptoms of physical distress
(such as feeling ‘funny’ or ‘different’)
a. (Webster, 1995; Kozier, et. al., 2000)

2.3 Body Temperature

The term temperature is defined as the state of heat or coldness within a

substance, which can be measured against a standard scale (0C or 0F) i.e. the
degree of hotness or coldness of an object measured against a standard scale.
Man and other mammals unlike fishes, reptiles, and other poikilothermic
animals are homoeothermic, that is warm blooded and maintain their body
temperature independently of the environment. Our body continually produces
heat as a by-product of metabolism. This heat is transported by blood round the
body. Heat is however also continually lost from the body. In essence, body
temperature as indicated
on a clinical
thermometer, is the
balance between the heat
produced and the heat
lost from the body
measured in heat units
called degree i.e. the
measure of heat inside the body.

77
Basically there are two kinds of body temperature viz: Core temperature and
Surface temperature. The core temperature is the temperature of the deep
tissues such as the cranium, thorax, abdominal cavity, and pelvic region. It
remains relatively constant. The surface temperature is the temperature of the
skin, the subcutaneous tissue, and fat. It by contrast, rises and falls in response
to the environment. The normal core body temperature is a range of

temperatures fluctuating between 36.1 and 37.20C (Kozier, et.al, 2000). The big
question however is – how is the core temperature kept within this relatively
narrow range? This forms the focus of the subsequent paragraphs.

Thermoregulation
Thermoregulation is the body’s physiological function of heat regulation to
maintain a relatively constant internal body temperature. This is achieved by a
complex interplay of physical and chemical/hormonal mechanism and
sympathetic stimulation that is coordinated by the heat- regulating center in the
brain called the hypothalamus. The hypothalamus controls the body temperature
in the same way that a thermostat works in the home. The hypothalamus does
this through its anterior and posterior part. The anterior hypothalamus is
concerned with heat dissipation while the posterior hypothalamus controls heat
conservation.
The hypothalamus senses minor changes in body temperature. When the body
temperature deviates from the set point, the temperature center of the
hypothalamus (hypothalamic integrator located in the preoptic area of the
hypothalamus) either activates heat loss (cooling) or heat production to ensure
that the core temperature remains within the safe physiological range (Cox,
1995).

78
Heat Production
Heat is produced in the body through the chemical oxidation of food substances
(metabolism of food substances) that results in the release of energy, and this is
a continuous process. The body converts energy supplied by metabolized
nutrients to energy forms that can be used directly by the body. One form of this
energy is thermal energy. Really, energy is measured in terms of heat. A
kilocalorie is an energy value (heat measure) of a given food; 1 kilocalorie
equals 1000 calories (the amount of heat required to raise temperature of 1

kilogram of water by 10 C. This type of heat liberation is usually expressed as

the metabolic rate and measured as basal metabolic rate or BMR (the rate of
energy use in the body needed to maintain essential activities). It should be
mentioned that heat production increases when a person is active and most heat
production comes from the deep tissue organs (brain, liver, and heart) and the
skeletal muscles (Estes, 1998).

Heat production in the body is however increased by epinephrine, nor

epinephrine, thyroxine and triiodothyronine. These hormones increase the rate
of cellular metabolism in many body tissues. Epinephrine and nor epinephrine
apart from its vasoconstrictive effect, directly affect liver and muscle cells,
thereby increasing cellular metabolism. Vasoconstriction in human’s internal
organs produces heat and blood flow from the internal organs carries heat to the
body surface. The thyroid hormones thyroxine and triiodothyronine increase
basal metabolism by breaking down glucose and fat. This effect is called
chemical thermogenesis (Kozier, et. al., 2000; Estes, 1998).

Muscular activity also produces heat from breakdown of carbohydrates and fats
and through shivering. The skin is well supplied with heat and cold receptors
but because cold receptors are more plentiful, the skin functions primarily to

79
detect cold surface temperature. When the skin becomes chilled, its sensors send
information to the hypothalamus, which initiates shivering (involuntary skeletal
muscles contractions in response to cold) and vasoconstriction. This leads to
increased muscular tone, which enhances further metabolism. Physical exercise,
often found comforting in cold weather also increases heat production by
increasing muscle tone and stimulating metabolism. In a nutshell, when the
body suffers a significant heat loss the hypothalamus transmit impulses to
stimulate heat production through vasoconstriction (narrowing of blood
vessels), muscle shivering, piloerection (hair standing on end) and inhibiting
sweating. However, apart from these major means of heat production, the body
also gains heat from its environment but this is negligible and of less
significance to the heat produced in the muscles (Webster, 1995; Estes, 1998;
Kozier, et. al., 2000).

Heat Loss
When the body heat rises, nerves in the hypothalamus (the sensors) become
heated and impulses/signals are then sent out to decrease heat production and
increase heat loss. This it does by triggering perspiration (diaphoresis) from
millions of sweat glands that lie deep below the dermal layer of the skin,
vasodilation (the widening of blood vessels), and inhibition of heat production.
The body cools itself. Heat is dissipated from the body primarily through
physical processes. As much as 95% is lost through radiation, convention, and
evaporation of water from the lungs and skin. Most of the remaining amount is
lost through urination and defecation and in raising the temperature of inhaled
air to body temperature. A negligible amount is lost through conduction except
when the body is in contact with cold surfaces for prolonged period of time.

80
Heat Loss Mechanisms
The various physical processes through which heat is lost from the body are:
Radiation: is the transfer of heat from the surface of one object to the surface of
another without contact between the two objects, mostly in the form of infrared
rays (Guyton, 1996). Heat radiates from the skin to cooler nearby objects and
radiates to the skin from warmer objects. The amount of heat lost by radiation
from the skin varies with the degree of dilation of surface blood vessels when
the body is overheated, and with the extent of vasoconstriction when the body is
chilled. Radiant heat loss can be enhanced by removing clothing or by wearing
light clothing meaning that heat loss through radiation can be curtailed by
covering the body with cloth especially dark, closely woven clothes. Another
thing that affects heat loss through radiation is positioning; a man in erect
position with arm and legs extended radiates more heat than one in dorsal
position (Webster, 1995).

Conduction: This is the transfer of heat from one object to another object of
lower temperature that is in contact with it. Notice that conductive transfer
cannot take place without contact between the molecules of both objects. The
amount of heat transferred depends on the temperature difference and the
amount and duration of the contact (Kozier, et. al., 2000). As earlier stated,
conduction accounts for minimal heat loss from the body except, when a body is
immersed in cold water. Interestingly, water conducts heat more efficiently than
air. Therefore water used for bathing the patient should be above body
temperature to prevent conductive heat loss. However, if the patient’s
temperature is abnormally high, the nurse can lower it by tepid sponging
thereby taking advantage of conductive heat loss (Webster, 1995).

81
Convention: Convention is the dispersion of heat by air currents. The body
usually has a small amount of warm air adjacent to it. This warm air rises and is
replaced by cooler air, and so people always lose a small amount of heat
through convention but can be artificially enhanced through the use of fan to
promote heat loss from febrile patient. It is important to note that the speed of
movement of air surrounding the skin increases, the convention of heat loss
from the skin increases (Webster, 1995; Kozier, et. al., 2000).

Evaporation: This simply means the vaporization of fluid i.e. changing from
liquid state to gaseous state. The physicist makes us to understand that heat
energy is needed to effect this change. Mountcastle (1980) reported that for each
gram of water that evaporates from the body surface, approximately
0.6kilocalorie of heat is lost. In view of the continuous evaporation of water
from the respiratory tract, the skin and the mucosa of the oral cavity tagged
insensible water loss, there is also accompanying insensible heat loss which
medical experts claim to accounts for about 10% of basal heat loss.

Behavioral Control of Body Temperature

In addition to heat production and heat loss mechanisms described above, the
body has potent mechanism for temperature control known as the behavioral
control. This encompasses voluntary acts that people take to maintain
comfortable temperatures in response to body signaling conditions of either
being overheated or too cold (Estes, 1998). They include such measures as
changing environment, adding more clothing or changing from light to thick
clothing, raising the temperature settings on heating thermostats, putting on air
conditioner, turning on fans, taking a cold shower, to mention a few.

82
2.4. Factors Influencing Body Temperature
Temperature monitoring, no doubt stands out as one of the commonest function
of the nurse and in view of the importance temperature variation in health
assessment, it has become expedient for nurses to become aware of factors that
influence body temperature. Among these factors are:
Age – At birth, the newborn leaves a warm, relatively constant environment and
enters one in which temperature fluctuates widely. Temperature control
mechanisms are not fully developed; thus an infant’s temperature may
change drastically with changes in the environment. Therefore, the
newborn must be protected from temperature extremes and clothing must be
adequate. Temperature regulation continues to be labile until children reach
puberty. Many older people, particularly those over 75 years, are at risk of

hypothermia (temperature below 360C for a variety of reasons, such as

inadequate diet, loss of subcutaneous fat, lack of activity, and
reduced thermoregulatory efficiency (Webster, 1995; Kozier, et. al. 2000).

Exercise – Muscular activity requires an increased blood supply and an increase

in carbohydrate and fat breakdown for more energy. This increased metabolism
causes increase in heat production and consequently the body temperature. As
such hard work or strenuous exercise can increase body temperature to as high

as 38.3 – 400C (Webster, 1995; Kozier, et. al. 2000).

Circadian Rhythms (Diurnal Variations) – Body temperature normally

changes throughout the day, varying as much as 10C between morning and late
afternoon. It is usually lowest during sleep between 1am and 4am and rises
steadily until about 6pm and then declines to early morning levels (Webster,
1995; Kozier, et. al. 2000).

83
Hormone Level – Women usually experience greater temperature fluctuations
than men. This has been attributed to greater hormonal fluctuations women
experiences. For instance during menstrual cycle, progesterone levels rise and
fall cyclically. Before start of menstrual cycle, progesterone levels are low, and
the body temperature falls a few tenths of a degree below the baseline. This
lower temperature persists until ovulation. During ovulation, greater amounts of
enter the circulatory system and raise the body temperature to previous baseline
levels or higher. Body temperature fluctuations also occur in menopausal
women due to instability of the vasomotor controls for vasodilation and
vasoconstriction. In fact one the cardinal symptoms of the post-menopausal
syndrome are the experience of periods of intense heat and sweating lasting
from 30 seconds to 5 minutes. The amount of thyroxine, triiodothyronine,
epinephrine/adrenaline, and
norepinephrine/noradrenali
ne circulating in the body
also affect heat production
and basal metabolic rate
(Webster, 1995).

Stress – Physical and emotional stress increase body temperature through

hormonal and neural stimulation which sets into motion chains of physiological
reactions. These physiological changes like the release of adrenaline with
associated increase in heart rate causes increased metabolism, which in turn
increases heat production. Nurses may therefore anticipate that individuals who
are anxious about entering the hospital or undergoing a surgical procedure could
register a higher than normal temperature (Webster, 1995).

84
Environment – Extremes in environmental temperatures can affect a person’s
temperature regulatory systems. If the temperature is assessed in a very warm
room and the body temperature cannot be modified by convention, conduction,
or radiation, the temperature will be elevated. Similarly if the client has been
outside in extremely cold weather without suitable clothing, the body
temperature may be low (Kozier, et. al. 2000).

2.5. Alterations in Body Temperature

Altered body temperature occurs when the body temperature rises above the
upper normal limit or fall below the lower normal limit (subnormal or lowered
body temperature). An extremely high or extremely low temperature can be

very fatal. Survival is rare if the core temperature is above 42.20C or below

340C (Roark, 1995).

Elevated Body Temperature – Body temperature rises when heat production

increases or when heat loss decreases or both occurring simultaneously. A body
temperature above the normal range is called pyrexia, what is referred to as
fever in lay language, and the client who has a fever is said to be pyretic on
febrile while the one who has not is being referred to as a febrile. Table 6-1
present the different shades of pyrexia.

Table 5 – 1 Levels of Pyrexia

37.3 – Low Pyrexia

38.30C -
Moderate Pyrexia
38.4 – - High Pyrexia
39.40C - Hyperpyrexia
39 5
Source: Adapted from Ross and Wilson Foundations of Nursing and First Aid
(6th Ed.).

85
Pyrexia/fever is a symptom of some disorder. It often accompanies illness or it
may a sign that the body is fighting an infection. In some cases a slightly above
normal temperature may be useful to fight microorganisms. For this reason, it
isn’t always desirable to treat fever immediately (Roark, 1995).
A true fever results from an alteration in the hypothalamic set point. Bacteria,
viruses, fungi and certain antigens are pyrogens (substances that causes a rise in
body temperature). Fever may also result from administration of a drug. A drug
fever can be hypersensitivity reaction accompanied by allergy symptoms such
as rash, itching (Hanson, 1991; Webster, 1995). For ease of assimilation, Fig 6 –
1 presents a simplified flow chart illustrating the pathophysiologic changes that
leads to development of fever.

Fig 5 – 1 Mechanism of Fever

Pyrogens such as bacteria, viruses, fungi & drug enter the body

Bacterial growth slowed by

trace metal levels. Antibody White blood cell
p r o d u c t i o n formation increases

Raises set point of

hypothalamus

Heat production and conservation to attain new set point

Vasoconstriction
Shivering
Adding clothing
Seeking a warmer place

Source: Adapted from Webster, C. 1995. In H. B. M. Heath ( Ed.) Potters

and Perry’s Foundations in Nursing Theory and Practice

86
After the cause of fever is removed (for example, destruction of bacteria by
antibiotic medication) the hypothalamic set point drops and the body initiates
the heat loss mechanisms earlier on described. A sudden drop from fever to
normal is however called crisis while a gradual return of an elevated
temperature to normal is referred to as lysis
Types of Fever
Four types of fever are identifiable. They are: Intermittent fever, Remittent
fever, Constant fever, and Relapsing fever. A temperature that alternates
between fever and normal or subnormal is called intermittent fever. In remittent
fever, there are wide fluctuations in body temperature over the 24hr period, all
of which are above normal or at best near normal.
When the body temperature fluctuates minimally while still being elevated, the
condition is termed constant fever. Relapsing fever on the other hand, is
characterized short febrile periods of a few days interspersed with periods of, 1
or 2 days of normal body temperature.

Clinical Signs of Fever

Irrespective of the initiating cause or the type of fever, the clinical features are
similar. Fig 6 – 2 therefore presents an outline of the varied manifestation of
fever.

87
 Table 5 – 2 Clinical Signs of Fever

Onset (cold or child Glassy-eyed appearance

stage)
Increased heart rate Increased pulse and
respiratory rates
Increased respiratory Increased thirst
rate and depth

Shivering Mild to severe dehydration

Pallid, cold skin Drowsiness,
restlessness, delirium,
Complaints of Herpetic lesions of the fever
feeling cold is prolonged
Cyanotic nail beds Loss of appetite (if the fever
is prolonged)
“Gooseflesh” Malaise, weakness,
appearance of the skin and aching muscles
Cessation of sweating
Course Effervescence(fever
Absence of chills Skin that appears flushed and
feels warm

Skin that feels warm Sweating

Photosensitivity Decreased shivering
Possible dehydration

Source: Adapted from Kozier, et. al. 2000. Assessing Health. In

Fundamental of Nursing: Concepts Process and Practice

Nursing Management of Clients with Fever

Nursing interventions for clients with fever could be summarized as follows:
i. Monitor vital signs
ii. Assess skin color and temperature

88
 iii. Monitor white blood cell count, hematocrit value, and other pertinent
laboratory reports for indications of infection or dehydration.
iv. Remove excess blankets when the client feels warm, but provide extra
warmth when the client feels chilled.
v. Provide adequate nutrition and fluids (e.g. 2500 – 3000ml per day) to
meet the increased metabolic demands and prevent dehydration. Clients
who sweat profusely can become dehydrated.
vi. Measure intake and output.
vii. Reduce physical activity to limit heat production, especially during the
flush stage.
viii. Administer antipyretics (drugs that reduce the level of fever) as ordered.
ix. Provide oral hygiene to keep the mucous membranes moist. They can
become dry and cracked as a result of excessive fluid loss.
x. Provide a tepid sponge bath to increase heat loss through conduction.
xi. Provide dry clothing and bed linens.

Lowered Body Temperature – A temperature significantly below normal is

called Hypothermia. Roark (1995) submitted that such temperature often
precedes normal death and may occur as a result of overexposure to extremely
cold environment or cold water, as in drowning. Kozier, et. al. in their write-up
(2000) attributed its development to three physiologic mechanisms: (a)
excessive heat loss,
inadequate heat production to counteract heat loss; and (c) impaired
hypothalamic thermoregulation. Patients most at risk include neonates &
infants; geriatric patients; traumatized patients; patients with stroke, diabetes,
and drug or alcohol intoxication Webster, 1995).
Hypothermia may however be accidental or induced. Accidental hypothermia is
life threatening and must be treated immediately. Induced hypothermia is

89
deliberate lowering of body temperature to decrease the need for oxygen by the
body tissues. It could involve the whole body or body part. It is sometimes
indicated prior to some surgical procedures e.g. cardiac and brain surgery
Kozier, et. al., 2000)

Clinical Signs of Hypothermia

i. Decreased body temperature, pulse, and respirations
ii. Uncontrolled severe shivering (initially)
iii. Feelings of clod and chills
iv. Pale, cool, waxy skin
v. Hypotension
vi. Cardiac dysrhythmias
vii. Decreased urinary output
viii. Lack of muscle coordination
ix. Disorientation
x. Drowsiness progressing to coma

Nursing Management of Hypothermia

The priority treatment is conscious prevention of further decrease in body
temperature. This could be achieved through a combination of measures stated
below:
i. Provision of warm environment (room temperature)
ii. Provision of dry clothing
iii. Application of warm blankets
iv. Keeping of limbs close to body
v. Covering the client scalp with a cap or turban.
vi. Supplying warm oral intravenous fluids.
vii. Application of warming pads.

90
2.6. Assessing Body Temperature
Sites for Assessment of body Temperature
The four most common sites are oral, rectal, Axillary, and the tympanic
membrane. Each has its own merit and demerits, which are summarized in
Table 6 – 2.

Table 5 – 3Advantages and Disadvantages of the four Sites for Body

Temperature Measurement

Site Advantages/Merits Disadvantages/Demerits/Flaws

Oral Most accessible and Mercury-in-glass thermometers can break if
convenient bitten; therefore they are contraindicated for
children under 6years and clients who are
confused or who have convulsive disorders
or patients who breathe only with mouth
open. Inaccurate if client has just ingested
hot or cold food or fluid or smoked. Could
injure the mouth following oral surgery.

91
Rectal Most reliable Inconvenient and more unpleasant for clients;
measurement difficult for client who cannot turn to the side.
Should not be used in patients who have a
rectal disorder like tumor or severe
hemorrhoids. Could injure the rectum
following rectal surgery. Placement of the
thermometer at different sites within the
rectum yields different temperatures, yet
placement at the same site each time is
difficult. A rectal glass thermometer does
respond to changes in arterial temperatures as
quickly as an oral thermometer, a fact that
may be potentially dangerous for febrile
clients because misleading information may
be acquired. Presence of stool may interfere
with thermometer placement. If the stool is
soft, the thermometer may be embedded in
stool rather than against the wall of the
rectum. If the stool is impacted, the depth of
the thermometer insertion may be insufficient.
In newborns and infants, insertion of the
rectal thermometer has resulted in ulceration
and rectal perforations. Many agencies advise
against using rectal thermometers on
neonates.

92
 Axillary Safest and most Requires the nurse to hold the thermometer
non- invasive in place for a long time; is less accurate.

Tympanic Readily accessible;Can be uncomfortable and involves risk of

Membrane reflects the coreinjuring the membrane if the probe is
temperature. Veryinserted too far. Repeated measurement
fast. may vary. Right and left measurements can
differ. Presence of cerumen can affect the
reading.

Guidelines for Taking body Temperature Preparation

i. Patient: Explain procedure to gain consent and co-operation. Assess
patient regarding site suitable for temperature recording (see Points for
Practice (PPP) overleaf). Patient should not have had a hot drink, smoked
a cigarette or exercised within the previous ten minutes.
ii. Equipment/Environment: Clinical mercury thermometer; Disposable
cover for the thermometer or alcohol swab for cleaning it; & Observation
chart.
iii. Nurse: Hands must be clean.
Procedure
Use of Mercury Thermometer
1. Collect the thermometer – Each patient may have an individual
thermometer kept at the bedside or there may be several for general use
kept centrally.
2. Inspect the thermometer to ensure that it is clean and reading below

350C. Shake down the mercury if necessary (see PPP).

3. If appropriate, apply the disposable cover according to the manufacturer’s
instructions and remove the backing paper.

93
Oral
1. Ask the patient to open his/her mouth and gently insert the thermometer
under their tongue next to the frenulum. This is adjacent to the sublingual
artery, so the temperature will be close to core temperature.
2. Ask the patient to close their lips, but not their teeth, around the
thermometer to prevent cool air circulating in the mouth.
3. Leave in position for 2-3 minutes (see PPP).
4. Remove the thermometer taking care to touch only the part that has not
been in contact with the patient’s mouth. If applicable, remove the
disposable cover according to the manufacturer’s instructions and dispose
of appropriately
5. Holding the thermometer horizontally at eye level, note the level of the
mercury.
Axilla
1. Do not use a disposable cover as this is not necessary and interferes with
skin contact.
2. Ask/assist the patient to expose his/her axilla, for an accurate recording,
the axilla must be dry.
3. Insert the thermometer into the axilla and ask/assist the patient to keep
their arm close against the chest wall to ensure good contact with the
skin.
4. Leave in position for five minutes.
5. Holding the thermometer horizontally at eye level, note the level of the
mercury

94
 Points for Practice
The rectal site is no longer recommended unless an electronic probe is being used. Shake
down the thermometer by holding firmly in your dominant hand. Stand back from any
furniture (e.g. bed table) to avoid striking with the thermometer. With a flicking action,
shake the thermometer until the mercury is down below 350C. This may take several
shakes to achieve. Unlike a room thermometer the mercury in the thermometer does not
go down as the temperature falls (i.e. when in storage) as there is a kink in the column,
which confers on it a self- registering property. The thermometer must remain in the
mouth for at least two minutes to obtain an accurate recording, but should not be left for
longer than three minutes as this is uncomfortable for the patient. Electronic oral and
tympanic thermometer and disposable thermometer are increasingly being used.

Post-Procedure
Patient: Ensure patient comfort. Answer any questions regarding the recording.
Equipment/Environment: Shake down the mercury. If a disposable cover has
been used no cleaning is necessary, if no cover has been used, the thermometer
should be cleaned with an alcohol swab and stored dry according to local
policy.
Nurse: Chart temperature recording. Report any abnormality

Use of Electronic Thermometers

Oral
Electronic oral thermometers are increasingly being used in hospitals. They are
efficient and easy to use, with an audible signal indicating when the maximum
temperature has been reached. The probe, covered by a disposable plastic cover,
is placed under the tongue in the same way as a mercury thermometer. Each
cover is for use by one patient only and is usually kept clean and dry on the
patient locker between use. It is discarded when the patient is discharged from
the ward.

95
Tympanic
Some electronic thermometers are designed to measure the temperature by
inserting probe into the outer ear, adjacent to (but not touching) the tympanic
membrane. Again a special cover is used for each patient to prevent cross-
infection. An infrared light detects heat radiated from the tympanic membrane
and provides a digital reading. This provides a more accurate measure of body
core temperature as it is close to the carotid artery. The patient may need more
explanation than usual because although most people will have had their
temperature recorded at some point, they may be surprised to find you
approaching their ear.

Conversion of Temperature Scales (Centigrade & Fahrenheit)

Depending on your country of practice you will be expected to be familiar with
either of these measuring scales. However, since nursing is an international
occupation, it is better to be conversant with the use of both scales. You can
easily convert centigrade to Fahrenheit by multiplying the centigrade

temperature by the fraction 9/5 and adding 32. But to convert Fahrenheit to
centigrade, first subtract 32 from the Fahrenheit temperature, and then multiply

by 5/9.
In-text Question 1 (A short question requiring a single sentence answer for quick reflection
over the read topic) List out the factors that can influence body temperature

Answer Age, exercise, circadian rhythms, hormone level, stress, and environment.

3.0 Tutor Marked Assignments (Individual or Group)

1. Describe the thermoregulatory mechanisms?

4.0 Conclusion/Summary
Conclusively, this unit has discussed vital signs with a view to enhancing
nurses’ technical skills in the art of assessing vital signs as well as deepening

96
their theoretical/knowledge base. This to our mind, will not only help nurses to
measure the vital signs correctly but will go a long way at assisting them to
understand and interpret the values, communicate findings appropriately and
begin interventions as needed
The importance of vital signs in health monitoring and evaluation of client’s
health status cannot be over-emphasized. Knowledge of factors affecting heat
production and heat loss helps the nurse to implement appropriate interventions
when the client has an altered body temperature.
Vital signs are signs reflecting the body’s physiological status. They comprise
temperature, pulse respiration, and blood pressure. Baseline values establish the
norm and variation from normal may indicate possible problems with client’s
health status. Human beings maintain a relatively constant temperature
independent of their environment. This the body achieve through
thermoregulation. The four sites commonly used for assessing body temperature
are oral, rectal, axillary, and tympanic membrane, each with its advantages and
disadvantages. The nurse selects the most appropriate site according to the
client’s age and condition. Factors affecting body temperature include age, sex,
diurnal variation, exercise, hormones, stress and environmental temperatures.
Apart from these normal deviations in health, altered temperature (fever or
hypothermia) may develop and it is the nurses’ responsibility to institute
appropriate therapy

5.0 Self-Assessment Questions

1. Explain the thermoregulatory mechanism and discuss the various
factors influencing body temperature.
2. Sade, a 6-year old girl was brought to your hospital following an
episode of high fever. Discuss your management of Sade during the
pyrexic phase.

97
6.0 References/Further Readings
Donovan, J.E.; Belsjoe, E.H. and Dillon, D.C. (1968). The Nurse Aide. New
York: McGraw-Hill Book Company.
Estes, M. E. Z. (1998). Vital Signs and Physical Examination. In S. C. Delaune
& P.K. Ladner (Eds.). Fundamentals of Nursing, Standards and Practice.
Albany: Delmar Publishers.

Guyton, A. C. (1996). Textbook of Medical Physiology (9th Ed.).

Philadelphia: Saunders.
Hanson, M. (1991). Drug Fever: Remember to consider it in Diagnosis. Kozier,
B.; Erb, G.; Berman, A.U. & Burke, K. (Eds.). (2000). Assessing Health

Fundamental of Nursing: Concepts Process and Practice (6th Ed.). New

Jersey: Prentice Hall, Inc.
Mount castle, V. B. (1980). Medical Physiology (14th ed. Vol 2). St Louis:
Mosby.
Postgraduate Medicine, 89(5):167.
Nursing Standard (2001). Essential Skills: Observation and Monitoring,
Recording Temperature.
Roark, M. L. (1995). Vital Signs. In C. B. Rosdahl (Ed.). Textbook of Basic
Nursing. Philadelphia: J.B. Lippincott Company.
Smith, J.P. (1982). Nursing Observations. In E. Pearce (Ed.). A General

Textbook of Nursing (20th Ed.). Norwich: The English Language Book

Society and Faber and Faber.
Usman, D. S.; Obajemihin, J. O.; Adegbite, M. F.; Bray, M. F., Wilson,
K. J. W., & Ross, J. S. (2000). Ross and Wilson Foundations of Nursing and
First Aid (6th Ed.). Singapore: Longman.
Webster, C. (1995). Health and Physical Assessment. In H. B. M. Heath (Ed.).
Potters and Perry’s Foundations in Nursing Theory and Practice. Italy:

98
 Mosby, An Imprint of Times Mirror International
MODULE 2
Health Assessment
Contents:
Study Session 1: Assessing Health II (Vital Signs)
Study Session 2: Assessing Health III (History Taking and Physical
examination)
Study Session 3: Diagnostic Measures in Patients Care
Study Session 4: Providing Safety and Comfort Measures I

STUDY SESSION 1
Assessing Health II (Vital Signs)
Section and Subsection Headings:
Introduction
1.0 Learning Outcomes
2.0 Main Content
2.1- Respiration
2.2- Mechanics and Regulation of Breathing
2.3- Altered Breathing Patterns and Sounds
2.4- Assessing Respiration
2.5- Heamodynamic Regulation
2.6- Assessing Pulse
2.7- Blood Pressure and its Determinants
2.8- Assessing Blood Pressure
3.0 Tutor Marked Assignments (Individual or Group assignments)
4.0 Study Session Summary and Conclusion
5.0 Self-Assessment Questions

99
6.0 Additional Activities (Videos, Animations & Out of Class activities)
7.0 References/Further Readings

Introduction:
This unit examines the other components that make up the vital signs, which are
respiration, pulse and blood pressure

1.0 Study Session Learning Outcomes

After studying this session, I expect you to be able to:
1. Describe the physiological mechanisms governing pulse, respiration, and
blood pressure
2. identify normal ranges for each vital sign
3. identify the variations in pulse, respirations, and blood pressure that
occurs in a normal healthy state from old age
4. select appropriate equipment needed for measuring each vital sign
5. identify the different sites for assessing pulse and list the characteristics
that should be included when assessing pulses
6. explain how to measure the apical pulse and the apical-radial pulse
7. describe the mechanics of breathing/the mechanism that controls
respiration and demonstrate the ability to count the respiration of a patient
accurately
8. discuss characteristics that should be included in a respiratory assessment
9. explain how to measure a blood pressure and differentiate between
systolic and diastolic pressure

2.0 Main Content

2.1 Respiration

100
Human survival depends on the
ability of oxygen (O2) to reach body
cells and carbon dioxide (CO2) to be
removed from the cell. The body
performs this heroic function via
respiration. Respiration is generally
defined as the act of breathing. This
involves two distinctly different
processes: external respiration,
which is the exchange of, gases between an organism and its environment i.e.
the process by which the lungs bring O2 into the body and remove CO2 wastes,
and internal respiration or tissue respiration, which is the interchange of
these same gases between the circulating blood and the cells of the body tissue.
Unlike external respiration that is restricted to the alveoli of the lungs and
pulmonary blood, internal respiration takes place throughout the body.
External respiration is made up of inspiration – the intake of air into the lungs
and expiration – the breathing out or the movement of gases from the lungs to
the atmosphere. The term ventilation is also used to describe this movement of
air in and out of the lungs. Ventilation can be hyper or hypo. Hyperventilation
refers to very deep, rapid respirations while hypoventilation refers to very
shallow respirations. The rate, depth, and rhythm of ventilatory movements
indicate the quality and efficiency of the respiratory process. The nurse can
directly assess only the process of external respiration, specifically by assessing
ventilation.

2.2. Mechanics and Regulation of Breathing

Regulation of Breathing

101
Breathing is generally a passive process. It is carried out automatically and
effortlessly; you breathe without thinking about it. Though can be controlled
momentarily, such willful control are usually too transient and automatic control
soon takes over. This automatic control is governed/regulated by (i) respiratory
centers in the medulla oblongata and the pons of the brain, and (ii)
chemoreceptors located centrally in the medulla and peripherally in the carotid
and aortic bodies. These centers are sensitive to amount of CO2, pH, and low
level of O2 (Hypoxia). Consequently, they respond to changes in the
concentrations

of O2, CO2, and H+ in the arterial blood. An elevation in the CO2

pressure of arterial blood causes the respiratory center to increase the rate and
depth of breathing. This
increased ventilatory effort
removes excess PCO2 during
exhalation. Similarly, if the
arterial O2 levels fall, the
chemoreceptors signal the
respiratory center to increase the
rate and depth of ventilation.
According to Webster (1995)
rising PCO2 levels naturally stimulate the initiation of inspiration but falling
PCO2 levels have a limited impact on the control of ventilation. He noted that in
patients with chronic lung disease such as bronchitis and emphysema, the
hypoxic drive to increase ventilation can become very important stressing that
these people may have chronic hypercarbia (a chronic excess of CO2 in arterial
blood), which can suppress the normal stimulus for ventilation. A low level of
arterial O2 then becomes the primary stimulus to breathing in such patients.

102
Mechanics of Breathing
Normal breathing is accomplished by: (a) the downward and upward movement
of the diaphragm to lengthen or shorten the chest cavity, and (b) the elevation
and depression of the ribs to increase and decrease the anteroposterior diameter
of the chest cavity. During inhalation, the diaphragm contracts (flattens), the
ribs move upward and outward, thus enlarging the thorax and permitting the
lungs to expand. This allows the inflowing of air into the lungs. In expiration or
exhalation, the diaphragm relaxes, the ribs move downward and inward,
decreasing the size of the thorax as the lungs are compressed, thus facilitating
the movement of air out of the lungs.

2.3 Altered Breathing Patterns and Sounds

For a good appreciation of what altered breathing patterns and sounds are, there
is a need learners to be conversant with what is considered as normal respiration
in terms of rate, rhythm, depth and sounds. Hence this section examines
alterations in respiration against the background of what is considered normal
respiration.
Normal Respiration
Normal respiration is quiet, rhythmical (regular), comfortable, being neither too
deep nor too shallow and of a rate considered normal for that age. Let us
quickly look at what deviation from normal can occur across these
characteristics.
Respiratory Rate – Respiratory rate is usually described in breathes per minute.
It is the number of ventilations that take place in 1 minute. Breathing that is
normal in rate and depth is called eupnoea. Respiratory rate have however been
observed to vary considerably in healthy people. The rate varies with age,
tending to drop as a person grows older. It is usually slightly rapid in women

103
than in men. Nonetheless, some normal ranges have been established. These
normal ranges are captured in the table below (Table 7 – 1).

Table 7 – 1 Variation in Normal Respiratory Rate by Age

Age Avera
Range 30 –
Newborns 40
25 –
Early Childhood 30
Late Childhood
Teens 20 –

Source: Adapted from Usman, et. al. 2000. Ross and Wilson Foundations of
Nursing and First Aid (6th Ed.). and Kozier, et. al. 2000. Assessing Health. In
Fundamental of Nursing: Concepts Process and Practice.

Factors Influencing Respiratory Rate

Besides age and sex, several other factors affect the rate and character of
respiration. They include:
Exercise – Exercises increases metabolism and increased metabolism requires
increase consumption of oxygen hence the increase in respiratory rate and depth
to meet the body’s greater oxygen needs.
Body Position – Straight, erect posture promotes full chest expansion. Stooped
or slumped position impairs respiratory movement.
Emotion – Fear, excitement, and anger all increase the rate of respiration as a
result of sympathetic stimulation.
Stress – Gets the body ready for ‘fight or flight’ with accompanying increase in
respiration.
Disease – Certain diseases increase the rate of respiration (e.g. pneumonia, heart
disease) while others decrease it.

104
Certain Drugs – Some drugs such as caffeine stimulate respiration. Others such
as narcotic analgesic and sedatives depress the respiratory center with
associated slowing down of respiratory rate.
Acute Pain – Pain increases rate and depth as a result of sympathetic
stimulation.
Fever – Increases metabolic rate and consequently increases respiratory rate.
Cold – Decreased temperature results in decrease respiration.
Increased Altitude – The higher the altitude the lower the oxygen
concentration. In a bid to make up for reduced oxygen concentration at high
altitude the body therefore increases the rate of breathing.
Smoking – Long-term smoking changes the lungs airways, resulting in an
increased rate.
(Donovan, Belsjoe, and Dillon, 1968; Webster, 1995; Kozier, et. al. 2000).
Respiratory Depth
The depth of respiration is assessed by observing the degree of movement in the
chest wall. Ventilatory movements are objectively described as shallow,
normal, or deep. During a normal, relaxed breath, a person inhales
approximately 500ml of air. This volume is called tidal volume. Deep
respirations are those in which a large volume of air is exhalation. Shallow
respirations involve the exchange of small volume of air and often the minimal
use of lung tissue.
The capacity of the lungs to take in air depends on gender and age. Lung
capacity is determined by taking as deep a breath as possible and then blowing
it entirely into a spirometer, a device that measures air volume. The amount of
air exhaled after a minimal full inspiration is the lung’s vital capacity and is
about 4800ml 0f air. Men tend to have a larger vital capacity than women of the
same age. Infants and young children have smaller vital capacities than

105
adolescents and adults. With advancing age, the lung loses its elasticity, and the
capacity for forcible exhalation declines (Webster, 1995).
Body position also affects the amount of air that can be inhaled. Kozier, et. al.
submitted that people in supine position experiences two physiological
processes that suppress respiration: an increase in the volume of blood inside
the thoracic cavity and compression of the chest. Consequently, clients lying on
their back have poorer lung aeration, which predisposes them to stasis of fluids
and subsequent infection. Certain drugs such as barbiturates that depresses the
respiratory center also affect the respiratory depth by depressing both
respiratory rate and depth.
Respiratory Rhythm
This refers to the regularity of ventilation. Normal breathing is evenly space i.e.
regular and uninterrupted. Hence respiratory rhythm is described as regular or
irregular. Generally infants’ respiratory rhythms are usually less regular than
those of the adults.
Respiratory Quality/Character
This refers to those aspects of breathing that are different from normal.
Depending on the level of oxygenation, respiratory alterations may bluish
discoloration of the skin (cyanosis) and altered level of consciousness. Whereas
normal breathing does not require any noticeable effort, some clients only
breathe with decided effort referred to as labored breathing. As breathing
becomes labored, a person uses accessory muscles in the chest and neck to
breath. The sound of breathing is also significant. Normal breathing is silent but
when breathing becomes noisy, it is an indication of some respiratory disorder.
This will be discussed in fuller detail in the next section.

(A) Abnormal Pattern/Dysfunctional

Respiration Rate:

106
Tachypnea – Persistent rapid respiration marked by quick shallow breaths
(greater
than 20 breaths per minute).
Bradypnea – Abnormally slow breathing; less than 10 breaths per minute.
Apnea – Cessation of breathing, which may be for a few seconds or prolonged.

Volume:
Hyperventilation – An increase in the amount of air in the lungs characterized
by prolonged and deep breaths; may be associated with anxiety.
Hypoventilation – A reduction in the amount of air in the lungs, characterized
by shallow respirations

Rhythm:
Cheyne-Strokes – Cyclic breathing pattern characterized by rhythmic waxing
and waning of respirations, from very deep to very shallow breathing and
temporary apnea. The respiration becomes deeper and deeper until they reach a
climax, after which they decline until there is complete cessation of breathing
for a few seconds and then the cycle is repeated. Often associated with cardiac
failure, increased intracranial pressure, and drug overdose.
Biot’s – Cyclic breathing pattern characterized by shallow breathing alternating
with periods of apnea. Seen in neurologic problems (meningitis, encephalitis),
head trauma brain abscess, heat stroke.
Ease or Effort:
Dyspnea – This is the term used for describing difficult or labored breathing.
The difficulty may be transient and may or may not be accompanied by pain.
Dyspneic patients usually appear anxious and worried. The nostrils flare
(widen) as the patient struggles to fill the lungs with air. Associated with some
lung and heart diseases.

107
Orthopnea – When difficulty becomes so marked that the patient can breathe
only when in an upright position, it is called Orthopnea. It is associated with
advanced heart disease. In many cases, it is helpful to pull a bed table up to the
patient, cover it with pillow, and allow the patient to lean forward.
Breath Sounds:
a. Stridor – A shrill, harsh sound heard during inspiration with laryngeal
obstruction.
b. Stertor – Loud snoring or sonorous respiration, usually due to partial
obstruction of the upper airway.
c. Wheeze – Continuous, high-pitched musical squeak or whistling sound
occurring on expiration and sometimes on inspiration when air moves
through a narrowed or partially obstructed airway as in asthma.
d. Whoop – This long drawn-out noisy inspiration occurring after a
paroxysm of coughing in whooping cough.
e. Grunting – Grunting at the end of respiration is sometimes noticed in
pneumonia.
f. Sighing – Sighing or air hunger, is characterized by slow inspiration and
rapid expiration. This occurs in shock following hemorrhage.
g. Bubbling – Gurgling sounds called bronchi are heard as air passes
through moist secretions in the respiratory tract.

Chest Movements
a. Intercostal Retraction – In drawing between the ribs.
b. Substernal Retraction – In drawing beneath the breast bone.
c. Suprasternal Retraction – In drawing above the clavicles.
d. Flail Chest – The ballooning out of chest wall through injured rib spaces;
results in paradoxical breathing, during which the chest wall balloons on
expiration but is depressed or sucked inward on inspiration.

108
(Webster, 1995; Roark, 1995; Timby, 1996; Usman, et. al. 2000; Kozier, et. al.
2000)

2.4 Assessing Respiration

Respirations are the easiest of vital signs to assess but are often the most
haphazardly done. Resting respirations should be assessed when the
patient/client is at rest.
Equipment: – Watch with second hand or indicator.

Table 7 – 2 Procedures for Assessing Respiration

Suggested Action Rationale

Assessment
-Determine when and how Demonstrate accountability for
frequently to monitor the making timely and appropriate
patient’s respiratory rate. assessments.

-Review the data collected in Aids in identifying trends and

previously recorded assessments analyzing significant patterns.
of the respiratory rate and other
vital signs.
-Read the patient’s history for Demonstrate an understanding
any reference to respiratory, of factors that may affect the
cardiac, or neurologic disorders. respiratory rate.
-Review the list of prescribed Helps in analyzing the results
drugs for any that may have assessments findings.
respiratory or neurologic effects.

109
Planning
-Arrange the plan for care so as Ensures consistency and accuracy.
to count the patient’s respiratory
rate as close to scheduled
routine as possible.
Make sure a watch with a second Ensures accurate counting.
hand is available.
-Plan to assess the patient’s Reflects the characteristics of
respiratory rate after a 5-minute respirations at rest rather than
period of inactivity. under the influence of activity.

Suggested Action Rationale

Implementation
-Introduce self to patient if this Demonstrates responsibility and
has not been done during accountability.
earlier contact.
-Explain the procedure to the Reduces apprehension and
patient. enhances cooperation.

-Raise the height of bed. Reduces Musculoskeletal strain.

Wash your hands Reduces spread of
microorganisms.

-Help patient to a sitting or lying Facilitates the ability to observe

position. breathing.
-Note the position of the second Identifies the point at which
hand on the wrist watch. assessment begins.

110
 -Choose a time when the patient is Prevents conscious control of
unaware of being watched; it may be breathing during the assessment.
helpful to count the respiratory rate while
appearing to count the pulse.

-Observe the rise and fall of the patient’s Determines the respiratory rate
chest for a full minute, if breathing is per minute.
unusual. If breathing appears noiseless
and effortless, count the ventilations for a
fraction of a minute and then multiply to
calculate the rate.

-Restore the patient to therapeutic Demonstrates responsibility for

position or one that provides comfort, patient care, safety and comfort.
and lower the height of bed.

-Document respiratory rate, depth, Ensures accurate documentation.

rhythm And character on the appropriate
records and allows for future
comparison.
-Verbally report rapid or slow respiratory Alerts others to monitor the
rates or any other unusual breathing patient closely and make
Care. changes in the plan
characteristics.
Evaluation Focus
Note the respiratory rate in relation to the baseline data or normal range for age,
relationship to other vital signs, respiratory depth, rhythm and character.

Source: Timby, B.K. (ed.) 1996. Vital Signs. Fundamental Skills and Concepts
in Patient Care (6th Ed.)

111
2.5 Heamodynamic Regulation
The normal physiological function of the cells requires continuous blood flow
and appropriate volume and distribution of blood to cells that need nutrients.
This is accomplished through the heart’s contraction and ejection of blood into
the aorta and distensibility of the arterial system. The combination of the
arterial distensibility and resistance reduces the pressure pulsations, allowing
continuous blood flow to the tissues. The dynamics of distensibility and
resistance maintain a constant blood flow; otherwise, blood would flow to the
tissues only during systole with an absence of blood flow during diastole
The circulatory system consists of the heart (the pump), the network o f blood
vessels (arteries, arteriole,
capillaries, venules and veins),
and the blood that bring oxygen
and nutrients to body cells and
carries away waste products.
The heart is a four-chambered
muscular organ (two upper
chambers called atria and two
lower chambers called
ventricles). When the right and left atrium contract blood is forced into the two
lower chambers, the right and left ventricle. As wave of contraction continues,
blood, which has filled each ventricle, is forced out into the two main arteries –
the aorta, which supplies the body; and the pulmonary artery, which supplies
blood to the lungs (systole). At the onset of systole the increase in ventricular
pressure causes the mitral and tricuspid valves to close. The closing of these
valves produces the first heart sound (S1). Ventricular pressure continues to
increase until it exceeds the pressure in the pulmonary artery and the aorta,

112
causing the aortic and pulmonic valves to open and allowing the ventricles to
eject blood into these arteries. Ventricular emptying and relaxation cause a
decrease in the ventricular pressure and closure of the aortic and pulmonic
valves (diastole). Closure of these valves produces the second heart sound (S2).
During diastole the pressure in the ventricles becomes lower than that in the
atria, causing the mitral and tricuspid valves to open. This together with atria
contraction allows the blood to flow into the ventricles. Ventricular filling
causes an increase in pressure that closes the mitral and tricuspid valves (the
beginning of systole) and starts another cardiac cycle (Estes, 1998).
The amount of blood pumped out into circulation at each systole is known as
the stroke volume. As the blood enters the artery, the artery expands. The
rhythmic expansion and contraction (recoil) of the elastic arteries during each
cardiac cycle creates a pressure wave (a pulse) that is transmitted through the
arterial tree with each heartbeat. This wave of distension and recoil of the
arterial wall can be felt particularly where a peripheral artery runs over a bone.
When adult is resting, the heart pumps about 5 litres of blood each minute. This
volume is called cardiac output (CO), which can be expressed mathematically
as follows:
CO = Stroke Volume x Heart Rate
A person’s heart rate varies throughout the day. Nevertheless the heart functions
to maintain a relatively constant circulatory blood flow (Webster, 1995). This it
does through the action of the cardiac center located in the medulla of the
brainstem. Upon receipt of sensory impulses from sensory receptors, the cardiac
center either speed up or slow down the heart rate through sympathetic and
parasympathetic innervation. There are however some factors that causes
normal variation in heart/pulse rate in health. These include:
Age – As the age increases, the pulse rate decreases. See Table 7 – 3 for
specific variation in pulse rate from birth to old age.

113
Table 7 – 3 Normal Age Related Variations in Pulse

Age Normal Range Average

Newborn 80 – 180 130
1 – 3yrs 80 – 140 120

6 – 8 yrs. 75 – 120 100

Teen years 50– 70
90
Adult 60 – 100 80
Older Adult 60– 65
70

Source: Adapted from Kozier, et. al. 2000. Assessing Health. In

Fundamental of Nursing: Concepts Process and Practice & Estes, M. E. Z.
1998. Vital Signs and Physical Examination. In S. C. Delaune & P.K. Ladner
(eds.) .Fundamentals of Nursing, Standards and Practice.

a. Sex – After puberty, the average female have a slightly higher pulse rate
than male.
b. Exercise – Pulse rate normally increases with activities.
c. Posture/Position – When a person assumes a sitting position, blood
supply usually pools in dependent vessels of the venous system. Pooling
results in transient decrease in the venous blood return to the heart and a
subsequent reduction in blood pressure and an increase in heart rate.

114
 d. Stress – In response to stress, sympathetic nervous stimulation increases
the overall activity of the heart. Stress increases the rate as well as the
force of the heartbeat. Fear and anxiety as well as the perception of pain
also stimulate the sympathetic system.
e. Medications – Some medications decrease the pulse rate while others
increase it. For instance digitalis preparations (e.g. digoxin) decrease the
pulse rate while epinephrine increases it.
f. Hemorrhage – Loss of significant amount of blood from the
cardiovascular system results in an increase in pulse as the body strives
frantically to compensate for the loss.
g. Fever – The peripheral vasodilation that occurs concomitantly with
elevated body temperature and increased metabolism associated with
fever results in an increase in pulse rate.

2.6 Assessing Pulse

In assessing pulse, the nurse is not just interested in the rate but the rhythm,
volume and tension as well. The rate talks about how many counts per minute.
The rhythm addresses the issue of regularity of the pulse i.e. the interval
between successive pulse while the volume refers to the strength or amplitude
of force exerted by the ejected blood against the arterial wall with each
contraction (It should require moderate pressure to obliterate the vessel). The
tension relates to state of the vessel wall when being felt or palpated – the vessel
should feel pliant and soft under the nurse’s finger; it should not be hard and
tortuous.

How to take the Patient’s Pulse

There are nine sites where pulse is commonly taken:

115
a. Radial – At the wrist, just above the base of the thumb (postero- inferior),
where the radial artery run along the radial bone. Readily accessible
b. Temporal – Just in front of the ear, where the temporal artery passes over
the temporal bone of the head. Used when radial pulse is not accessible.
c. Carotid – On the side of the neck where carotid artery runs between the
trachea and sternocleidomastoid muscle. Used for infants and in cases of
cardiac arrest.

d. Apical – Apex beat can be heard by placing the stethoscope over the 5th
intercostal space in the mid clavicular line on the left side of the chest in
non-cardiac patients. Routinely used for infants and children up to 3 years
of age. Also used to clarify discrepancies with radial pulse.
e. Brachial – locatable at the inner aspect of the biceps muscle of the arm or
medially in the antecubital space (elbow crease). Employed in blood
pressure measurement. Also used during cardiac arrest for infants.
f. Femoral – In the groin where femoral artery passes alongside with the
inguinal ligament. Used for infants and children. Used to determine
circulation to the leg as well.
g. Popliteal – Where the Popliteal artery passes behind knee. Difficult to
find but accessible when the patient flexes his knee slightly. Used to
determine circulation to the lower leg.
h. Posterior Tibial – On the medial surface of the ankle where the posterior
tibial artery passes behind the medial malleolus. Used to determine
circulation to the foot.
i. Pedal – Where the dorsalis pedis artery passes over the bone of the foot.
Can be palpated by feeling the dorsum (upper surface) of the foot on an
imaginary line drawn from the midline of the ankle to the space between
the big and second toes. Used to determine circulation to the foot.

116
Assessing the Radial Pulse
Equipment – Watch with a second hand or indicator.

Intervention
Prepare the client – Inform the client and explain the procedure to him. Select
the pulse point and assist the client to comfortable and relaxed position. For
clients in supine/dorsal position, the arm can rest alongside the body with palm
facing downward or over the abdomen except where contraindicated. For clients
who can sit, the forearm can rest across the thigh, with the palm facing
downward or inward. With infants, have the parent close by. Having the parent
close or holding the child may decrease anxiety and yield more accurate results.
Palpate and count pulse – Place the first two or three fingers lightly and
squarely over the medial aspect of the wrist just above the base of the thumb.
Using a thumb is contraindicated because thumb has a pulse that the nurse could
mistake for client’s pulse. Feel the pulsation but before counting the pulse, note
the rhythm, volume, and the state of the vessel wall. If the pulse is regular,
count for 30seconds and multiply by 2. If it is irregular, count for a full minute.
Count for a full minute also when taking a client’s pulse for the first time or
obtaining baseline data. An irregular rhythm requires a full minute’s count for a
correct assessment and indicate need to take apical pulse.
Document and report pertinent assessment – Record the pulse rate, rhythm
and volume on the appropriate records. Report to the nurse in charge abnormal
variations in pulse (Usman, et. al. 2000; Kozier, et. al. 2000).

Abnormal Variations in Pulse

The pulse may vary in one or more of its characteristics.
Rate: An abnormally elevated pulse/heart rate above 100 beats per minute in
adults is referred to as Tachycardia. This is found in certain heart conditions

117
and in some anaemias. Tachycardia may be continuous or paroxysmal.
Bradycardia on the other hand is a pulse/heart rate that is less than 60 beats per
minute in adults. Could occur in cases of head injury.
Rhythm: Arrthythmia is the name given to irregularities in heart rhythm. A
pulse is described as irregular when the interval between successive beat is
uneven. Intermittent pulse means that a pulsation is being missed and it may
occur at regular or irregular intervals. Extra systoles are actually extra beats
produced by an excessively irritable cardiac muscle with resultant irregularity.
2.7 Blood Pressure and its Determinants
Blood pressure (Bp) is the force exerted by the blood against the walls of the
vessels that carry it measured by an instrument called sphygmomanometer. In
other words Bp is a product of cardiac output and total peripheral resistance
(TPR).
Bp = CO x TPR

As earlier stated, the CO is the quantity of blood being pumped out of the heart
per minute while TPR represents the total force exerted by the heart and the
walls of the vessels against the blood.
Bp is highest during ventricular contraction. This is systolic pressure, that is,
the pressure of the height of the blood wave. The pressure diminishes as the
heart relaxes and is lowest when the heart is relaxed before it begins to contract
again; this is diastolic pressure that is the pressure when the ventricles are at
rest. Bp is measured in millimeters of mercury (mmHg) and recorded as
fraction, the systolic pressure written over the diastolic pressure. Diastolic
pressure then, is the lower pressure, present at all times within the arteries. The
difference between the two readings is called pulse pressure.

Bp can either be high or low. The World Health Organization has considered a
range of 90/60 – 140/95mmHg as normal. Therefore, when there is a persistent

118
rise in Bp above what is considered as average for an age and sex, a condition
known as Hypertension is said to have developed. On the other hand, when the
Bp falls extremely below normal range for an age, e.g. a systolic reading
consistently between 85 and 110mmHg in an adult, hypotension is said to have
set in.

Determinants of Blood Pressure

Arterial Bp is the result of several factors. These include:
The Pumping Action of the Heart – When the pumping action of the heart is
strong, the volume of blood pumped into circulation tends to increase with
corresponding increase in Bp and vice versa.
Peripheral Vascular Resistance – The higher the peripheral resistance (TPR),
the higher the Bp. Some of the factors create TPR are the size of the blood
lumen, the compliance of the arteries and the viscosity of the blood. The
smaller the lumen of a vessel, the greater the resistance. Normally, the arteries
are in a state of partial constriction, increased vasoconstriction therefore raises
the Bp. The degree of distensibility (compliance) of the arterial wall, which is a
factor of the elasticity of the arterial wall is yet another factor in TPR.
Blood Volume – The smaller the blood volume, the lower the Bp and the
greater the blood volume the higher the Bp.

Blood Viscosity – In viscous (thick) fluid, there is a great deal of friction

among the molecules as they slide by each other. This explains why the Bp is
higher when the blood is highly viscous as it’s usually the case when the
hematocrit is more than 60 – 65%.

Mechanism involved in Blood Pressure Regulation

1. Sympathetic Stimulation/Cardiac Accelerator (Adrenalin) – Increases
peripheral resistance and heart rate and consequently increases the Bp.

119
2. Parasympathetic (Vagal) Stimulation – Cardiac inhibitor; reduces Bp.
3. Baroreceptor Mechanism – The baroreceptor are nerve receptors in the wall
of most great vessels like the aorta and the carotids that are sensitive to changes
in Bp. When the arterial pressure becomes great, these baroreceptors are
stimulated excessively, and impulses are transmitted to the medulla of the brain.
Here the impulses inhibit the vasomotor center, which in turn decreases the
number of impulses transmitted through the sympathetic nervous system to the
heart and blood vessels. Lack of these impulses causes diminished pumping
activity of the heart and an increased ease of blood flow through the peripheral
vessels both of which lowers the arterial pressure back to normal. Conversely, a
fall in arterial pressure relaxes the stretch receptors, allowing the vasomotor
center to become more active than usual with resultant rise in Bp.

4. Renin-Angiotensin Phenomenon - Narrowing of the lumen of an artery as a

result of arteriosclerosis or renal artery stenosis results in a decrease in the
volume of blood to the kidney. The kidney by virtue of its receptors that are
very sensitive to changes in blood volume secretes a substance called rennin.
Renin while circulating in the blood acts on a protein component
(angiotensinogen) and convert it to angiotensin. Angiotensin causes constriction
of blood vessels and also stimulates the release of aldosterone from the adrenal
gland. Aldosterone causes salt and water retention. The net result is a rise in Bp.

Factors Influencing Blood Pressure: The various factors influencing Bp are

outlined as follows:
Age – Bp increases with age. In old age, as part of the degenerative process, the
arterial wall becomes more rigid and less yielding to pressure and no longer
retract as flexibly to decreased pressure, hence the high Bp associated with this
group.

120
Exercise – This increases cardiac output with consequent increase in Bp.
Stress – The stimulation of the sympathetic nervous system as observable in
stress causes increased the cardiac output with increased vasoconstriction. The
aftermath is increased Blood pressure. Pain however can decrease Blood
pressure greatly and cause shock by inhibiting the vasomotor center and
producing vasodilation.
Race – The Negroid race tend to have higher Bp than the Caucasians.
Obesity – Bp is generally higher in obese people than in individuals with
normal weight (due to possible arteriosclerosis).
Sex – After puberty, females usually have lower Bp than males of the same age
probably due to hormonal variation.
Medications – Some medication increases the Bp while many others decreases
it. To this end the nurse needs to be conversant with the actions and side effects
of drugs and consider their possible impact on the health status of their client.
Disease Process – Many conditions that affect cardiac output, blood volume,
the arterial network and renal system exact a direct effect on Bp.
Diurnal Variations – Bp is usually lowest early in the morning, when the
metabolic rate is lowest, then rises throughout the day and peaks in the late
afternoon or early evening. (Kozier, et. al. 2000).

2.8 Assessing Blood Pressure

Since blood pressure can
vary considerably, it is
expedient for the nurse to
know a specific clients
baseline Bp.
Preparation

121
Patient: The patient should be resting in a bed, couch or chair, in a quiet
location. The patient should not have had a meal/alcohol or caffeine or have
smoked or exercised in the previous 30 minutes.
Equipment/Environment: Sphygmomanometer with appropriate size cuff (see
Points for Practice), Stethoscope, Alcohol- impregnated swabs, Observation
chart
Nurse: The hands should be clean. No special preparation is necessary unless
required by the patient’s condition.
Procedure
2.1.1 Assess the patients knowledge of the procedure and explain as necessary
2.1.2 Ensure the patient is resting in a comfortable position. If a comparison
between lying and standing blood pressure is required, the lying recording
should be done first.
2.1.3 When applying the cuff, no clothing should be underneath it if clothing
constricts the arm remove the arm from the sleeve (see PPP)
2.1.4 Apply the cuff so that the center of the bladder is over the brachial artery 2
- 3cm above the antecubital fossa. This is easier to do if the cuff tubing is
disconnected from the sphygmomanometer.
2.1.5 The arm should be positioned so that the cuff is level with the heart and
may be more comfortable resting on a pillow
2.1.6 The sphygmomanometer should be placed on a firm surface, facing you,
with the center of the mercury column at eye level. Connect the cuff tubing
to the sphygmomanometer.
2.1.7 Locate the radial pulse. Squeeze the bulb slowly to inflate the cuff while
still feeling the pulse. Observe the mercury column and note the level
when the pulse can no longer be felt. Unscrew the valve and quickly
release the pressure in the cuff.
2.1.8 If using a communal stethoscope clean the earpieces with an alcohol-

122
 impregnated swab. Curving the ends of the stethoscope slightly forward,
place the earpieces in your ears. Check that the tubes are not twisted
2.1.9 Check that the stethoscope is turned to the diaphragm side by tapping it
with your finger.
2.1.10 Palpate the brachial artery, which is located on the medial aspects of

antecubital fossa.
2.1.11 Place the diaphragm of the stethoscope over the artery, and hold it in place

with your thumb while using your fingers to support the patient’s elbow.
2.1.12 Position yourself so that the column of mercury in the
sphygmomanometer is clearly visible.
2.1.13 Ensure that the valve on the bulb is closed firmly but not too tightly, so

that it can be loosened with one hand. Inflate the cuff to 20 - 30 mmHg
above the level noted in step 7 Open the valve to allow the column of
mercury to drop slowly (2mm per second).
2.1.14 While observing the level of mercury as it fails, listen for korotkoff

(thudding) sounds: Sudden appearance of a sharp click sound which

increases in intensity and duration until it reaches a peak, then suddenly
becomes muffled and less intense after a further fall of about 5mmHg.
The systolic pressure is the level where this is first heard; the diastolic
pressure is the level where the sounds disappear.

123
 2.1.15 Once the sounds have disappeared, open the valve fully, to completely

deflate the cuff, and remove it from the patient’s arm

Points for Practice

The sphygmomanometer may be mercury or an aneroid type. These are used in
exactly the same way, however, unlike the mercury column, which must be placed in
an upright position for accurate recording, the dial on an aneroid
sphygmomanometer may be positioned anywhere. The bladder of the cuff must cover
at least three quarters of the circumference of the upper arm. If the patient is
receiving intravenous therapy, avoid using the arm that has the intravenous cannula
or infusion in progress. If the patient is unable to lift his/her arm, tuck the patient’s
hand under your arm to support the arm while you position the cuff. If recording lying
and standing blood pressure, do not remove the cuff between recordings, keep it in the
same position. The doctor may have requested that the patient stands for at least five
minutes before the standing blood pressure is recorded. Be aware that the patient may
feel dizzy on getting out of bed (postural hypotension). Electronic blood pressure
recording machines are now often used. The cuff should be positioned in the same
way as described in step 4 but no stethoscope is required because the machine
provides a digital display of the systolic and diastolic pressures.

In-text Question 1 (A short question requiring a single sentence answer for quick reflection
over the read topic): What are the requirements for observing a patients respiration, pulse
and temperature?

Answer Thermometer, sphygmomanometer, stethoscope, spirit swabs and observation chart

for record, pen and meter rule.

3.0 Tutor Marked Assignments (Individual or Group)

1. Describe the physiological mechanisms governing pulse, respiration and
blood pressure?

4.0 Conclusion/Summary
This unit has examines the other components that make up the vital signs, which
are respiration, pulse and blood pressure. Considering the place of assessment as
a major component of nursing care and if good nursing care entails meeting the

124
needs of the clients, then these needs must first be identified by all nurses that
are competent in these invaluable asset.
The assessment of physiological functioning provides specific data regarding
the client’s current condition. It also provides a basis for evaluating response to
nursing interventions. However, most accurate values could only be obtained
when the client is at rest, the environment controlled for comfort, and the
nurses well-armed with knowledge and skills for assessing vital signs.
The assessment of the other components of vital signs (i.e. respiration, pulse and
blood pressure) is as crucial as that of temperature and various sites and
methods can be used to obtain them. Respirations are normally quiet, effortless,
and automatic and when assessing respiration care must be taken to ascertain
the respiratory rate, depth, rhythm, and sound. The normal physiological
function of the cells requires continuous blood flow and appropriate volume and
distribution of blood to cells that need nutrients. The pulse rate, rhythm, and
volume, in addition to blood pressure are good indicators of the functionality of
this system. Although the radial pulse is the site commonly used, eight other
sites may be used in certain situations. Blood pressure which is a product of
cardiac output, peripheral resistance, and blood volume and blood viscosity can
be measured by auscultation using a sphygmomanometer and a stethoscope.
And like temperature, several factors cause changes in one or more of these
vital signs. These include: age, sex, exercise, anxiety and stress, metabolism,
diurnal variation, hormones, medication, pain and alteration in physiological
functions.

5.0 Self-Assessment Questions

1. What are the determinants of Blood Pressure?

6.0 References/Further Readings

Donovan, J.E.; Belsjoe, E.H., and Dillon, D.C. (1968). The Nurse Aide. New

125
 York: McGraw-Hill Book Company.
Estes, M. E. Z. (1998). Vital Signs and Physical Examination. In S. C. Delaune
& P.K. Ladner (Eds.). Fundamentals of Nursing, Standards and Practice.
Albany: Delmar Publishers.

Guyton, A. C. (1996). Textbook of Medical Physiology (9th Ed.).

Philadelphia: Saunders.
Hanson, M. (1991). Drug Fever: Remember to consider it in Diagnosis. Kozier,
B.; Erb, G.; Berman, A.U. & Burke, K. (Eds.). (2000). Assessing Health

Fundamental of Nursing: Concepts Process and Practice (6th Ed.). New

Jersey: Prentice Hall, Inc.

Mountcastle, V. B. (1980). Medical Physiology (14th ed. Vol 2). St Louis:

Mosby. Postgraduate Medicine, 89(5):167.
Nursing Standard (2001). Essential Skills: Observation and Monitoring,
Recording Temperature.
Roark, M. L. (1995). Vital Signs. In C. B. Rosdahl (Ed.). Textbook of Basic
Nursing. Philadelphia: J.B. Lippincott Company.
Usman, D. S.; Obajemihin, J. O.; Adegbite, M. F.; Bray, M. F.; W i l s o n ,
K. J. W. & Ross, J. S. 2000. Ross and Wilson Foundations of Nursing and First

Aid (6th Ed.). Singapore: Longman.

Smith, J.P. (1982). Nursing Observations. In E. Pearce (Ed.). A General

Textbook of Nursing (20th Ed.). Norwich: The English Language Book

Society and Faber and Faber.
Timby, B.K. (Ed.). (1996). Vital Signs. Fundamental Skills and Concepts in

Patient Care (6th Ed.). Philadelphia: Lippincott.

Webster, C. (1995). Health and Physical Assessment. In H. B. M. Heath (Ed.).
Potters and Perry’s Foundations in Nursing Theory and Practice. Italy:
Mosby, An Imprint of Times Mirror International.

126
 STUDY SESSION 2
Assessing Health III – History Taking/Physical Exam
Section and Subsection Headings:
Introduction
1.0 Learning Outcomes
2.0 Main Content
2.1- Types of Assessment
2.2- Indications for Health Assessment
2.3- Data Collection
2.4- Interviewing/History Taking
2.5- Health History and Nursing History
2.6- Physical Examination
3.0 Tutor Marked Assignments (Individual or Group assignments)

127
4.0 Study Session Summary and Conclusion
5.0 Self-Assessment Questions
6.0 Additional Activities (Videos, Animations & Out of Class activities)
7.0 References/Further Readings

Introduction:
Assessing health status is a major component of nursing care. Smith (1982)
remarked that if good nursing care entails meeting the needs of the clients, then
these needs must first be identified. As such, the skill of observation becomes an
invaluable asset. Assessment technique is therefore a skill that nurses must
develop right from the very beginning of their training. Speaking in the same
vein, Swash and Mason (1986) submitted that one statement that gets near to the
truth is that diagnosis should precede treatment whenever possible. They
observed that are two steps critical to making a diagnosis: the first is
observation by history taking, physical examination, and ancillary
investigations; and the second – interpretation of information obtained in terms
of a disorder of function and structure, then in terms of pathology. These two
steps put together form part of the assessment phase of the Nursing process,
which incidentally has become the decision making tool in Nursing practice.
However, as beginners, will be limiting ourselves to the first step, knowing fully
well that a thorough understanding of it is vital to elucidating our clients
problem(s) without which the resolution of such problem(s) will be elusive.
Therefore, this unit focuses on the purpose, components, and techniques related
to the health history and physical examination.

1.0 Study Session Learning Outcomes

After studying this session, I expect you to be able to:

128
 1. explain the purpose, components, and techniques related to the health
history and physical examination
2. differentiate between health history and nursing history
3. identify information to collect from nursing history before an
examination
4. describe the appropriate use and techniques of inspection, palpation
percussion, and auscultation
5. identify some of the equipment needed to perform a physical examination
6. conduct physical assessments correctly in the right sequence and in an
organized fashion

2.0 Main Content

2.1. Types of Assessment
Generally speaking, three types of assessment are employed in evaluating the
health status of patients/clients. They are: Comprehensive Assessment,
Focused Assessment, and Ongoing Assessment. However, it is health care
setting and needs of the patient that literally dictates what type of assessment
that is needed.

Comprehensive Assessment – As the name suggest, this is a comprehensive

assessment that is usually collected upon admission to a health care agency. It
includes a complete health history to determine the current needs of the client.
This database provides a baseline against which changes in the client health
status can be measured and should include assessment of physical and
psychosocial aspects of client’s health, the client’s perception of health, the
presence of health risk factors and the client’s coping patterns (Moffett, 1998).
While it is true that comprehensive assessment is the most desirable in the initial
assessment of client’s health needs, time constraint or special circumstances

129
may indicate the need for the abbreviated data collection, the focused
assessment.

Focused Assessment – As insinuate in the preceding paragraph, this assessment

is limited in scope (in comparison with comprehensive assessment) in order to
focus on a particular need or health care problem or potential health care risks.
It is often used in health care agencies in which short stays are anticipated (e.g.
Emergency departments), in specialty areas such as labor and delivery, and in
mental health settings or for the purposes of screening for specific problems or
risk factors as obtainable in well child clinic (Moffett, 1998).

Ongoing Assessment – An ongoing

assessment is a continuous systematic
assessment and reassessment or
evaluation of a client’s health status with
revision of care plan. This type of
assessment allows the nurse to broaden
the database or to confirm the validity of the data obtained during the initial
assessment and to measure the effectiveness of nursing interventions.
In-text Question 1 (A short question requiring a single sentence answer for quick reflection
over the read topic): What is Focused Assessment?

Answer This assessment is limited in scope (in comparison with comprehensive assessment)
in order to focus on a particular need or health care problem or potential health care risks

2.2 Indications for Health Assessment

The purposes of health assessment include to:
i. Collect data about the client through observation, interview and physical
examination.
ii. Assess the patient’s current physical condition.

130
iii. Establish a database for future comparisons.
iv. Continuously update database.
v. Detect early signs of developing health problems
vi. Evaluate responses to medical and nursing interventions.
vii. Make clinical judgments about a client’s changing health status and
management.

2.3 Data Collection

This is the process of gathering information about a client’s health status. It
must be both systematic and continuous to prevent omission of significant data
and reflect a client’s changing health status. A database (baseline data) is all
information about a client; it includes the nursing health history, physical
assessment, the physician’s history and physical examination, results of
laboratory and diagnostic tests, and materials contributed by other health
personnel (Wilkinson, 2000).
Types of Data
There are basically two types of data: objective data and subjective data.
Objective data also referred to as signs or overt data are factual measurable
and observable information about the patient and his overall state of health i.e.
they can be seen, heard, felt, or smelled, and they can be obtained by
observation or physical examination. Example includes vital signs; height;
weight; urine colour, volume and odour; skin rashes e. t. c. Subjective Data
sometimes called symptoms or covert data are data client’s point of view that
cannot be empirically validated. Encompasses patient’s opinion or feelings,
client’s sensation, values, beliefs, and perception of personal health status and
life situation. For instance, only the patient can tell you that he/she is afraid or
has pain or experiencing itching.

131
Methods of Data Collection
The basic methods employed in data collection or data gathering are:
1. Observation
2. Interview, and
3. Physical Examination.

Observation
The term observation is defined as a systematic and exhaustive search for any
significant physical deviation from the normal. Observation has two aspects: (a)
noticing the stimuli and (b) selecting, organizing, and interpreting the data
including distinguishing stimuli in a meaningful manner. Observation as an
assessment techniques involve the use of all the five senses:
Visual Observation: Sight provides an abundance of visual clues about general
appearances, mannerisms, facial expressions, mode of dress, family – friend’s
interaction, to mention but a few.
Tactile Observation: Touching or palpating any part of the patient can provide
information such as hotness/coldness of the body, swelling, edema, muscle
strength e.t.c.

Auditory Observation: The sense of hearing. Quite a lot of information can be

gathered through mere listening to the patient or using specialized equipment
like the stethoscope to listen to breath sounds, bowel sounds, and heart sounds.
Olfactory or Gustatory Observation: The sense of smell identifies odors that
can be specific to a patient’s condition or state of health. This include body and
breathe odour which might indicate Gamalin poisoning, alcohol intoxification,
poor hygiene, diabetic ketoacidosis e.t.c.

2.4 Interviewing/History Taking

132
This is a planned communication or a conversation with a purpose, for example,
to get or give information, identify problems of mutual concern, evaluate
change, teach, provide support, or provide counseling or therapy (Wilkinson,
2000). During assessment, the purpose of interview is to gather information
about client’s health history. The goal of history taking is to get from the client
an accurate account of his complaint and see this against the background of his
life as a whole. How well this is achieved is a factor of the nurse’s knowledge
and skill at eliciting information from the client using appropriate techniques of
communication and observation of nonverbal cues. Effective communication is
therefore a key factor in the interview process (Cecere & McCash, 1992).
There are two approaches to interviewing: directive and nondirective. The
directive interview is highly structured and elicits specific information. The
nurse establishes the purpose of the interview and controls the interview, at least
at the outset, by asking closed-ended questions that call for specific data. During
the nondirective interview, or rapport-building interview, the nurse allows the
client to control the purpose, the subject matter, and pacing. The nurse
encourages communication by asking open-ended questions and providing
empathetic responses (Wilkinson, 2000).

Guidelines for an Effective Interview/History Taking

i. Be prepared – The interview is more productive if the nurse has an
opportunity to prepare for the interaction. Such preparation includes the
review of client’s clinical record, conversation with other health care
personnel, and literatures about client’s health problem (Moffett, 1998,
Wilkinson, 2000). This will focus the interview and prevent tiring the
client, and save your time.
ii. Appropriate Timing – Schedule interviews with client at a time when
the client is physically comfortable and free of pain, and when

133
 interruptions by friends, family, and other health professionals are
minimal.
iii. Create a Pleasant Interviewing Atmosphere – A quiet, well- lighted,
well-ventilated and relaxed setting, relatively devoid of noise and
interruptions enhances communication. A relaxed atmosphere eases the
patient’s anxiety, promotes comfort, and conveys your willingness to
listen. Ensure privacy, as some clients will not share personal information
if they suspect others can overhear. In all instances, the client should be
made to feel comfortable and unhurried.

Establish a Good Rapport – Greet the client by name if possible; sit and chat
with the client before the interview. Be sure to explain the purpose of the
interview and show concern for the patient’s story.
Set the Tone and be Focused – Encourage the client to talk about his chief
complaint. This helps you to focus on his most troublesome symptoms. Keep
the interview informal while still being professional. Speak clearly and simply,
avoiding medical jargons and be sure patient understands you.
Choose your Words Carefully – Ask open-ended questions to encourage the
client to provide complete and pertinent information.
Take Notes – Avoid documenting everything during the interview but make
sure you jot down important information such as date, times.

2.5 Health History and Nursing History

The primary focus of the data collection interview is the health history and
Nursing history. A health history is designed to collect data to be used
primarily by the physician to diagnose a health problem and it usually collected
by the medical team. Often the admitting
nurse also collects this same information

134
during the admission interview. However, there is a growing disapproval of the
nurse repeating this process, as credibility is lost when the nurse repeats
virtually all the questions that others have already asked. A nursing history on
the other hand has a different focus – the client’s response to the health
problems, which assist the nurse more accurately in identifying nursing
diagnoses (Cecere, & McCash, 1992). While the health history concentrate on
symptoms and progression of disease, the nursing history focuses on client’s
functional patterns, responses to changes in health status and alterations in
lifestyle.

Health History – The components of a health history include:

Demographic Information – encompasses demographic variables such as
name, date, age, sex, e.t.c.
Chief/Presenting Complaint – try to define what has motivated the client to
seek health care and its duration.
History of Present Illness (HPI) – HPI provides detailed data about the chief
complaint or reason for entering the health care system.
Past Health History – provides information about the client’s prior state of
health. Includes questions about childhood and adult illnesses, immunizations,
injuries, hospitalizations, s u r g e r i e s , therapeutic regimens, allergies, travels,
habits, and use of supportive devices.
Family Health History (FHH) – FHH notes illnesses that have environmental,
genetic, or familial tendency or that are communicable. A genetic chart or
family tree of three generations can be developed to illustrate the family health
history.
Social and Occupational History – Enquire about what may be grouped as the
client’s physical and emotional environment, his surroundings both at home and
work, his habits and his own mental attitude to life and to his work.

135
Review of Systems – This is the final portion of health history. It is systematic
collection of specific information about the client’s past and present health
status related to common problems of body systems. (Swash & Mason, 1986;
Cecere, & McCash, 1992).
It is important to mention here as Swash & Mason, (1986) noted, that in taking
history, it neither possible nor desirable to tie a patient down to a particular
sequence. The client must be allowed to tell his own story. Besides, a good
clinician begins the examination of a patient as the latter walks into the room –
his appearance, the way he walks, the way he answers questions and so on – and
only finishes taking the history when the consultation is over. Occasionally a
vital piece of information may come out just when the patient is leaving. Swash
& Mason, (1986) remarked that while the list of headings is formidable, it does
take some experience to know in a given case which part of the history is
particularly worth pursuing. And following the health history, a general survey
statement is made, which is a statement of the provider’s impression of a client,
including behavioral observations.

Nursing History – Numerous nursing history/database formats are available in

literatures (Carpenito, 1989; Christensen & Kenney, 1990; Cecere, & McCash,
1992). The format in use in most clinical setting is the 11 functional patterns
credited to Majory Gordon. This format (presented below) allows systematic
data gathering and facilitates making inferences (nursing diagnosis).

Health-Perception-Health-Management Pattern – Focuses on client’s

perceived level of health and well-being and on personal practices for
maintaining health. It also embraces preventive screening activities such as
breast and testicular examination; hypertension and cardiac risk factor screening
e.t.c.

136
Nutritional-Metabolic Pattern – Assesses food and fluid intake, food
References/Further Reading and taboos, cultural factors relating to food and
nutrition, e.t.c. Also explores difficulties if any with ingestion, digestion,
absorption, transport and metabolism of nutrients.
Elimination Pattern – Assesses bowel and bladder functions such as
frequency, amount, relationship of output to intake, and any discomfort or
difficulty associated with each function.
Activity-Exercise Pattern – Explores the client’s activities of daily living
including client’s usual pattern of exercise, leisure and recreation.
Sleep-Rest Pattern – This inquires about the client’s pattern of sleep, rest and
relaxation in a 24hour period, noting any deviation from client’s premorbid rest
and sleep pattern.
Cognitive-Perceptual Pattern – Assessment of this pattern involves a
description of all the senses (vision, hearing, taste, touch, smell and pain) and
the cognitive functions (such as communication, memory, and decision
making).
Self-Perception-Self-Concept Pattern – This pattern explores the client’s self-
concept, which is critical to determining the way the client interacts with others.
Attitudes about self, perception of personal abilities and body image, and
general sense of worth are also addressed under this pattern.
Role-Relationship Pattern – Describes the client’s role and relationships
including major responsibilities of the individual. It examines person’s self-
evaluation of the performance of expected behaviors related to these roles.
Sexuality-Reproductive Pattern – This pattern describes satisfaction or
dissatisfaction with personal sexuality and describes the reproductive pattern.
Coping-Stress Tolerance Pattern – This pattern explores the client’s general
coping pattern and the effectiveness of the coping mechanisms. It encompasses

137
analyzing the specific stressors or problems that confront the client, the client’s
perception of the stressor and the person’s response to the stressor.
Value-Belief Pattern – Describes the values,
goals, and beliefs (including spiritual) that guide
health related choices. (Cecere, & McCash, 1992).

2.6 Physical Examination

Physical examination or physical assessment is a
systematic examination of the body structures.
There are basically four techniques of conducting a
physical examination and the examination may be
done using the cephalocaudal (head – to – toe)
approach or the body systems approach. The four techniques are:
Inspection: - Inspection is the most frequently used assessment techniques. It
involves deliberate, purposeful and systematic observation to identify deviation
from normal.

Percussion: - The assessment techniques least used by nurses. It requires

considerable skills. Percussion involves striking or tapping a particular part of
the body to produce vibratory sounds. The quality of sound aids in determining
the location, size and density of underlying structures. If the sound is different
from that which is normally expected, it suggests that there may be some
pathologic changes in the area being examined.
Types of percussion: There are three types of percussion viz: Indirect, Direct,
and Blunt percussion:
Indirect Percussion: The most commonly used. Produces clear, crisp sounds
when performed correctly. To perform indirect percussion, use the middle
finger of your non-dominant hand as the pleximeter by placing it firmly on the

138
part that is to be percussed. The back of its middle phalanx is then struck with
the top of the middle finger of the dominant hand (the flexor). The stroke should
be delivered from the wrist and finger joints, not from the elbow, and the
percussing finger (the flexor) should be held perpendicular to the pleximeter.
Tap lightly and quickly, removing the flexor as soon as you have delivered each
blow.
Direct Percussion: In direct percussion, the nurse strikes the area to be
percussed directly with the pads of two or three or four fingers or with the pad
of the middle finger. This method helps in assessing an adult sinus for
tenderness.
Blunt Percussion: This is done by striking the ulnar surface of your fist against
the body surface. Alternatively, both arms may be used with the palm of one
hand placed over the areas to be percussed and then striking it’s back with the
fist of the other hand. Both techniques aim at eliciting tenderness (not to create a
sound) over such organs as the kidneys, gallbladder, or liver (another blunt
percussion method used in the neurologic exam involves tapping a rubber –
tipped reflex hammer against a tendon to create a reflexive muscle contraction).

Palpation: This is an assessment technique that uses sense of feeling and

pressure to assess structure size, placement, texture, temperature, distension,
mobility, pulsation and tenderness. There are two types of palpation:
Light Palpation: Involves the use of pads of fingertips, the dorsum (back) of
the hand or the palm. Used because their concentration of nerve endings makes
them highly sensitive to tactile discrimination. In light palpation, the body
surface is indented gently using the slightest touch possible; too much pressure
blunts your sensitivity. The nurse extends the dominant hand’s fingers parallel
to the skin surface and presses gently while moving the hand in a circle.

139
Deep Palpation: Deep palpation is done with two hands (bimanually) or with
one hand. In deep palpation, the hand is held flat and relaxed and molded to the
body surface as in light palpation. The best movement is gentle but with firm
pressure with the finger held almost straight but slightly flexed at the

metacarpophalangeal joints. Indent the skin or tissue about 1-11/2 inches (2.5 -
4cm). Place your other hand on top of the palpating hand to control and guide
your movements. This approach (bimanual palpation) is usually employed while
palpating for deep, underlying, hard – to – palpate organs (such as the kidney,
liver or spleen) or to fix or stabilize an organ (such as the uterus) while
palpating with the other hand. To perform a variation of deep palpation that
allows pinpointing an inflamed area, press firmly with one hand, and then lift
your hand away quickly. If the patient complains of increased pains as you
released the pressure, you have identified rebound tenderness. Other variations
of deep palpation are: Light Ballottement usually performed by applying light
rapid pressure from quadrant to quadrant of the patient’s abdomen. Hands are
kept on the skin surface to detect tissue rebound. Deep Ballottement on the
other hand, is performed by applying abrupt, deep pressure and releasing it
while maintaining contact.

NOTE: Palpation forms the most important of abdominal examinations. Tell

the patient to relax as best as he can, to breathe quietly and that you will be as
gentle as possible. Enquire for the site of any pain and come to this region last.
It is helpful to have a logical sequence to follow and if this is done as a matter of
routine, then no important point will be omitted. Presented below are the
different regions of the abdomen and the different incision line employed in
abdominal surgeries.

140
Fig 7 – 1 Regions of the Abdomen

1. Right hypochondrion 6. Left lumbar

2. Epigastruium 7. Right Iliac
3. Left hypochondrion 8. Hypogastrium or suprapubic
4. Right lumbar 9. Left Iliac
5. Umbilical

Source: Adapted from Swash & Mason, 1986. Hutchison’s Clinical Methods
(18th Ed)

Fig 7 – 2 Some Commonly Employed Abdominal Incisions

1. Upper midline 5. Gridiron (appendectomy)

2. Right sub costal (Kocher’s) 6. Left
3. Right paramedian 7. Suprapubic

141
 4. Lower midline

Source: Adapted from Swash & Mason, 1986. Hutchison’s Clinical Methods
(18th Ed).

Auscultation: Auscultation is an assessment technique that involves listening to

sounds created in body organs to detect variations from normal. Some sounds
can be heard with unassisted ear, but most sounds are heard through a
stethoscope. You must first become familiar with normal sounds before you
can be able to pick abnormal sounds. The heart, lungs and abdomen are the
structures that are most often assessed by this technique. To auscultate
effectively therefore requires good hearing acuity, a good stethoscope and
knowledge of how to use the stethoscope correctly.

Assessing High-Pitched Sounds – Example of high-pitched sounds are 1st and

2nd heart sounds (S1 & S2) and breath sound. This is done with the use of the
diaphragm of the stethoscope. Ensure that the diaphragm entire surface is
closely / firmly applied to the patient’s skin.
Assessing Low-Pitched Sounds – The heart murmurs, 3rd and 4th heart sounds
(S3 and S4) are all low-pitched sounds. To pick such sounds lightly place the
bell of the stethoscope on the appropriate areas. Do not exert pressure. If you
do, the patient’s chest will act as diaphragm and you will miss low-pitched
sounds.
Like all the other assessment techniques, it requires conscious effort and regular
practice to become proficient in its use.

In-text Question 1 (A short question requiring a single sentence answer for quick reflection
over the read topic): What is the use of the four (4) special senses in observation/physical
examination

142
Answer 1. Eye (Sight) for visual clues e.g. patient’s appearance, mannerisms, mode of
dressing.
2. Touch (Tactile) for palpating any part of the patient to provide information such as
coldness, swelling etc.
3. Auditory (Ear) - use of hearing aids to collect
information (stethoscope).
4. Olfactory (Nose) an offensive smell when perceived around a patient can be suggestive of
an underlying problem.

3.0 Tutor Marked Assignments (Individual or Group)

1. Explain the purpose, components, and techniques related to the health
history and physical examination
2. describe the appropriate use and techniques of inspection, palpation
percussion, and auscultation

4.0 Conclusion/Summary
Health assessment is a vital part of nursing care and it is conducted in a
systematic manner through history taking and physical examination. Effective
nursing history requires good communication and interpersonal skills while
skills in inspection, palpation, percussion, and auscultation are needed for
complete physical examination. Furthermore, knowledge of the normal
structure and function of body parts and systems is an essential perquisite to
conducting physical assessment.
In spite of proliferation of ancillary aids, history taking and physical
examination remain essential skills for nurses. The unit though might not have
included the interpretation of findings; it has presented a comprehensive
package on assessment techniques, especially as relating to knowledge that are
vital to skill acquisition.

5.0 Self-Assessment Questions

1. You are asked to make an initial assessment on a woman entering the
nursing home. Describe the methods/techniques you will use in making

143
 the assessment and identify types of data you will collect.

6.0 References/Further Readings

Carpenito, L. (1989). Nursing Diagnosis, Application to Clinical Practice (3rd
Ed.). Philadelphia: J.B Lippincott.
Cecere, M. C. & McCash, K. E. (1992). Health History and Physical
Examination. In S. M. Lewis and I. C. Collier (eds.) Medical- Surgical

Nursing; Assessment and Management of Clinical Problems (3rd Ed.). St

Louis: Mosby-Year Book, Inc.
Christensen, P. & Kenney, J. (1990). Nursing Process: Application of

Conceptual Models (3rd Ed.). St. Louis: Mosby-Year Book Inc.

Cynthia, C.; Breuninger, T. A.; Ginnona, J. G. & Mintzer, D. W. (1994).
Nurse’s Pocket Companion. Pennsylvania: Springhouse Corporation.
Donovan, J.E.; Belsjoe, E.H. and Dillon, D.C. (1968). The Nurse Aide.
New York: McGraw-Hill Book Company.
Moffett, B. S. (1998). Assessment. In S. C. Delaune & P.K. Ladner (Eds.).
Fundamentals of Nursing, Standards and Practice. Albany: Delmar
Publishers.
Roark, M. L. (1995). Vital Signs. In C. B. Rosdahl (Ed.). Textbook of Basic
Nursing. Philadelphia: J.B. Lippincott Company.
Smith, J.P. (1982). Nursing Observations. In E. Pearce (ed.) A General

Textbook of Nursing (20th Ed.). Norwich: The English Language Book

Society and Faber and Faber.

Swash, M. & Mason, S. (1986). Hutchison’s Clinical Methods (18th Ed.). East
Sussex: Bailliere Tindall.
Timby, B.K. (Ed.). (1996). Vital Signs. Fundamental Skills and Concepts in

Patient Care (6th Ed.). Philadelphia: Lippincott.

144
Webster, C. (1995). Health and Physical Assessment. In H. B. M. Heath (ed.)
Potters and Perry’s Foundations in Nursing Theory and Practice. Italy:
Mosby, An Imprint of Times Mirror International.

STUDY SESSION 3
Diagnostic Measures in Patients Care
Section and Subsection Headings:
Introduction
1.0 Learning Outcomes
2.0 Main Content
2.1- Preparing a Client for Diagnostic Investigation
2.2- Common Laboratory Tests
2.3- Lumbar Puncture
2.4- Sputum Studies
2.5– Urinalysis

145
 2.6- Radiological Studies
3.0 Tutor Marked Assignments (Individual or Group assignments)
4.0 Study Session Summary and Conclusion
5.0 Self-Assessment Questions
6.0 Additional Activities (Videos, Animations & Out of Class activities)
7.0 References/Further Readings

Introduction:
A mastery of assessment technique no doubt will go a long way in assisting a
clinician in elucidating clients’ problems. However, experience has shown that
occasionally the findings generated from physical assessment no matter how
comprehensive may be insufficient for making a definite diagnosis. This is not
surprising as many diseases present with similar clinical features; hence
without the benefit of hindsight it may be difficult if not impossible to make an
accurate diagnosis. Diagnostic investigations provide this benefit of hindsight.
Diagnostic investigations could therefore be likened to the third leg to making
an appropriate diagnosis. Consequently, it is expedient for nurses to become
conversant with simple diagnostic techniques that are employed in the
management of clients/patients conditions. Unlike the preceding unit, students
are provided information on how these investigations are carried out and
possible interpretation of results.

1.0 Study Session Learning Outcomes

After studying this session, I expect you to be able to:
1. describe common invasive and noninvasive diagnostic procedures
2. explain to patient what is involved to allay anxieties
3. discuss the relevant client teaching guidelines for care of client before,
during and after diagnostic testing

146
 4. identify specific physical preparations (such as bowel preparation, fluid
deprivation e.t.c.) needed for certain diagnostic procedures
5. describe accurately sample collection techniques and means of ensuring
delivery to right places
6. determine what routine observations are required to spot dangers
associated with certain investigations that carry risks (e.g. renal biopsy)
and be equipped with what measure to take to avert such risks.

2.0 Main Content

2.1. Preparing a Client for Diagnostic Investigations
The nurse plays a key role in scheduling and preparing the client for diagnostic
investigations. When tests are not scheduled correctly, the clients are not only
inconvenienced, but also deprived of timely interventions, thus further
subjecting the client to untold hardship and further risk. The institution is also at
risk of losing money (Delaune & Ladner, 1998).

General Nursing Responsibilities

Explain to clients why the test needs to be performed, what is involved, an
estimation of how long the test will
take, outcome and adverse effects of
the test, and assess effectiveness of
teaching. An investigation that
involves the cooperation of patients
requires the nurse to give definite
instructions to clients on what they
are expected to do. This helps to allay
clients’ anxiety, enhances their cooperation, encourages relaxation of muscles to

147
facilitate instrumentation, promotes reliability of test and efficient utilization of
time, and above all, increases cost effectiveness.
1. Ensure proper identification of clients. This promotes client’s safety.
2. Review client’s medical record for allergies and previous adverse
reactions to nip in the bud any anaphylactic reaction and its associated
complications. Notify other physician accordingly.
3. Assess the presence, location, and characteristics of physical and
communicative limitations or preexisting conditions.
4. Assess vital signs of clients scheduled for invasive investigations to
establish baseline data. Establish intravenous access if necessary for
procedure.
5. Adequate physical preparation such as bowel preparation, fluid
deprivation e.t.c. Clarify with practitioner if regularly scheduled
medications are to be administered. The nil per oral (NPO) status is
determined by the type of investigation. Monitor level of hydration and
weakness for clients who are NPO, especially geriatric and pediatric
population. Administer cathartics or laxatives as denoted by the test’s
protocol.
6. Evaluates client’s knowledge of what to expect, client’s anxiety and
client’s level of safety and comfort.
In-text Question 1 (A short question requiring a single sentence answer for quick reflection
over the read topic) List out the purpose of glucose fasting plasma.

Answer To screen for diabetes mellitus and other glucose metabolism disorders.
To monitor drug or dietary therapy in patients with diabetes mellitus.
To help determine the insulin requirements of patients who have uncontrolled
diabetes mellitus and those who require parental or enteral nutritional support.
To help evaluate patients with known or suspected hypoglycemia.

2.2 Common Laboratory Tests

Common laboratory studies are usually simple measurements to determine how
much or how many analytes, (a substance dissolved in a solution, also called a

148
solute) are present in a specimen. Laboratory tests are ordered by the
practitioners to:
i. Detect and qualify the risk of future disease
ii. Establish and exclude diagnoses
iii. Assess the severity of the disease process and determine the prognosis
iv. Guide the selection of interventions
v. Monitor the progress of the disorder
vi. Monitor the effectiveness of the treatment
The laboratory results are interpreted and compared to the clinical observations.

Hematocrit
Hematocrit measures the percentage of packed red blood cells (RBC) in a whole
blood sample. The hematocrit value depends mainly on the number of RBC but
is also influenced by the size of the average RBC. Therefore, conditions that
result in elevated concentrations of blood glucose and sodium (which cause
swelling of RBC) may produce elevated hematocrit.
Procedure-Related Nursing Care: Explain the purpose to the patient and tell
him it requires a blood sample drawn from his finger. Then perform a
fingerstick on an adult, using a heparinized capillary tube with red band on the
anticoagulant end. Fill the capillary tube from the red- banded end to about two-
thirds’ capacity, and seal this end with clay.
Interpretation of Result: Hematocrit values vary with age and sex, the type of
sample, and the laboratory performing the test. Reference values range from

149
40% – 54% for men and from 37% – 47% for women. High hematocrit suggests
polycythemia or hemoconcentration caused by blood loss; low hematocrit may
indicate anemia or hemodilution.

Red Blood Cell Count or Erythrocyte Count

This is part of full blood count. This test determines the number of RBCs in a
cubic millimeter (microliter) of whole blood. Can be used to calculate two RBC
indices, mean corpuscular volume and mean corpuscular hemoglobin. These, in
turn, reveal RBC size and hemoglobin concentration and weight.
Procedure-Related Nursing Care: Explain the purpose of the test to the
patient and tell him you will need a blood sample. Then draw a venous blood
sample, using a 7ml lavender-top tube. Fill the collection tube completely, and
invert it gently several times to mix the sample and the anticoagulant. Handle
the sample gently to prevent hemolysis.
Interpretation of Result: RBC values vary with age and sex, the type of
sample, and altitude. In men, normal RBC counts range from 4.5 –

6.2 million/mm3 (4.5 – 6.2 x 1012/L) of venous blood; in women, from

4.2 – 5.4 million/mm3 (4.2 – 5.4 x 1012/L) of venous blood. People living at
high altitude usually have higher values. An elevated RBC may indicate primary
or secondary polycythemia or dehydration. A depressed count may signify
anemia, fluid overload, or recent hemorrhage.

White Blood Cell (WBC) Count

Like the RBC Count, this is also part of full blood count. WBC count reports the
number of WBC found in a cubic millimeter (microliter) of whole blood. On
any given day, the WBC count can vary by as much as 2,000. Such variations
may result from strenuous exercise, stress, or digestion. The WBC count can
rise and fall significantly in certain diseases, but the count is diagnostically

150
useful only when interpreted in the light of WBC differential and patient’s
current clinical status. It is particularly useful for determining the presence of
infection and for monitoring patient’s response to chemotherapy.
Procedure-Related Nursing Care: Explain the purpose of the test to the
patient. Tell him to avoid strenuous exercise for 24 hours before the test. If he is
receiving treatment for an infection, advise him that this test may be repeated to
monitor his progress. Perform venipuncture, collecting the sample in a 7ml
lavender top tube. Handle the sample gently to prevent hemolysis. After the
procedure tell the patient he may resume normal activities.
Interpretation of Result: The WBC normally ranges from 4, 00 – 10,

9000/mm3. An elevated WBC count (leukocytosis) usually signifies infection.

A high count may also be secondary to leukemia or tissue necrosis emanating
from burns, myocardial infarction or gangrene. On the other hand, a low count
(leukopenia) indicates bone marrow depression which may be secondary to
viral infections or toxic reactions following ingestion of mercury or other heavy
metals. It could also be complication of treatment with antineoplastics, or
exposure to benzene or arsenicals. Leukopenia also characteristically
accompanies influenza, typhoid fever, measles, infectious hepatitis,
mononucleosis, and rubella.

Creatinine Clearance
This test determines how efficiently the kidneys clear creatinine from the blood.
The clearance rate is expressed in terms of the value of blood (in milliliters) that
the kidneys can clear of creatinine in 1 minute. The test requires a blood sample
and a timed urine specimen. Creatinine, the chief metabolite of creatinine, is
produced and excreted in constant amounts that are proportional to total muscle
mass. Normal physical activities, diet, and urine volume have little effect on this
production, although strenuous exercise and a high-protein diet can affect it.

151
Purpose
i. To assess renal function (primarily glomerular filtration)
ii. To monitor the progression of renal insufficiency.
Procedure-Related Nursing Care: Explain the purpose of the test to the
patient. Tell him that you will need a timed urine specimen and at least one
blood sample. Describe the urine collection procedure. Also inform client on
need to avoid eating an excessive amount of meat before the procedure and to
avoid strenuous exercise during the urine collection period. Collect a timed
urine specimen for a 2, 6, 12, or 24 hour period. Perform a venipuncture, and
collect the blood sample in the appropriate specimen bottle. Collect the urine
specimen in a bottle containing a preservative to prevent creatinine
degeneration. Refrigerate it or keep it on ice during the collection period. At the
end of the period send the specimen to the laboratory. Then inform patient he
may resume normal diet and activities.
Interpretation of Result: For men at age 20, the creatinine clearance rate
should be 90ml/minute/1.73m square of body surface. For women at age 20, the
creatinine clearance rate should be 84ml/minute/1.73m square of body surface.
The clearance rate declines by 6ml/minute for each decade of life. A low
creatinine clearance rate may result from reduced renal blood flow (from shock
or renal artery obstruction), acute tubular necrosis, acute or chronic
glomerulonephritis, advanced bilateral renal lesions (as occur in polycystic
kidney disease, renal tuberculosis, or cancer), or nephrosclerosis, congestive
heart failure and severe dehydration may also cause the creatinine clearance rate
to drop. An elevated creatinine clearance rate usually has little diagnostic
significance.

Erythrocyte Sedimentation Rate

152
A sensitive but nonspecific test, the erythrocyte sedimentation rate (ESR)
measures the time needed for erythrocytes (red blood cells) in a whole blood
sample to settle to the bottom of a vertical tube. It commonly provides the
earliest indication of disease when other chemical or physical signs are still
normal. The rate typically rises significantly in widespread inflammatory
disorders caused by infection or autoimmune mechanisms. Localized
inflammation and cancer may prolong the ESR elevation.

Purpose
1. To aid in diagnosing occult disease such as tuberculosis and connective
tissue disease
2. To monitor inflammatory and malignant disease.
Procedure-Related Nursing Care: Explain the purpose of the test to the
patient, and inform him on the need for his blood sample. Then perform a
venipuncture, collecting sample in appropriate bottle. Examine the sample for
clots and clumps; then send it to the laboratory immediately.
Interpretation of Result: The ESR normally ranges from 0 to 20mm/hour; it
increases with age. The ESR rises in most aneamias, pregnancy, acute or
chronic inflammation, tuberculosis, paraproteinemias (especially multiple
myeloma and waldenstrom’s macroglobulinemia), rheumatoid arthritis, and
some type of cancer. Polycythemia, sickle cell anemia, hyperviscosity, and low
plasma protein levels tends to depress the ESR.

Glucose, Fasting Plasma

Also known as the fasting sugar test, the fasting plasma glucose tests measures
the patient’s plasma glucose level after an 8 to 12 hours fast. When a patient
fasts, his plasma glucose level decreases stimulating the release of the hormone
glucagon. This hormone raises plasma glucose level by accelerating

153
glycogenolysis, stimulating gluconeogenesis, and inhibiting glycogen synthesis.
Normally the secretion of insulin stops the rise in glucose level. In patients with
diabetes however, the absence or deficiency of insulin allows glucose level to
remain persistently elevated.
Purpose
a. To screen for diabetes mellitus and other glucose metabolism disorders.
b. To monitor drug or dietary therapy in patients with diabetes mellitus.
c. To help determine the insulin requirements of patients who have
uncontrolled diabetes mellitus and those who require parental or enteral
nutritional support.
d. To help evaluate patients with known or suspected hypoglycemia
Procedure-Related Nursing Care: Explain the purpose of the test to the
patient. Tell him that it requires a blood sample and that he must fast (taking
only water) for 8 to 12 hours before the test. If the patient is known to have
diabetes, you should draw his blood before insulin or an oral antidiabetic drug.
Tell him to watch for symptoms of hypoglycemia, such as weakness,
restlessness, nervousness, hunger and sweating. Stress that he could report such
symptoms immediately. Prepare the laboratory slip for the blood sample, noting
the time of the patient’ last pretest meal and pretest medication. Also record the
time the sample was collected. Perform a venipuncture collecting the sample in
appropriate sample bottle. If the sample cannot be sent to the laboratory
immediately, refrigerate it and transport it as soon as possible. Give the patient a
balanced meal or a snack after the procedure. Assure him that he can now take
medications withheld before the procedure.
Interpretation of Result: The normal range for fasting plasma glucose level
varies according to the length of the fast. Generally, after an 8 to 12 hours fast,
normal values are between 70 and 115mg/dl. Fasting plasma glucose levels
greater than 115mg/dl but less than 140mg/dl may suggest impaired glucose

154
tolerance. A 2-hour glucose tolerance test that yields a plasma glucose level
between 140 and 200mg/dl, and an intervening oral glucose test that yield a
plasma glucose level greater than or equal to 200mg/dl confirms the diagnosis.
Levels greater than or equal to 140mg/dl (obtained on two or more occasions)
may indicate diabetes mellitus if other causes of patient’s hyperglycemia have
been ruled out. Such a patient will also have a random plasma glucose level
greater than or equal to 200mg/dl along with the classic signs and symptoms of
diabetes mellitus, such as polydipsia, polyuria, ketonuria, polyphagia and rapid
weight loss. Elevated levels can also result from pancreatitis, hyperthyroidism,
adenoma and pheochromocytoma. Hyperglycemia can also stem from
chronic hepatic disease, brain trauma, chronic

2.3 -Lumbar Puncture (Cerebrospinal Fluid Analysis)

The cerebrospinal fluid (CSF), a clear substance circulating in the subarachnoid
space, has several vital functions. It protects the brain and spinal cord from
injury and transports products of neurosecretion, cellular biosynthesis, and
cellular metabolism through the central nervous system (CNS). Most
commonly, a doctor obtains three CSF samples by lumbar puncture between the
third and fourth lumbar vertebrae. If a patient has an infection at this site,
lumbar puncture is contraindicated, and the doctor may instead perform a
cisternal puncture. If a patient has increased intracranial pressure, the doctor
must remove the CSF with extreme caution because the removal of fluid causes
a rapid reduction in pressure which could trigger brain stem herniation. The
doctor may instead perform a ventricular puncture on this patient. CSF samples
may also be obtained during other neurologic tests – myelography or
pneumoencephalography for instance.

155
Purpose
1. To measure CSF pressure and to detect possible obstruction of CSF
circulation.
2. To aid in diagnosing viral or bacterial meningitis, and subarachnoid or
intracranial hemorrhage, tumors, and abscesses.
3. To aid in diagnosing neurosyphilis and chronic CNS infections.

Procedure-Related Nursing Care

Before the Procedure: Explain the
purpose of the test to the patient and
describe the procedure. Tell him to remain
still and breathe normally during the
procedure because movement and
hyperventilation can alter pressure
readings and cause injury. Following these
instructions will also reduce his risk of developing a headache – the most
common adverse effect of a lumbar puncture. Just before the procedure, obtain a
lumbar puncture tray. Place the labeled tubes at the bedside, making sure the
labels are numbered sequentially, and include the patients name, the date, and
his room number as well as any laboratory instructions.
During the Procedure: If you’re assisting with the procedure, position the
patient as directed – usually, on his side at the edge of the bed with his knees
drawn up as far as possible (lateral decubitus position). This position allows full
flexion of the spine and easy access to the lumbar subarachnoid space. Place a
small pillow under the patient’s head and bend his head forward so that his
chin touches his chest. Help him maintain this position during the procedure.
Stand in front of him, and place one hand around his neck and the other around
his knees. If the doctor wants the patient in sitting position, have him sit on the
edge of the bed and lower his chest and head toward his knees. Help the patient

156
maintain this position throughout the procedure. Monitor the patient for signs of
adverse reactions, such as elevated pulse rate, pallor, or clammy skin. Make
sure the samples are placed in the appropriately labeled tubes. Record the time
of collection on the test request form; then send the form and the labeled
samples to the laboratory immediately.

After the Procedure: After a lumbar puncture, the patient usually lies flat for 8
hours. Some doctors, however allow a 30-degree elevation of the head of the
bed. Encourage the patient to drink plenty of fluids and remind him that raising
his head may cause a headache. If he develops a headache administer an
analgesic as ordered. Check the puncture site for redness, swelling, drainage,
CSF leakage and hematoma every hour for the first 4 hours, then every 4 hours
for the next 20 hours. Monitor the patient level of consciousness, pupillary
reaction, and vital signs. Also observe him for signs and symptoms of
complications of the lumbar puncture such as meningitis, cerebellar tonsillar
herniation, and medullary compression.
Interpretation of Result: Normal CSF pressure ranges from 50 – 180 mm
H2O. The CSF should appear clear and colorless. Normal protein content ranges
between 15 and 45 mg/dl; normal gamma globulin level, between 3% and 12%
of total protein. Glucose levels range between 45 and 85 mg/dl, which is two–
thirds of the blood glucose level. CSF should contain 0 – 5 white blood cells per
microliter and no red blood cells All serologic tests should be nonreactive. The
chloride level should be 118 to 130 Eq/liter and the Gram-stain should reveal no
organism. CSF abnormal results are summarized below:

Element Abnormal Result Possible Causes

CSF Pressure - Increase - Increased Intracranial
- Decrease Pressure
Appearance - Cloudy - Infection

157
 - Xanthochromic - Elevated protein level
- Bloody or RBC breakdown.
- Subarachnoid,

- Brown intracerebral, or
- Orange intraventricular
haemorrhage; spinal cord
obstruction; traumatic
Protein - Marked increase - Tumor, trauma,
haemorrhage, Diabetes
mellitus, polyneuritis,
Gamma k dd
- Increase - Demyelinating disease
globulin (such as Multiple
sclerosis) neurosyphilis
Glucose - Increase - Systemic hyperglycemia
-Decrease - Systemic hypoglycemia,
bacterial or fungal
infection, meningitis,
mumps post subarachnoid
Cell count - Increase in WBC - Meningitis, acute
count infection, onset of chronic
illness, tumor, abscess
-RBC present infarction, demyelinating
disease
Source: Cynthia, Breuninger, Ginnona, & Mintzer, 1 9 9 4 . Nurse’s
Pocket Companion.

2.4 Sputum Studies

Purpose – Examination of sputum to identify the pathogenic organism and the
presence of malignant cells.
Nursing Responsibilities – (a) Obtain a morning specimen. (b) Instruct the
patient to clear nose and throat, rinse mouth, and take a few deep breaths; then

158
have him/her cough up specimen from lung and tracheobronchial tree. (c) Send
specimen to the laboratory immediately, or refrigerate to prevent overgrowth of
organism. (d) Obtain specimen for culture before initiating anti-invectives.

2.5 Urinalysis
Simple urinalysis is usually performed at the side wards. Investigations
involving blood, microscopy, culture and sensitivity however need a laboratory
environment for meaningful result. Hence urinalysis can be classified as both
laboratory and side ward investigation.
Purpose – To detect blood, casts, and other abnormalities of urine; renal or
urinary tract disease; & metabolic or systemic disease.
Description – Obtain a urine specimen of at least 10 ml. A fresh morning
specimen is usually preferred. Observe the urine for colour, clarity, volume
(quantity), PH, specific gravity, deposits odour (Physical Examination).

Quick Dipstick Tests

The older chemical tests for urine have largely been replaced by simple
dipsticks where the presence of glucose, blood, or protein can be readily
detected. They are accurate and sensitive. Examples include:
i. Litmus paper for PH (Acid urine turns blue litmus paper to red while
alkaline urine turns red litmus paper to blue.
ii. Clinistix strip for sugar.
iii. Albustix strip for protein.
iv. Multistix strip for a wide range of substances.
v. Ketostix for acetone/ketone bodies
vi. Haemastix.

Procedure:

159
 i. Completely immerse all reagent areas of the strip in fresh, well- mixed,
uncentrifuged urine and remove immediately.
ii. Tap edge of strip against the side of urine container to remove excess
urine. Hold strip in a horizontal position to prevent possible soiling of
hands with urine or mixing chemical from adjacent reagent areas, making
sure that the test areas face upwards.
iii. Compare test areas closely with corresponding colour charts on the bottle
label at the times specified. Hold strip close to colour blocks and watch
carefully.
Test for Sugar
Cold Test
Clinictest Reagent Tablet – This is a quantitative test for sugar.
Equipment – Clinictest tablet, test tube, and dropper.
Procedure: (a) Place 5 drops of urine into a test tube with the aid of the special
dropper provided. Rinse the dropper and add 10 drops pf water to the urine.
Drop in one clinictest tablet. Effervescence will occur. Watch the test carefully
until effervescence stops and for 15secs longer. Then shake the tube gently and
compare the colour with the colour range on the chart scale.

Hot Test
Benedict’s Qualitative Test
Equipment: Bunsen burner, test tube, benedict solution.
Procedure: Drop 5ml of Benedict’s reagent into a test tube and add 8 – 10
drops of urine. Boil this mixture vigorously for 2 minutes. If sugar is present,
green, yellow, or brick-red coloration will occur. The changes from green to
back-red indicates out of sugar

Fehling Test
Equipment: Bunsen burner, test tube, Fehling solution A & B.

160
Procedure: To equal quality of Fehling solution A & B, add 8 – 10 drops of
urine and boil for 2 – 3 minutes. Any colour change from blue to brick-red is
indicative of presence of sugar.

Test for Protein Cold Test

Salicylsulphonic Acid Test Equipment: salicylsulphonic acid, test tube.
Procedure: Add 5 drops of 25% salicylsulphonic acid to about 5ml of urine in a
test tube. Shake the tube and look for cloudiness in the urine. The appearance of
opacity indicates the presence of protein and the degree of cloudiness gives
some idea of the relative protein concentration.

Esbach Quantitative Test

Equipment: Esbach Urinometer, Esbach’s reagent.

Procedure: Esbach Urinometer is used for this test. All urine passed by the
subject over a period, say 6 hours, is collected in a chem. Stoppered bottle and
mixed. Measure its specific gravity. If this exceeds 1.010, dilute a portion with
an equal volume of water. If the urine is alkaline, acidify it with a few drops of
10% acetic acid. Add urine to an Esbach tube to the level marked U. Add
Esbach’s reagent up to the level marked R. Cork the tube and invert it gently
several times to mix the contents. Stand the tube upright and leave it in a
constant temperature for 24 hours. Then read the level of the precipitate of
protein on the tube’s scale, with the eye on a level with the top of the sediment.
This gives the protein concentrate of the urine in parts per 1000 (g/l).

Boiling Test
Heat plus Acetic Acid
Equipment: Bunsen burner, test tube, dropper, acetic acid.

Procedure: Check that urine is mildly acidic. If it is not, add 10% acetic acid
solution until it is. Failure to check initial PH and adjust if necessary can

161
invalidate this test. If urine is cloudy, filter some for this procedure. Fill a
boiling tube about three-quarter (¾) full with urine and heat the top inch of the
liquid gently over a Bunsen flame, turning the tube while heating to prevent it
from cracking. Let it boil for a few moments. Compare the top boiled part of
the urine with the lower part to see if any cloudiness has appeared. If cloudy,
add a drop of acetic acid. If cloudiness or flocculation disappears, it has been
due to the presence of phosphate and is of no significance. But if it remains or
persists, it indicates the presence of albumin.

Test for Acetone or Ketone Bodies

Acetest Reagent Tablets
Equipment: Acetest tablets (Acetest tablets contain sodium nitroprusside,
glycine and buffers), Clean white paper.
Procedure: Place an Acetest tablets on clean, dry, white paper. Put 1 drop of
urine on the tablet, leave for 30 seconds, and then compare any colour change
with the colour chart. A positive result varies from lavender to deep purple, and
may be recorded as a trace to strongly positive.

Rothera’s Test
Equipment: Ammonium sulphate, freshly prepared 2% sodium nitroprusside,
strong ammonia solution.
Procedure: Saturate a portion of urine with ammonium sulphate by shaking
about 5ml of urine in a test tube with about the same volume of crystals of this
salt. Add 10 drops of freshly prepared 2% solution of sodium nitroprusside. Add
10 drops of strong ammonia solution. Allow to stand for 15 minutes. The
development of a purple colour indicates Ketone. This test is considered to be
too sensitive, as it often gives a positive result on a well subject who has not
eaten for several hours

162
Test for Blood
Occultest – This is a test that determines the presence of blood but not
necessarily the amount of blood present.

Equipment: Occultest tablet, filter paper, water.

Procedure: Place 1 drop of urine on a filter paper square and put one occultest
tablet in the center of the moist area. Add 2 drops of water to the tablet and
allow it to stand for 2 minutes. If after 2 minutes a diffuse blue colour appears
on the filter paper around the tablet, blood is present. The amount of blood is
proportional to the intensity of the colour and the speed with which it develops.
If no blue colour appears, the test is negative.

Test for Bile Pigments

Ictotest – A special test mat is required. 5 drops of urine are placed on this
special mat and one Ictotest reagent tablet is put in the center of the moistened
area. Flow 2 drops of water over the tablet. If bilirubin is present, a bluish-purple
colour appears around the tablet in about 30 seconds. The amount of bilirubin
present is determined by the speed of intensity of the reaction. If there is no
colour change or only a pinkish colour, then there is no bilirubin.

Iodine test – About an inch of urine is poured into each of the two test tubes.
Several drops of tincture of iodine are added drop by drop to one of them.
Shake the test tube with the iodine and urine, and compare it with the control
test tube. If a green colour develops, it is positive for bile pigments.

Fractional Urine
Purpose: To determine site and degree of bleeding after prostate surgery.
Description: Patient voids into one urine container and then without stopping
the stream, continues to void into another container. The amount of blood in
each container gives an indication of the degree and site of bleeding.

163
Nursing Responsibility: Provide 2 or 3 urine containers and instruct patient to
switch containers midway through the voiding without stopping the stream.

Urine Culture and Sensitivity

Purpose: For diagnosis of urinary tract infection (UTI) and identification of
causative agent or organism.
Description: A midstream clean catch or sterile catheterized specimen is
obtained, and the urine is placed in a culture medium for growth of bacterial
colonies. After incubation, the colonies are counted. If more than 100,000
organisms per milliliter are counted, there is a UTI. The organisms are then
identified as to type and a sensitivity test is run on it. Sensitivity tests involve
exposing the bacteria to various anti-infectives to see which most effectively
kills the organism.
Nursing Responsibilities: Instruct the patient in method for collection of a
‘clean catch’ specimen. Instructions come with the specimen container. Allow
time for questions after patient is familiar with directives. Send specimen to
laboratory immediately to prevent chance in PH which can affect bacterial
growth.

Urine Osmolality
Purpose: To determine urine concentrating ability of the kidney.
Description: The patient is either placed on fluid restrictions or given a specific
amount of fluid to drink before the test.
Nursing Responsibilities: Give high protein diet for 3 days prior to the urine
collection. Restrict fluids for 8 – 12 hours before obtaining specimen. Collect a
random urine specimen preferably in the morning, label it (including the time),
and send to laboratory.

24 Hours Urine Collection

164
Purpose: To determine how well kidneys can excrete creatinine (creatinine
clearance) i.e. glomerular filtration rate (GRF).

Description: A 24 hours urine specimen is obtained and a blood specimen is

also taken. Elevated serum creatinine with increased urine creatinine indicates
decreased kidney function.
Nursing Responsibilities: Place a sign on patient’s door and over the toilet
stating 24 hours urine collection in progress, so that everyone can save the urine
properly. Decide in conjunction with the laboratory technologist on a suitable
time. Have patient void and discard the urine. Note the time and put successive
voiding into the collection container. At the time the test is to end, ask the
patient to void and add this to the collection bottle. Label the specimen
adequately and send to the laboratory with the accompanying blood
specimen/sample (5ml).

2.6 Radiologic Studies

Radiography (the study of x-rays or gamma ray exposed film through the
action of ionizing radiation) is used by practitioner to study internal organ
structure.
Chest X-Ray
The most common radiologic study is the noninvasive, noncontrasted chest x-
ray. The best results are obtained when the
films are taken in the radiology
department; however a portable chest x-
ray can be performed at the bedside.
Radiologic projections of chest x-ray films
are taken from various views. Multiple
views of the chest are necessary for the
practitioner to assess the entire lung field.

165
Indications: Chest films can indicate the following alterations and diseases:
1. Lesions (tumors, cysts, masses) in the lung tissue, chest wall or bony
thorax or heart.
2. Inflammation of lung tissue (pneumonia, atelectasis, abscesses,
tuberculosis); pleura (pleuritis); and pericardium (pericarditis).
3. Fluid accumulation in the lung tissue (pulmonary edema,
hemothorax); pleura (pleural effusion)
4. Bone deformities and fractures of the rib and sternum.
5. Air accumulation in the lungs (chronic obstructive pulmonary disease,
emphysema); and pleura (pneumothorax).
6. Diaphragmatic hernia.
Nurses Responsibilities: To prepare a client for a chest x-ray, remove metal
objects (jewelry) and all clothing from waist up and replace with a gown. Metal
will appear on the x-ray film thereby obscuring visualization of parts of the
chest. Pregnant women are draped with a metal apron to protect the fetus.

Ultrasound
This is a non-invasive radiological investigation that employs high frequency
sound waves and oscilloscope screen to visualize deep body structures. This
study should be scheduled before any studies using a contrast medium or air to
ensure accuracy.
Purpose: To evaluate size, shape, and location of internal some
structures/organs such as: the brain, vascular structure, spleen, liver,
gallbladder, pancreas, uterus, and e.t.c. It is also done during pregnancy to
determine the gestational age, the expected day of delivery, the sex, the lie, the
position and the size of the fetus including the location of the placenta.
Description: A coupling agent (lubricant) is placed on the surface of the body
to be studied to increase the contact between the skin and the transducer

166
(instrument that converts electrical energy to sound waves). The transducer
emits waves that travel through the body tissue and are reflected back to the
transducer and recorded. The varying density of body tissues deflects the waves
into differentiated pattern on an oscilloscope. Photographs can be taken of the
sound wave pattern on the oscilloscope.
Nursing Responsibilities: Explain the purpose and procedure to the patient.
The client is instructed to lie still during the procedure. Instruct patients to drink
6 – 8 glasses of fluid and avoid urination prior to sonogram.

In-text Question 1 (A short question requiring a single sentence answer for quick reflection
over the read topic) Mention at least five (5) abnormalities which chest examination can
reveal.

Answer Lesions (tumors, cysts, masses) in the lung tissue, chest wall or bony thorax or heart.
Inflammation of lung tissue (pneumonia, atelectasis, abscesses, tuberculosis); pleura
(pleuritis); and pericardium (pericarditis).
Fluid accumulation in the lung tissue (pulmonary edema, hemothorax); pleura
(pleural effusion)
Bone deformities and fractures of the rib and sternum.
Air accumulation in the lungs (chronic obstructive pulmonary disease, emphysema);
and pleura (pneumothorax).
Diaphragmatic hernia.

3.0 Tutor Marked Assignments (Individual or Group)

1. identify specific physical preparations (such as bowel preparation, fluid
deprivation e.t.c.) needed for certain diagnostic procedures
2. describe accurately sample collection techniques and means of ensuring
delivery to right places

4.0 Conclusion/Summary
From the fore going, this study session has been able to discussed assessment
comprehensively and indications for its application that will enable nurses to
gets near to the truth of diagnosis which usually precede treatment whenever
possible, thus, serving as decision making tool in Nursing practice.

167
The unit has taken an incisive look at some of the common diagnostic tests
employed in clinical practice. It specifically discusses the purpose, description
with particular emphasis on nurses’ responsibilities before, during and after the
performance of such investigation, and interpretation of results that could be
obtained from the conduction of each investigation
As obvious from this unit there are so many diagnostic investigations for
elucidating patients problems exist in clinical practice. The list is inexhaustible.
Howbeit, thorough history taking and comprehensive physical assessment helps
in knowing which will be most helpful to diagnosing the patient’s condition

5.0 Self-Assessment Questions

Self-Assessment Questions (Should correspond to the No of Session Learning
Outcomes & each should relate to the corresponding Learning Outcome)
1. Discuss your nursing roles before, during and after; fasting blood.

6.0 References/Further Readings

Casapao, L.; Kellock, A. M.; Schnaebel, P.; Smalls, S., & Sutton, L. (1990).
Barron’s How to Prepare for the National Council Licensure Examination
for Registered Nurses – NCLEX RN (2nd Ed.). New York: Barron
Educational Series, Inc.
Cynthia, C.; Breuninger, T. A.; Ginnona, J. G. & Mintzer, D. W. (1994).
Nurse’s Pocket Companion. Pennsylvania: Springhouse Corporation.
Delaune, S. C. & Ladner, P.K. (Eds.). (1998). Responding to the Client
Undergoing Diagnostic Testing. Fundamentals of Nursing, Standards and
Practice. Albany: Delmar Publishers.
Roper, N. (1984). Churchill Livingstone Pocket Medical D i c t i o n a r y

(13th Ed.). New York: Churchill Livingstone Inc.

Usman, D. S.; Obajemihin, J. O.; Adegbite, M. F.; Bray, M. F.; W i l s o n ,

168
K. J. W. & Ross, J. S. (2000). Ross and Wilson Foundations of Nursing and
First Aid (6th Ed.). Singapore: Longman.

STUDY SESSION 4
Providing Safety and Comfort I
Section and Subsection Headings:
Introduction
1.0 Learning Outcomes
2.0 Main Content
2.1- General Safety Rules and Practices
2.2- The Role of the Nurse in Moving and Handling Patients
2.3- Control of Infection
2.4- Commonly Employed Comfort Measures in the Hospital
3.0 Tutor Marked Assignments (Individual or Group assignments)
4.0 Study Session Summary and Conclusion
5.0 Self-Assessment Questions
6.0 Additional Activities (Videos, Animations & Out of Class activities)
7.0 References/Further Readings

Introduction:
Safety, prevention of accidents and promotion of comfort are vital to survival,
and these needs continue throughout life. When a client/patient enters the health
care facility, an unwritten contract is established between the client/patient and
health care personnel. Inherent in this contract is fact that the health personnel
owe the patient a duty of service. As part of the package of that duty of care is

169
the obligation to safeguard the patient from harm/danger as well as to ensure
that the patient is made comfortable throughout his/her period of hospitalization.
In view of their infirmities, hospital patients are more susceptible to accidents
than any other group of people. As such the management of all hospitals must
be safety conscious. Even though it may be argued that safety in the health care
setting is everybody’s responsibility, the nurse is usually at a vantage point to
detect any unsafe condition that could precipitate injury to patients and visitors
in health setting and promptly institute corrective measures. Hence, the nurse
should be well informed and be acquainted with safety practices in the ward
setting and measures that promote patients’ comfort.

1.0 Study Session Learning Outcomes

After studying this session, I expect you to be able to:
1. outline the general safety rules and practices in the health care setting
2. describe the role of the nurse in moving and handling patients including
principles underlying moving and lifting of patients
3. give examples of risks in a health care setting and suggest preventive
measures
4. describe the role of the nurse in infection control
5. describe the different comfort measures employed in patient’s care in the
hospital and explain their underlying principles.

2.0 Main Content

2.1. General Safety Rules and Practices
First, it is important for you to believe that most accidents are preventable.
Secondly, most accidents in the hospital result from carelessness or an error in
judgment (Donovan, Belsjoe, and Dillon, 1968). Here however are some of the
safety regulations and practices in the health care setting:

170
a. Walk rather than run – especially on stairs and along corridors.
b. Open doors slowly. Do not open a door by pushing on the glass part.
c. Walk on right in halls – especially when pushing a wheelchair or
stretcher. Installing corridor mirrors which enable those wheeling a
stretcher or other patient vehicles to see around blind corners.
d. Installing safety devices, wherever practicable including cautious use of
bedside rails.
e. Ensure adequate lighting by illuminating areas in which people move and
work.
f. Ensure good housekeeping and avoid wet patches on the floor. Using
non-slip floor coatings. Placing rubber mats on inclines and in the bathtub
before a patient uses the tub.
g. Do not engage in horseplay or practical jokes.
h. Observe principles of good body mechanics. Follow correct lifting
procedures when lifting a heavy object or lifting a patient. Possibly
introducing safety classes which teach correct lifting procedures and
other safety principles.
i. Remember the elderly and the very young are more accident- prone than
the adult. Protect them as much as possible.
j. Endeavor to properly label all materials including medicaments and water
taps in bathrooms. Discard all unlabeled containers and bottles. Never use
the content of an unlabeled container. Analyze causes of medication
errors and instituting changes.
k. Provision for refuse collection and proper waste disposal to maintain
hygienic condition.
l. Ensure proper bed spacing is maintained.
m. Maintaining aseptic technique for all invasive procedures.

171
 n. Appropriate institution of isolation techniques and barrier nursing in
infectious cases.
o. Periodic fumigation of hospital ward and surgical theatres.
p. Never overload an electric socket and avoid using defective electric
equipment.
q. All electrical appliances left on should be switched off and deplugged at
the close of the day. Employ measures which minimize the accumulation
of static electricity.
r. Obey all NO SMOKING signs. Never smoke or permit anyone to smoke
in the vicinity of oxygen equipment that is in use.
s. When smoking in designated areas, see that cigarettes are completely
extinguished in receptacles provided.
t. Report any injury to self or to others immediately and secure first aid.
u. Be safety-conscious at all times. If you notice a safety hazard, report it at
once to the right person. Provide educational programs for employee
which emphasize that accidents are preventable.
v. When in doubt about how to handle or do something the safe way, ask
someone with more experience and training than you for help or advice.
w. Instituting incident reporting system and appointing members to a safety
committee who are saddled with the responsibility of reviewing safety
practices, analyzing potential safety hazards, and recommending
constructive procedures to prevent accidents.
(Donovan, Belsjoe, and Dillon, 1968)
In-text Question 1 (A short question requiring a single sentence answer for quick
reflection over the read topic): Quickly recap an indication for perineal care.

Answer Following a vaginal delivery or gynecologic or rectal surgery, so that

the impaired skin is kept as clean as possible.

2.2 The Role of the Nurse in Moving and Handling Patients

172
In professional nursing practice there will always be the need to move patients
or heavy equipment from one point to the other and this exposes the nurse to
additional risks. Parboteeah (2002) quoting the Disabled Living Foundation
(1994) indicated that one in four nurses has taken time off with back injury
sustained at work, this for some meaning the end of their nursing career.

The back is like a mast or a pillar that makes functional and productive
movement possible. Geographically it is an entity comprising the vertebral
column with its articular and periarticular structure and the musculature
extending from the occiput to the sacrum. The back functions as a structure as
well as a mechanism. As a structure, the back can withstand a comprehensive
force 10 times the weight it normally supports. As a mechanism, with little
effort the back can bent forward, backwards, sideways and even twisted.
However as strong as back is and as vital as it is, it is not immune to injury
especially those arising from poor lifting techniques.
While it is beyond the scope of this unit to go into the pathogenesis of back
pain, there may be no better period than now to examine what constitute correct
lifting technique. Nurse should also know how to set the back muscles (i.e. keep
their back muscles partially tensed to absorb any imminent shock) particularly
when lifting, or bending forward to pick or give out something. In lifting:
i. Keep as close as possible and safe to the object to be lifted.
ii. Maintain a good base of support.
iii. Keep the back as vertical as possible.
iv. Remember not to carry alone object than 70% of your body weight.

These four principles must always be borne in mind when lifting or transferring
patients.

173
Here are additional safety tips or precautions that must be observed in the health
care setting:
i. Always make sure the brake is on when transferring patients to
wheelchairs or stretchers or when the patient is left momentarily in a
wheelchair or stretcher. Instruct the patient not to step on the footrest in
getting into and out of the wheelchair.
ii. When transporting a patient on a stretcher, stand at his head and move
slowly. Be alert for moving persons or conveyances coming from any
possible direction.
iii. When going down an incline, guide the stretcher from the foot and
proceed slowly.
iv. Check restraining straps for proper fastening.
v. Never lift a patient who is too heavy without assistance.
vi. Never leave a paralyzed patient alone in the bathroom or in bed with the
side rails down.
vii. Never leave a paralyzed or helpless patient sitting in a chair without a
protective restraint around the waist.
viii. Never allow a patient who is in an oxygen tent to have any electric
appliances inside the tent. This includes the electric call bell (Donovan,
Belsjoe, and Dillon, 1968).

2.3 Control of Infection

Microorganisms exist everywhere in the environment: in water, soil, and on
body surfaces such as the skin, gastrointestinal tract, vaginal, e.t.c (Kozier, et
al., 2000). Some are harmless; some are beneficial while others otherwise
referred to as pathogens are harmful to the body that is, capable of producing
infection. The term infection is used to describe the invasion and development
or multiplication of pathogens in the body of man or animal. Infection could be
apparent/manifest, or in apparent/symptomatic/subclinical infection. It could be

174
autoinfection (self-infection), or cross infection (contracted from other sources
such as other individuals harboring or suffering from the same infection or
associated with the delivery of health care services in health care setting, usually
referred to as Nosocomial or hospital acquired infection including Iatrogenic
infection i.e. those are due to any aspect of therapy). It is therefore the nurses’
responsibility to provide biologically safe environment and reduce the spread of
infection within the health care setting.
Below are some of the measures employed by nurses to achieve this lofty
objective:
Hand Hygiene – Many infections are spread by contact, the hands being a
major vehicle in the transmission of infection (RCN, 1992). In Parboteeah
(2002) words ‘normal skin has a resident population of microorganisms, other
transient organisms being picked up and shed during contact in the delivery of
nursing care’. Parboteeah stated further that the goal of handwashing is to
remove these transient organisms or reduce their number below that of infective
dose before that are transmitted to a patient. Handwashing therefore is the most
important method of preventing spread by contact. According to Parboteeah
(2002) indications for handwashing include: Before and after aseptic techniques
or invasive procedures; Before contact with susceptible patient; After handling
body fluids; After handling contaminated items; Prior to the administration of
drugs; Before serving meals; After removing aprons and gloves; At the
beginning and end of duty; and If in any doubt. It is equally important that
patients’ hands are kept clean.

The Use of Face Mask – Masks are worn to reduce the transmission of
organisms by the droplet contact, airborne routes, and splatters of body
substances. The CDC recommends that masks be worn under the following
conditions: (1) Only by those close to the client if the infection is transmitted by

175
large-particle aerosols (droplets) like measles, mumps and other
acute
respiratory tract infections; (2) By all persons entering the room if the infection
is transmitted by small-particle aerosols (droplet nuclei) e.g. Tuberculosis; (3)
During certain techniques requiring surgical asepsis to prevent droplet contact
transmission of exhaled microorganisms to the sterile field or to a client’s open
wound (Kozier, et al., 2000).

Sterilization – The process of destroying all microorganisms and their

pathogenic agents e.g. spores. Often employed in the preparation of dressing
materials, equipment and other materials needed for surgeries and all invasive
procedures. Detailed discussion of sterilization techniques will be considered in
some other units.

Disinfection – This is defined as the killing of infectious agents outside the

body by chemical or physical means, directly applied. Could be an on-going
process (Concurrent disinfection) or Terminal – the application of
disinfective measures after the patient has been discharged from the hospital or
has ceased to be a source of infection.

Isolation – Isolation refers to measures designed to prevent the direct and

indirect conveyance of the infectious agent from those infected to susceptible
individuals (other clients, visitors and health care personnel). A variety of
isolation techniques are used in the health care setting. This will be expatiated in
some other units but it is suffice to state that when patients are isolated because
of contagious and infectious diseases, the nurse must be certain that proper
technique is carried out in caring for them and must be sure that their visitors
also understand and carry out necessary precautions.

176
Others are: Adequate Bed-Spacing; Proper Waste Disposal; Health
Education e.t.c.

2.4 Commonly Employed Comfort Measures in the Hospital

(a) Bed making
Hospital patients spend varying degree of time in bed, as such; their comfort is
of utmost importance. The need to improve and maintain, for as long as
possible, the comfort of these patients therefore forms the primary reason for
bed making. A related one is the need to relieve pressure from certain parts of
the body and stimulates circulation thereby preventing the development of
decubitus ulcer (pressure sore).

A Typical Hospital Bed

A typical hospital bed is higher than the conventional beds at homes. This is to
reduce undue physical strain to the nurses’ back while attending to the patient.
The bedstead is usually 6ft 6 inches long, 3ft wide and 26inches high. The
framework is steel or iron; the castors are well made and move easily without
jarring the bed. In some cases the height may be adjustable, and the head or foot
of the bedstead may be raised or lowered by levers. A movable back is supplied
with most beds. This can be brought forward to act as a backrest, or removed
completely for any treatment when necessary. A mattress is placed on the
bedstead. Hair, interior spring, rubber foam, plastic foam, sorbo rubber are the
types commonly used in hospital wards.
The mattress is usually covered with a
polythene sheet or protective waterproof
material.

177
The number of pillows used will depend on the need of the patient. Pillows are
usually stuffed with foams/hairs with a protective cover under the pillowcase.
Blankets – Turkish toweling, cellular cotton, synthetic material or wool
blankets may be used to keep the patient warm without being unnecessarily
heavy or causing discomfort to the patient. Terry blankets and cellular cotton
blankets are most commonly used nowadays. Bed sheets must be long and wide
enough for the type of bed used. Sheets are often made of cotton,
polyester/cotton mixture or linen. Counterpanes or bedspread are usually light
in colour and weight. Draw sheets are usually placed over a polythene protector
(mackintosh) across the bed under the patient’s buttocks. They are often placed
in such a way that they could be drawn at frequent intervals to give the patient a
clean, cool, fresh piece of sheet to lie on. The standard size of drawn sheet is 2

yards wide and 11/2 yards long. Long waterproof sheets – these are used
routinely to cover the entire mattress in some hospitals while in others they are
only used for selected patients.

Adjuncts to Hospital Bed/Special Appliances used in Bed making

Bed tables - Preferably of adjustable height. Meant for eating or leaning arms
on when sitting upright or when in respiratory embarrassment.
Bed cradles - Made of metal. Used for keeping the weight of bedclothes off the
patient’s legs or body, especially in weak or debilitated patients. Particularly
useful after Plaster of Paris (POP) has been applied to fractured leg.
Bed rest – Usually attached to but may be separate from the bed. More often
than not metal but occasionally could be made of wood especially the separate
type. Most commonly used in putting the patient in sitting up position with
pillows placed between it and the patient.
Bed elevators & bed blocks – A number of beds have elevators built into them
so that the head or foot of the bed may be raised as required. In some cases, the

178
elevators, which are usually metal, have several rungs at varying heights on
which the bar of the bed may be supported at desired height. Sometimes a
portable wooden bed blocks may be used for the same purpose. Such blocks
usually have a depression at their tops into which the castors of the bed can fit.
They also vary in height.
Bed – strippers – These are stands placed at the foot of the bed over which
bedclothes are draped during bed making. Sometimes, two chairs placed back to
back can be improvised for this.
Air rings /Air cushions/Foam rubber rings – These may be placed under the
patient’s buttocks to relieve pressure.

Fracture boards – Wooden. May be placed under the mattress to provide a

firmer based on which to lie. In other words, they prevent the mattress from
sagging. Patients with spinal conditions, back injuries and some fractures find
this most helpful.
Sand bags – These are made of impermeable materials, which are filled with
sand. They are used for immobilization of limb(s) in the treatment of special
conditions e.g. amputation to control phantom movement/pain. They must
always be covered with cotton.
Hot water bottles – These are made of rubber or aluminum. They are used to
give added warmth to patient.
Others are Drip stand, Bed stirrup e.t.c

Principles Governing Bed making

Bed making is essentially two-man procedure. Some of the principles guiding
this procedure are outlined below:
1. Principle of Organization – Bedclothes and other materials needed must
be arranged in order of priority. The two nurses must work from top to

179
 bottom of the bed. They must equally work in unison/harmony i.e. there
must be synchronicity of action.
2. Principle of Body Mechanics – There must be economy of movement.
3. Principle of Comfort and Safety – The two nurses must maintain a near
erect position and avoid straining or overstretching their back to prevent
injury. The bed should be crump and wrinkle free. Always lift the patient
off the bed or roll from side to side in case of occupied bed. On no
account should the patient be dragged on bed.
4. Principle of Asepsis – Fans must be put off. There should be no jarring
or flying of bed sheets in the air to prevent cross infection. Uniforms are
prevented from touching bedclothes and hands are washed before and
after the procedure.
5. Time Management – The two nurses must work with speed and
accuracy. There must be economy of movement.

Bed making: Definition and Types

The process of applying or changing linens is what is referred to as bed making.
Types are:
The Unoccupied Bed: There are two types of unoccupied bed viz – The Closed
Bed and the Open Bed. A closed bed is the bed making process that is
performed following the discharge or transfer of a patient when no new patient
is expected. An Open Bed on the other hand is the bed making process that is
carried out when the occupant is able to be up while the bed is being made i.e.
the type that is made for an ambulant or out-of-bed patient
The Occupied Bed: Bed making process in which the bed is made while the
patient is in it. There are different typologies – Fractured Bed (Characterized
by a firm lying surface its offers the patient. Often employed in the care of
patient with back pain and those with fractures); Divided Bed (So named by the
fashion in which it is made. Used mostly in the care of amputees. Also

180
employed in the drying of Plaster of Paris). Post-Operative Bed/Operation Bed
– This is the bed that is prepared to receive a post-surgical patient with minimal
disturbance.
Making the Unoccupied Bed Points to Keep in Mind
Whether or not making empty beds for new patients is one of your
responsibilities, bed making is a frequent procedure for any staff member giving
nursing care.
Many patients are required by doctor's orders to sit up in a chair, even for a
short time. So most patients' beds are unoccupied at one time or another during
the morning and can be made when the patient is out of it.
In any case, it is important to remember that soon a patient will be occupying
the bed. If the bottom sheet is anchored properly, it will not loosen and bunch in
wrinkles under the patient's back. The top covers will be high enough to cover
the shoulders, yet loose enough so that the patient's feet will not be restrained
and pulled forward in an abnormal position.
In the procedure described here, there is no linen on the bed to start with; it is
made with clean linen throughout. However, if the bed is unoccupied only
because the patient is out of it for a while, then there will be linens on the bed.
Thus the list below would be adjusted to those items needed in your situation.

Equipment Needed
1. Cotton quilted mattress pad or mattress cover according to policy.
2. 2 large sheets
3. Rubber or plastic draw sheet, if it is the policy to use one
4. Cotton draw sheet
5. Blanket, if needed
6. Bedspread
7. Pillowcase for each pillow used

181
 Important Steps Reasons for Action
1. Wash your hands before selecting Unclean hands may spread disease
linens; then take everything needed germs to clean linen, and to patient
next to patient's unit. who is to be to and pillowcase.
2. Place linen on straight chair near Stacking linens in this manner saves
foot of bed. Stack the items in order time and effort later on.
of use, that is, bedspread and
pillowcase on bottom, and so on
with the mattress pad on top.
3. See that bed is in high position and The higher level will cause less strain
is flat and that wheels are locked. on back and leg muscles.
4. Place the folded quilted mattress Lifting and shaking any item of linen
pad on near side of bed and unfold may stir up dust and lint which may
it without lifting or shaking it out which may carry and disease-causing
5. Place folded sheet on near side of Also ilifting and flapping linen at
bed and unfold it lengthwise in the shoulder level to unfold it causes
same manner described above, that unnecessary strain and fatigue on the
is without shaking or flapping it back, shoulder, and arm muscles.
Arrange sheet in this way:

182
 (a) With bottom hem even with Placing the bottom sheet correctly is
foot of mattress, depending on the most important step in bed
length of sheet. making.

(b) Allow 15 to 18 inches at head The Foundation sheet should be

of bed tuck under mattress. secure against anything that might
tend to loosen it. For this reason,
never skimp on this 15– to–18 inches
allowance to tuck under head of
mattress.
(c) With center of sheet at center
of bed, fanfold the far half of Covering foot of mattress is far less
sheet beyond the center of bed. Important.

The sheet is doubled back on itself in

folds of several inches - like a fan.

6. Lift the head of mattress with one If you face in the direction of your
hand and pull sheet under the work and move along in this position,
mattress with the other hand. See you will Avoid twisting groups of
that material is smooth after muscles, thus reducing strain and
tucking under. fatigue.
7. Make a mitered c o r n e r a t
head of mattress.
8. Continue tucking sheet under side Move along with your work, facing
of mattress from head to foot. side of mattress as you tuck sheet
from head to foot of bed. Keep feet
slightly separated.
9. If rubber draw sheet is used, place Where plasticized mattresses are
it about 12 to 15 inches from head used, it is often the policy to omit a
of mattress. Tuck smoothly under waterproof sheet. It is sometimes
mattress on near side. placed over the mattress and under
the quilted mattress pad.

183
10. Cover rubber sheet with cotton Lying directly on even a small strip
draw the sheet or a large sheet of rubber sheet will be uncomfortable
folded once may Cross-wise. and cause skin irritation to patient.
Place this cotton sheet about two or
three inches higher than the rubber
sheet and see that it is completely
covered.
11. Tuck cotton draw sheet smoothly
under side of mattresses on near
side. Fanfold far side of the sheet at
center of bed.
12. Go to other side of bed and tuck You may be taught to make on entire
bottom sheet smoothly under head side of the bed before going to the
of mattress. Make a mitered corner. other side. If careful attention is given
to unnecessary motion and energy
there may not be much difference.
13. Grasping bottom sheet with both By keeping your feet slightly
hands, tuck under mattress separated and your back straight, you
alongside of bed, tightening and will reduce s t r a i n .
smoothing it, as you Move from
head to foot of bed.
14. Pull rubber draw sheet (at center of When holding the sheet with palms
bed) toward you and smooth it out. downward, the strong muscles of the
Grasp with both hands, holding shoulders and arms are used. Keep
palms downward on level with one foot in front and rock backward
mattress; tighten the sheet and tuck on the other, as you tighten the sheet.
under side of mattress.

15. Pull the cotton draw sheet toward

you and smooth it in place over the
rubber sheet. Grasp it with both
hands and tuck under side of
mattress in the manner described
above.

Now you are ready to make the top part of the bed:

184
16. Continue on same side of bed. If wrong side of them is up, when the
Place the folded top sheet on near top edge of the sheet is turned down
side of bed and unfold it in the over the edge of bedspread, the right
manner described earlier. Arrange side of hem will show.
it this way:

(a) with upper edge of sheet even

with head of mattress
(b) with center of sheet straight and
at the center of bed
17. Tuck sheet (and blanket if used)
under foot of mattress and make a
corner.
Tuck under mattress at corner but
DO NOT tuck in along the side of
the bed. Allow it to hang free
18. Place folded spread on bed and
unfold it as described earlier :

(a) The upper edge is even with

head of mattress.
(b) It is centered and hangs evenly,
covering the sheet and blanket
completely.
19. Tuck bedspread under the mattress Allow the top covers to hang free at
at foot of bed. Make a corner on side of bed.
near side, but do not tuck the
finished corner under mattress.

20. Go to opposite side of bed and

repeat steps to complete making
the bed.

185
21. Rest the pillow on foot of bed and If pillowcase is considerably wider
draw on pillowcase - in this way: than the pillow, tuck the excess
and grasp the inside seam at end ofmaterial into a smooth fold on one
case. side, making the case fit well over the
pillow. Keep this tuck in place when
(a) Slip your hand inside placing on bed.
pillowcase and grasp the inside
seam at end of case.
(b) Still holding the inside seam,
place this same hand over the end
of pillow and pull on pillowcase
(c) Fit corners of case over
corners of pillow.

22. Place the pillow(s) flat on the bed

23. If you wish to "open" this bed, here Opening the bed, that is, turning the
is one of various ways it might be covers down, makes it look more
done: inviting to the patient sitting for a
time in a chair. If your patient has
(a) With both hands grasp the gone to a treatment room or X-ray
upper edge of the top covers; Department, it will be easier to assist
carefully bring your arms toward him back in bed.
foot of bed, until the upper edge
of cuff is at the foot of the bed.

(b) With hands still in place,

bring the cuff up to the fold
halfway up the bed. Straighten
and smooth the cuff.

186
24. If you wish a "closed" bed for a The steps of this procedure lend well
patient not yet admitted, the upper to learning good body mechanics.
edge of bedspread is left even with There is a certain rhythm that can be
the head of mattress. developed which will help you do job
in less time and with much less effort.
Try it.

Making the Occupied bed Points to Keep in Mind

1. Making the bed with a patient in it is necessary when the patient is too ill or
disabled to be out of bed. It is a long procedure and if not accomplished
skillfully, can be an extremely exhausting experience for the patient. It is
therefore a time when individual adjustments are needed to save time and to
lessen the exertion of the patient. And it calls for skills in handling each
step smoothly and avoiding irritations, such as bumping and jarring the bed.
2. It is also a time to observe the patient and to give him chance to talk about
anything on his mind. This may be done by listening, not talking about your
own problems and experiences.
3. If this procedure follows the patient's bath in bed, the first steps as given
here will have already been accomplished. For instance, all the top linen
would have been removed and the patient covered with a bath blanket.
However, to give a complete description here, this procedure starts with all
bed linens in place.

Equipment Needed
1. 2 large sheets, or as many as policy calls for
2. Cotton draw sheet; if used, top sheet is now used for draw sheet
3. Bedspread
4. Pillowcase for each pillow
5. Bath blanket.

187
 Important Steps Reasons for Action
1. Wash your hands before selecting If this procedure follows the
linens. Take everything needed to patient's bath, start with step 5
patient's unit and stack items on and loosen all the lower sheets.
chair in order of use. The reason is that the clean linen
will already be stacked on chair at
bedside. If top covers are
removed and bath blanket is on
the patient, move on to step 10.

2. Provide for privacy by placing

screen or pulling curtain.
3. Adjust the bed to level position
and lock the wheels. Remove all
but one pillow from under the
patient’s head.
4. See that laundry bag is in a place
Close-by.
5. Loosen all bottom sheets all You will be delayed later if sheets
around the bed. are still tucked securely under
mattress.
6. Remove bedspread by grasping it
at top edge and folding it to foot
of bed. If it is not to be used
again, fold and bunch it and drop
in laundry
hamper.
7. Place the folded bath blanket on If patient is not familiar with this
near side of bed and unfold it over step for removing sheet, tell him
top sheet If patient is not too ill, what you will do, so that he can
ask him to hold the top edge of be sure that he will not be
8. Slip hands under side of blanket
and grasp upper edge of sheet and
pull it from under the blanket to
the foot of bed.

188
9. Bring the top and bottom hems Shaking and flapping linens
together and fold the sheet on (especially used linen) stirs up
lower part of bed without shaking dust and lint which carry disease-
it out. causing organisms into the air.
10. Place folded top sheet on back of This top sheet will be used again
chair. as a bottom sheet or to cover
rubber draw sheet.
11. Go to other side of bed and help It is much easier to remove sheets
patient move toward you, then and replace them if there are no
turn him to side- lying position, pillows on the sheets. However,
facing you. Position him in good one pillow can be managed, if
alignment without pillow, if this patient is uncomfortable without
is not too uncomfortable for him. it.
12. Raise the side rail on that side of If patient is turned away from you
bed before returning to your to his side, he may just keep on
original position. turning and fall out of bed. There
is real danger of this.
13. Fold the near half of used cotton
draw sheet close against the
patient's back.
14. Fanfold the rubber draw sheet These sheets are folded separately
smoothly to the back of patient. Because each will be removed
later (except the rubber draw
sheet) one at a time.
15. Fanfold the entire length of the
used bottom sheet to the center of
bed and close to the patient's
back. Tuck each sheet under the
one before.

189
16. Place the folded clean bottom
sheet on the near side of bed and
unfold it length-wise in this
manner:

(a) With center fold straight with Face the direction of your work
mattress with it. and move Keep back straight but
not rigid; bend at hips. Knees
(b) Allow 15 to 18 inches at head should be slightly flexed and feet
of mattress. apart throughout action.

(c) With bottom hem even with

foot of mattress. This sheet will be placed under
the patient later. Do not wrinkle
(d) Fanfold far half of sheet or pull it out of shape.
carefully to patient's back.

17. Lift corner of mattress with one

hand as you tuck sheet under
head of mattress with the other
hand
18. Make a mitered corner at head of
mattress.
19. Tuck sheet smoothly under
mattress alongside of bed from
head to foot.
20. Locate the free end of the rubber
sheet near patient and pull it
toward you, without disturbing
the folded bottom Sheet.

190
21. Straighten the rubber sheet in Make sure that rubber sheet will
place and tuck it under mattress at never be next to patient's skin,
side of bed. because it will be irritating.
Allow the cotton draw sheet to
overlap the rubber sheet by two
or three inches at upper and lower
edges.
22. Place the used top sheet (folded
once crosswise) over the rubber
draw sheet and completely cover
it. Fold far half of sheet next to
patient's back. Tuck hanging part
under mattress, and make sure
both rubber sheet and draw sheet
are smooth.
23. Let the patient know that it is
time for him to roll back toward
you and that he is to roll over the
folded sheets which are at the
center of
the bed.
24. First, cradle the patient's feet and Try to keep the patient's body in
lower legs in your arms and move as good ' alignment as possible. It
towards you over the "bump" of will be much - less strain on him.
folded line (Keep edges of the Also, it will cause you less strain
bath blanket folded up on the and fatigue, if you keep your back
patient so it will be out of the way straight your knees slightly
of patient's movements and your flexed. Keep one foot a little in
action). front of the other. This allows you
to use the long strong thigh
muscles rather than the small
muscles of the back.
25. Next, give patient the assistance
he needs to move his hips and
shoulders as he rolls toward you
to his side.

191
26. Reach over the patient and push If patient has a drainage tube of
folded sheets away from patient's any kind, see that there is enough
back toward the far side of bed. slack in tube for turning.
27. Raise the side guard on your side, Use these side guards if available
then go the other side of bed. because the patient may misjudge
the width of bed and move to near
edge.
28. Lower side guard. Starting with Hold linens away from uniform
soiled bottom sheet, fold and and drop in laundry hamper.
bunch it as you remove it from
the bed.
29. Remove and discard cotton draw If patient is becoming
sheet in the same manner. uncomfortable Without a pillow,
reach for the one you put aside
earlier change pillowcase and
place under patient's head.
30. Pull clean bottom sheet in place;
tuck under mattress at head of
bed; make mitered corner and
tuck under mattress alongside of
bed.
31. Pull both draw sheets toward you
and straighten them. Tuck free
end of rubber draw sheet under
mattress, keeping it smooth and
tight.
32. Straighten clean cotton draw There is no reason to overdo the
sheet. Grasping and pulling at this tugging in place over rubber
step. It with both hands (palms sheet. If you lift the draw sheet up
down), hold it at level with higher than mattress level, you
mattress. Pull it tightly, but may cause the patient to roll out
without lifting it up, and tuck of bed. The cause and effect of
under side of mattress. this is something like using
crowbar to pry up a heavy object.

192
 33. Place clean top sheet on near side
of bed and unfold it on blanket
top of bath blanket
34. Have patient hold upper edge of This is done to prevent exposing
sheet while you fold bath blanket patient. At the same time, folding
to foot of bed and remove it. the blanket toward the foot of bed
under the top sheet does not stir
up dust.

35. Arrange top sheet to extend high

enough to cover
patient's shoulders; leave
excess at foot of bed; see that it
hangs evenly on both sides.
36. Before tucking sheet (and blanket, Tight top covers not only are
if used) under foot of mattress, uncomfortable for patient's feet
make a toe pleat to allow room for but may cause a serious
patient's feet. When blanket is condition. If the feet are
used, make the pleat in sheet and restrained in a forward position
blanket together. The toe pleat over a period of time, the
may be made in this way. muscles of the soles of the feet
are weakened. Th1s results in a
serious deformity called drop
foot.

Note: The other types of bed making will be discussed in some other units.

Personal Hygiene Practices

Maintenance of personal hygiene is necessary for comfort, safety and well-
being. Hygiene refers to practices that promote health through personally
cleanliness and it is fostered through activities like bathing, tooth brushing,
cleaning and maintaining fingernails and toenails, and shampooing and
grooming hair. Many a people shed their worries along with the day’s
accumulation of dirt by taking baths or showers. Man considers important to his

193
well-being not only having his skin cleaned but also being well groomed –
wearing decent clothes with nails cut and clean, and feet well shod. When clean
and attractively dressed, a person often gains confidence and can face difficulty
with equanimity.
Cleanliness and good
grooming are even
more important in
illness than in health.
Many a nurse has had
experience of seeing a
sick and uncomfortable
patient drop off into a
restful sleep after
taking his bath and having his bed changed. Oral care to relieve bitter/distasteful
taste and a general dryness of the mouth which is often associated with ill
health; and hair care to bring refreshing feeling are all essential adjuncts of care.
But when these factors are left unattended, the patient looks and feels more
miserable than his state of health warrants.
Healthy individuals are capable of meeting their own hygiene. Sick people are
however incapacitated by their ill health and as such require the nurses’
assistance to meet all their hygiene needs. The onus therefore lies on the nurses
to assess the person’s ability to perform self-care, plan necessary intervention to
meet any deficit and evaluate the effectiveness of the care.
Hygiene practices and needs may differ according to age, inherited
characteristics of the skin and hair, cultural values and of course health
problems. Whatever, the point to be made is that, most hygiene practices are
based or maintaining or restoring healthy qualities of the integument system.

194
Care of the Skin
In view of the enormous functions of the skin, it is just rational for the skin to be
kept healthy. One of the principal ways to ensure this is by bathing. Bathing is
the medium and method of cleansing the body. Although it’s primarily objective
is restoring cleanliness, it confers other benefits on the body. Such include:
1. Keeps the body clean of accumulated dirt, perspiration, secretions,
microorganism and debris, which can clog the skin pores, and thereby
reduce irritation and soreness. Removing these accumulations, which can
act as culture media for pathogens also aids in preventing infection and
preserving the healthy, unbroken condition of the skin?
2. Provides comfort and relaxation to a tired, restless patient.
3. Stimulates circulation, both systematically and locally.
4. Promotes muscle tone by active and or passive exercise.
5. Enhances elimination of wastes from the skin
6. Reduces, if not totally eliminate unpleasant body odour.
7. Prevents lung congestion by stimulating respiration through change of
position
8. Improve the patient’s self-esteem (self-image) through improved
appearance, which lead to increased interaction with others.

Types
The different kinds of bathing that people undertake can be subsumed into two
major groups:
1. Cleansing Bath: - Tub bath or showers
- Partial bath
- Complete bed bath
2. Therapeutic Bath: - Sitz bath
- Emollient bath or medicated bath
Cleansing Bath: The Objectives of cleansing bath are to:

195
 i. promote hygiene and comfort for the patient
ii. observed the patient’s skin condition
iii. assess the patient’s range of motion.
iv. encourage the patient to be as independent as possible on allowed
v. assess the patient’s physical and mental status
vi. establish a communication pattern between patient and nurse that
promotes health teaching and expression of patient concerns.
Providing a Tub Bath or shower
Equipment: - Buckets; Sponge/body flannel; Soap in soap dish; Small bowl;
Towel; Body lotions; Pyjamas.

Procedure
Actions Rationale
(a) Assessment
• Check nursing care plan for Ensures continuity of care.
hygiene directives.
• Assess the patient’s level of Provides data for evaluating the patient’s
consciousness, orientation, ability to carry out hygiene practices
strength, and mobility independently.
• Check for gauze dressings, plaster Contraindicates taking a tub bath or
cast, or electrical or battery shower.
operated equipment
• Determine if
and when any Aids time management
laboratory or diagnostic
procedures are scheduled
• Check the occupancy and Helps in organizing the plan for care.
cleanliness of the tub or shower
(b) Planning
• Clean tub or shower if it Reduces the potential for spreading
appears to need it microorganisms.

196
• Consult with patient about a Facilitate cooperation between the patient
convenient time for tending to and nurse.
hygiene needs.
• Assemble supplies, floor mat, Demonstrate organization and time
towels, face cloth, soap, clean management.
pyjamas or gowns
(c) Implementation
• Escort the patient to the shower orShow concern for the patient’s Safety
bathroom
• Demonstrate how to operate water Ensures the patient’s safety and comfort.
faucet and drain
• If the patient cannot operate the Demonstrate concern for the
water faucet, fill the tub patient’s safety and comfort.
approximately half full with water
between 1050F-1100F (40- 430C) or
adjust the shower to a similar
• Place a DO NOT DISTURB or IN Ensures privacy
USE Sign on the outer door.

• Help the patient into the tub if Reduces the risk of falling.
assistance is needed; this may be
done by:
- placing a chair next to the tub
- having the patient swing his/her
feet over the edge of the tub
- leaning forward, grabbing a support
bar and raising the buttocks and
body until they can be lowered
within the tub.
• Have patient sit on a stool or seat Ensures safety.
within the tub or shower, if the
patient will have difficulty existing
from the tub or may become weak
while bathing.

197
• Show the patient how to summon Promotes safety.
help.
• Stay close at hand. Ensure proximity in case there is a need to
assist the patient.
• Check the patient at frequent Shows respect for privacy yet
intervals by knocking at the door & concerns for safety.
waiting for a response.
• Escort the patient back to his/her Demonstrates concern for safety & welfare.
room on completion of the bath or
shower.
• Clean the tub or shower with Reduces the spread of microorganism and
antiseptic/antibacterial agent and demonstrate a conscientious concern for
dispose of the soiled linen in its the person who will use the tub shower or.
designated location.
• Remove the IN USE sign from the Indicates that the bathing room is
door. unoccupied.
(d) Evaluation
Patient is clean; Patient remains
uninjured.
(e) Document: Sample documentation: Date and time, Tub bath taken
independently, signature, title.

Source: Timby, B.K. (ed.) (1996). Fundamental Skills and Concepts in Patient
Care (6th Ed.).

Partial Bath
A daily bath or shower is not always necessary. In fact, the older adults who do
not perspire as much as younger adults and who are prone to dry skin, frequent
washing with soap may further deplete the oil from their skin. Therefore, there
may be certain instances when partial bathing may be appropriate.
A partial bath consists of washing those areas of the body that are subjected to
the greatest soiling or source of body odour such as the face, hands, and axillae.

198
Partial bathing may be done at a sink or with a basin at the bedside. There may
also be situations in which just the perineum, the areas around the genitals and
rectum are bathed. This is often referred to as perineal care.
Perineal Care Indications
i. Following a vaginal delivery or gynecologic or rectal surgery, so that the
impaired skin is kept as clean as possible.
ii. Whenever male or female patients have bloody drainage (urine/stool);
blood is a good medium for growth and development of microbes,
therefore its removal through perineal care reduces risk of infection.
Principles Guiding Perineal Care
i. Prevents direct contact between the nurse and the secretion or excretion
that may be present, and
ii. Cleanse in such a manner as to remove secretions and excretions from
less soiled to more soiled areas.

The Sitz Bath

A major component of perineal care is the sitz bath. It is the immersion of

buttocks, thighs, and lower trunk in water of a temperature from 1100 to 1150F.
The sitz bath may be given in a regular bathtub, filled approximately one third
full. There are however specially designed sitz tubs that allow the patient to sit
comfortably with hips and buttocks immersed in water. A portable sitz basin is
also is also available for use in commodes, chairs or even in bed. If nothing else
is available, a large basin could be used. It is important to point out here that;
local vasodilatation of the lower extremities may draw blood away from the
perineal area when the feet and the legs are completely immersed in the water as
in a bathtub. Therefore, wherever feasible, the feet and the legs should not be
immersed in the water. As such seating a patient in a basin is more desirable
than sitting him in a bathtub (King, Wieck & Dyer, 1977).

199
Indication
i. The sitz bath is used to relieve discomfort, congestion, or inflammation in
the pelvic and rectal regions.
ii. Promotes phagocytosis through increased peripheral vasodilation.
iii. Stimulate formation of new tissue through increased blood supply.
iv. Promote relaxation of local muscles.
v. Provide for cleanliness.
Equipment – Sitz tub or bathtub, Bath thermometer, Water of indicated
temperature, Rubber or plastic ring, Bath blankets and towel, Straight chair or
bath stool.

Procedure
Suggested Action Reason for Action
(a) Assessment
• Pull the privacy curtain. Demonstrate respect for modesty.
• Inspect t h e genital a n d Provides data for determining if perineal care
r e c t a l areas of the patient. is necessary.
(b) Planning
• Explain the procedure to the Reduce anxiety and promote
patient. cooperation

• Wash your hands. Reduces spread of

microorganisms.
• Gather equipment. Demonstrate organization and time
management.
• Place the patient in dorsal Provides access to the perineum.
recumbent position and cover
with a bath blanket.
• With gloved hands remove Soiled dressing are contaminated
soiled dressings and disposed
of properly.

200
 • Consult the patient’s folder Engenders accuracy and enhances maximal
for prescribed water Benefits from treatment.
temperature.
(c) Implementation

• Check the temperature of the Facilitates bath and prevent possible one-third
water with your bath full with warm water.
thermometer as you fill the
tub scalding.
• Place the bath stool or the Ensures safety.
straight chair next to the
bathtub and cover the seat
with one of the bath towels
you have obtained.
• Assist the patient in removing Promotes safety.
his bathrobe and have him sit
on the bath towel.
• Take the bath blanket and Helps in avoiding chilling which may cause
drape it around the patient. Pin the end together at the back.
vasoconstriction.
• If indicated, place rubber ring Sitting the patient on rubber ring will relieve
in bathtub. Pressure and discomfort if he has rectal or
Perineal sutures or pain.

• Help the patient get into the Reduces the risk of falling and sustaining
tub. Take the towel the patient injury.
was sitting on and place it
under his buttocks.
• Check the water temperature Fluctuations in water temperature can cause
from time to time and add cardiovascular stress.
warm water as required.

201
 • After the prescribed time Maximum benefit is obtained within the first
for treatment has elapsed, 20 minutes. Prolonging the procedure tires the
usually 20 patient and increases chances of cardio-
– 30 minutes, help the patient out vascular stress.
of the bath tub.
• If necessary or requested by Demonstrate concern for welfare.
the patient, help him to dry
himself and put on a clean
gown.
• Help the patient to return to Promotes comfort.
bed. See that the bed is dry
and warm. Arrange the
bedding for patient’s comfort.
• Return to bathroom. Wash the tub; disinfect Reduces the spread of
microorganism, if necessary.
• Return to bathroom. Wash the Reduces the spread of microorganism and
tub, disinfect it, if necessary. demonstrate a conscientious concern for the
Place used towels/washcloths next person who will use the tub.
in the hamper. Treat rubber
rings as instructed and return it
to designated storage.
(d) Evaluation
• Note and document the patient’s total reaction Helps in monitoring patient’s
response to treatment, including the colour of skin, therapy. The write-up
serves as a vehicle pulse and respiration. In addition, note the communication
with other team members. Length of time in bath.

Source: Donovan, Belsjoe, & Dillon (1968) The Nurse Aide; King,
Wieck, & Dyer (1977) Illustrated Manual of Nursing Techniques.

The need for safety and comfort in the health care settings cannot be
overemphasized. Hence the unit opens with a discussion on the general safety
rules and practices in the health care setting. It particularly examined the role of
the nurse clinician in moving and handling patients and the guiding principles

202
thereof. The role of the nurse in infection control was equally examined. Last
but not the least, the unit takes a detailed look at a few of the comfort measures
currently being employed in our hospitals. However, like we did note, there are
one thousand and one thing that could be done to ensure patient comfort and it
is a dynamic issue as it differ from patient to patient and changes as the
In-text Question 1 (A short question requiring a single sentence answer for quick
reflection over the read topic): List the principles guiding bed making

Answer Principle of organization, principle of body mechanics, principle of

comfort and safety, principle of asepsis and principle of time management.

3.0 Tutor Marked Assignments (Individual or Group)

1. describe the role of the nurse in infection control?
2. describe the different comfort measures employed in patient’s care in the
hospital and explain their underlying principles?

4.0Conclusion/Summary
To wrap it up, ensuring safety and providing comfort are vital to survival and
these continue throughout life. Having this in mind will make nurses to honour
an unwritten contract between the nurse and client. Via an extensive discussion
in this unit, am sure we are informed and acquainted with safety practices in the
ward setting and measures that promote patients’ comfort.
Provision of comfort and safety no doubt stands out as one of the nonnegotiable
requirements for successful recuperation and rehabilitation of our clients. To say
it is vital to good nursing care is to put it mildly. This explains why the unit has
taken time to examine steps that could be taken to reduce threats to patients’ life
and discussed a few comfort measures commonly employed by nurses. You
may ask why few? Well, that is what the scope of this unit can conveniently
accommodate. Besides, the issue of comfort and safety is an ongoing thing, so it

203
is going to be a recurring theme throughout the period of your training and
beyond.
The need for safety and comfort in the health care settings cannot be
overemphasized. Hence the unit opens with a discussion on the general safety
rules and practices in the health care setting. It particularly examined the role of
the nurse clinician in moving and handling patients and the guiding principles
thereof. The role of the nurse in infection control was equally examined. Last
but not the least, the unit takes a detailed look at a few of the comfort measures
currently being employed in our hospitals. However, like we did note, there are
one thousand and one thing that could be done to ensure patient comfort and it
is a dynamic issue as it differ from patient to patient and changes as the
patient’s condition changes. So the list is inexhaustible. The few examples given
here definitely would have help us to appreciate how far these seemingly simple
measures can go in alleviating the varying degree of discomfort experienced by
our clients

5.0 Self-Assessment Questions

1. What are the measures employed by nurses to achieve infection
control?

7.0 References/Further Readings

Donovan, J.E.; Belsjoe, E.H. and Dillon, D.C. (1968). The Nurse Aide.
New York: McGraw-Hill Book Company.
Fuerst, E.V.; Wolff, L.U. & Weitzel, M. H. (Eds.). (1974). Fundamentals of
Nursing (5th Ed.). Toronto: J. B Lippincott Company.
King, E. M.; Wieck, L. & Dyer, M. (1977). Illustrated Manual of Nursing
Techniques. Philadelphia: J.B. Lippincott Company.
Kozier, B.; Erb, G.; Berman, A.U. & Burke, K. (Eds.). (2000). Health, Wellness

204
 and Illness. Fundamental of Nursing: Concepts Process and Practice (6th
Ed.). New Jersey: Prentice Hall, Inc.
Parboteeah, S. (2002). Safety in Practice. In R. Hogston & P. M. Simpson
(Eds.).

Foundations of Nursing Practice; Making the Difference (2nd Ed.). New

York: Palgrave Macmillan.
RCN (Royal College of Nursing) (1992). Safety Representatives Conference
Committee. Introduction to Methicillin Resistant Staphylococcus Aureus.
RCN, London.
Timby, B.K. (ed.) (1996). Fundamental Skills and Concepts in Patient Care
(6th
Ed.). Philadelphia: Lippincott.

205
 MODULE 3
Providing Safety and Comfort Measures II (Pain Management)
Contents:
Study Session 1: Providing Safety and Comfort II (Pain Management
Study Session 2a: Infection Control, Sexuality and Gender Issues
Study Session 2b: Sexuality and Gender Issues
Study Session 3a: Ethical and Legal Issues in Nursing I
Study Session 3b: Legal Aspects of Professional Nursing I
Study Session 3c: Legal Aspects of Professional Nursing II
Study Session 4a: Stress and Adaptation, Nursing and Society
Study Session 4b: Nursing and Society
Study Session 5: Health Education

STUDY SESSION 1
Providing Safety and Comfort Measures II (Pain Management
Section and Subsection Headings:
Introduction
1.0 Learning Outcomes
2.0 Main Content
2.1- Nature and Concept of Pain
2.2- Prejudices and Misconceptions
2.3- Types of Pain
2.4- Causes of Pain
2.5- Pain Perceptions and Reaction or Response

206
 2.6- Pain Management
3.0 Tutor Marked Assignments (Individual or Group assignments)
4.0 Study Session Summary and Conclusion
5.0 Self-Assessment Questions
6.0 Additional Activities (Videos, Animations & Out of Class activities)
7.0References/Further Readings

Introduction:
Everyone at one point or the other has experienced some type or degree of pain.
Inspite of its universality and eternal presence among mankind, the nature of
pain remains an enigma (Fuerst, Wolff, & Weitzel, 1974). Pain is a complex
experience that is not easily communicated; yet it is one of the most common
reasons for seeking health care. It is the chief reason people take medication and
a leading cause of disability and hospitalization. Pain is subjective and highly
individualized and its interpretation and meaning involve psychosocial and
cultural factors. In other words the person experiencing pain is the only
authority on it. Besides, no two persons experience pain in the same way and no
two painful events create identical reports or feeling in a person. And as the
average life span increases, more people have chronic disease, in which pain is a
common symptom. In addition medical advances have resulted in diagnostic
and therapeutic measures that are often uncomfortable. One therefore cannot
but agree with White (1995) that pain is one of the most common problems
faced by nurses, yet it is a source of frustration and is often one of the most
misunderstood problems that the nurse confronts. The truth however is that
when patients are comfortable, encouraging necessary activities often become
easier both for the patient and the nurse. This explains why much of nursing
care revolves round relieving pain and ensuring comfort. This unit therefore

207
discusses pain in its entirety with particular focus on pain management
strategies.

1.0 Study Session Learning Outcomes

After studying this session, I expect you to be able to:
1. discuss the nature and concept of pain
2. identify major causes of pain
3. differentiate between acute and chronic pain
4. discuss common misconceptions about pain
5. outline factors influencing people’s response to pain
6. discuss pain-relieving strategies.

2.0 Main Content

2.1 Nature and Concept of Pain
Pain of any kind is difficult to define, in view of its subjective nature. Pain is
much more than a single sensation caused by a specific stimulus. Pain is a
complex mixture of physical, emotional, and behavioral reactions. Pain is a
subjective and highly individualistic, and interpretation and meaning of pain
involve psychosocial and cultural factors. Pain cannot be objectively measured,
such as with x-ray examination or blood test, and although certain types of pain
creates predictable signs and symptoms, often the nurse can only assess pain by
relying on the clients words and behaviour. This coupled with the fact that the
nurse along with the physician and other health practitioners cannot see or feel
to which they attend, makes the person experiencing pain the only authority on
it. No wonder that a noted pain theorist, McCaffery (1980) defined pain as
“what the person experiencing it says it is; and existing whenever he says it

208
does”. Therefore to help a client gain relief, the nurse must believe that the pain
exists.
The most commonly accepted definition however is that of the International
Association for the Study of Pain (IASP) which acknowledges the multi-
factorial nature and the importance of individual interpretation and experience:
Pain is an unpleasant sensory and emotional experience associated with actual
or potential tissue damage, or described by the patient in terms of such damage
(Blair, 2002). Pain has also been defined, and occasionally still is, on a
philosophical and religious basis as punishment for wrongdoing. Aristotle
defined pain as well as anyone when he wrote that it is the ‘antithesis of
pleasure…. the epitome of unpleasantness’ (Fuerst, Wolff, & Weitzel, 1974).
Fuerst, Wolff, & Weitzel, (1974) submitted further that another typical
definition depicts pain as basically an unpleasant sensation referred to the body
which represents the suffering induced by the psychic perception of real,
threatened, or phantasied injury. Pain could therefore be viewed as a protective
physiological mechanism.
A person with sprained ankles for instance avoids bearing full weight on the
foot to prevent further injury, warning the body that tissue damaged has
occurred. Even though pain may warn of tissue injury or disease, it should be
noted that the degree of pain is not necessarily in direct proportion to the
amount of tissue damage, nor tissue damage always present when pain occurs.
In-text Question 1 (A short question requiring a single sentence answer for quick
reflection over the read topic) List out the prejudices and misconceptions people
have about pain.

Answer Drug abusers and alcoholics overreact to discomfort with severe

physical illness.
Administering analgesics regularly will lead to drug dependence
The amount of tissue damage in an injury can accurately indicate pain
intensity.

209
 Health care personnel are the best authorities on the nature of the
patient’s/client’ pain.
Psychogenic pain is not real.
Patients/Clients with minor illnesses have less pain than those illness.

2.2. Prejudices and Misconceptions

Health personnel often hold prejudices against patients/clients in pain especially
those suffering from chronic pain, except where the client manifest objective
signs. White (1995) outlined the following as common biases and
misconceptions about pain:
1. Drug abusers and alcoholics overreact to discomfort.
2. Patients/Clients with minor illnesses have less pain than those with severe
physical illness.
3. Administering analgesics regularly will lead to drug dependence.
4. The amount of tissue damage in an injury can accurately indicate pain
intensity.
5. Health care personnel are the best authorities on the nature of the
patient’s/client’ pain.
6. Psychogenic pain is not real.

Unfortunately, all people are influenced by prejudices based on their culture,

education, and experience. As such the extent to which nurses allow themselves
to be influenced by prejudices may seriously limit their ability to offer effective
pain relief. It is the realization of this fact that makes White (1995) to assert that
the nurse must acknowledge his/her prejudices and of course view the
experience through the patient’s eyes to be able to render meaningful and
formidable assistance to the patient.

2.3-Types of Pain

210
There are several ways to classify pain. Pain can be classified based on its
duration, location and causes. As such the following are the different typologies
of pain that exist:

Classification based on Duration

Acute Pain – Acute pain is the sensation that results abruptly from an injury or
disease and usually it is short-lived. Meinhart and McCaffery(1983) defined it
as pain that follows an acute injury, disease, or types of surgery and has a rapid
onset, varying in intensity (mild to severe) and lasting for a brief time. The
client can frequently describe the pain, which may subside with or without
treatment (Royle and Walsh, 1992). Acute pain however serves a biologic
purpose. It acts as warning signal through activation of the sympathetic nervous
system which causes the release of catecholamine neurotransmitters, such as
epinephrine that gives rise to various physiologic responses similar to those
found in fight reaction (Guyton, 1991).

Acute pain is usually confined to the affected area (localized) sometimes resolve
with or without treatment after a damaged area heals. Could however lead to
chronic pain if the cause is not discovered or not cared for properly (Cheney-
Stern, 1995). In addition, acute pain seriously threatens recovery and therefore
should be one of the nurses’ priorities of care. For example, acute post-operative
pain hampers the patient’s ability to become mobile and increases the risk of
complications from immobility (White, 1995)

Chronic Pain
Chronic pain is prolonged, varies in intensity, and usually last more than six
months (Anderson et al, 1987), sometimes lasting throughout life. Onset is

211
gradual and the character and the quality of the pain changes over time. Chronic
pain is associated with variety of health problem such as cancer, connective
tissue diseases, peripheral vascular diseases and musculoskeletal disorders,
posttraumatic problems such as phantom limb pain and low back pain. While it
is true that it is a symptom associated with many of the common primary care
conditions, it may also occur as a distinct entity. The effects of chronic pain are
far- reaching, and are at least as important as its cause. The degree of chronic
pain varies depending on the types of problems and whether it is progressive,
stable, or capable of resolution. The patient/client with chronic pain often has
periods of remission (partial or complete disappearance of symptoms) and
exacerbations (increase in severity). However, chronic pain may be severe and
constant i.e. unrelenting. This sort of pain is referred to as intractable pain.
Chronic pain presents a major challenge to primary care and since chronic pain
persists for extended period, it can interfere with activities of daily living and
personal relationship. It stimulates a huge number of prescriptions,
investigations and referrals, causes frustration in its resistance to treatment, and
leaves patients and doctors with low expectations of successful outcomes.
Hence, can result in emotional and financial burdens sometimes leading to
psychological depression. Thus, its management requires the effort of an
interdisciplinary health care team otherwise it may become an overwhelming
frustrating experience for both the sufferer and the caregiver. While treatment of
acute pain tends to focus on its cause, with a view to a cure, treatment of
chronic pain must also focus on its effects, with a view to limiting disability and
maximizing potential. Assessment and management must be multidimensional
and rehabilitative, and agreed, realistic treatment goals are important. The goal
of nursing nonetheless must be to reduce the patient’s perception of pain and to

212
promote patients and family adaptation through identification and enhancement
of coping strategies (White, 1995; Blair, 2002).

Classification based on Pain Location

Pain may be categorized in relation to the area of the body where it originates.
Superficial Pain – Originates in the skin or mucous membranes. The source
usually can be located easily because there are many nerve endings in the
affected structures. The patient often describes superficial pain as prickling,
burning, or dull.

Deep Pain – Pain emanating from inner body structures. Could manifest with
vomiting, blood pressure changes, or weakness. Unlike superficial pain, the
patient may have difficulty in pinpointing the exact location of deep pain. It is
sometimes referred. Patient more often than not describes it as aching, shooting,
grinding, or cramping.
Central Pain – Believed to originate within the brain itself (in the pain
interpretation, and/or receiving centers)
Referred Pain – This is pain felt in a location different from the actual origin
e.g. pain felt in the scapular region secondary to diseases of the gall bladder.
Phantom Pain – This is used to describe pain felt in an area that has been
amputated.
Angina Pain is pain associated with cardiac pathology while Neuralgia is an
intense burning sensation that follows a peripheral nerve. (Cheney- Stern, 1995)

2.4-Causes of Pain
There are many causes of pain. According to Cheney-Stern, (1995) these causes
can be broadly grouped into three viz:

213
Physical Causes – Physical causes include: Muscle tightness (secondary to
muscle spasm and resultant decrease in blood supply to that muscle); disease;
infection; trauma; space-occupying lesions (tumor); metabolic factors; burns
and temperature extremes.

Chemical Causes – Chemical factors include caustic chemicals and toxins such
as alcohol, drugs, cigarettes, and pollution in the air and water.
Psychogenic Causes – That is, originating from the mind and has no
identifiable physical cause. It can be as severe as pain from a physical cause.

2.5 Pain Perceptions and Reaction or Response

There are two facets to pain – perception and reaction or response. Pain
perception is concerned with the sensory processes when a stimulus for pain is
present. The threshold of perception is the lowest intensity of a stimulus that
causes the subject to recognize pain. This threshold is remarkably similar for
everyone though some authorities have theorized that a phenomenon of
adaptation does occur; that is the threshold of pain can be changed within
certain ranges (Fuerst, Wolff, & Weitzel, 1974).
While it may be true that there are no specific pain organs or cells, an
interlacing network of undifferentiated nerve endings receives painful stimuli.
Sensation is transmitted up the dorsal gray horn cells of the spiral cord, then to
the spinothalamic tract and eventually to the cerebral cortex. Following pain
impulse transmission within the higher brain centers including the reticular
formation, limbic system thalamus and sensory cortex, a person then perceives
the sensation of pain. However, there is an interaction of psychological and
cognitive factors with neurophysiological ones in the perception of pain.
Meinhart and McCaffery (1983) described the three interactional system of pain
perception as sensory-discriminative, motivational-affective, and cognitive-

214
evaluative. In addition, the Gate Control Theory suggests that gating mechanism
can also be uttered by thoughts, feelings and memories. In essence the cerebral
cortex and thalamus can influence whether pain impulses reach a person’s
consciousness. This realization that there is a conscious control over pain
perception helps explain the different ways people react and adjust to pain.
Pain Reaction
The reaction or response to pain is concerned with the individual’s method of
coping with the sensation. This comprises the physiological and behavioral
responses that occur after pain is perceived.
Physiological Responses
White (1995) submitted that as pain impulses ascend the spinal cord towards the
brain stem and thalamus, the autonomic nervous system become stimulated as
part of the stress response. Acute pain of low to moderate intensity, and
superficial pain elicit the “flight or fight” reaction of the general adaptation
syndrome. Stimulation of the sympathetic branch of the autonomic nervous
system results in physiological responses such as: dilation of bronchial tube and
increased respiratory rate; increased heart rate; peripheral vasoconstriction
(pallor, elevation in blood pressure); increased blood glucose level; diaphoresis;
Increase muscles tension; dilation of pupils; and decreased gastrointestinal
motility. However, if the pain is unrelenting, severe, or deep, typically
originating form involvement of the visceral organs (such as with a myocardial
infarction and colic from gallbladder or renal stones), the parasympathetic
nervous system goes into action resulting in the following responses: pallor;
muscles tension; decreased heart rate and blood pressure; rapid irregular
breathing; nausea and vomiting; weakness and exhaustion. Sustained
physiological responses to pain could cause serious harm to an individual.
Except in some cases of severe traumatic pain, which may send a person into

215
shock, most people reach a level of adaptation in which physical signs return to
normal. Thus a client in pain will not always exhibit physical signs.

Behavioral Responses
White paraphrasing the work of Meinhart and McCaffery (1983) on behavioral
responses to pain identifies the three phases of a pain experience as:
anticipation, sensation, and aftermath. The anticipation phase according to
her occurs before pain is perceived. A person knows that pain will occur. The
anticipation phase is perhaps most important, because it can affect the other
two. In situations of traumatic injury in foreseen painful procedures a person
will not anticipate pain. Anticipation of pain often allows a person to learn
about pain and its relief. With adequate instruction and support, clients learn to
understand pain and control anxiety before it occurs. Nurses play an important
role-helping client during the anticipation phase. With proper guidance, clients
become aware of the unknown and thus cope with their discomfort. In situation
in which clients are too fearful or anxious, anticipation of pain can heighten the
perception of pain severity.
She stated further that the Sensation of pain occurs when pain it felt. According
to her, the ways that people choose to react to discomfort vary widely adding
that a person’s tolerance of pain is the point at which there is an unwillingness
to accept pain of greater severity or duration.
Howbeit, the extent to which a person tolerates pain depends on attitudes,
motivation and values.
She noted that pain threatens physical and psychological well-being and that
client may choose not to express pain, considering it as a sign of weakness. In
her words ‘often clients believe that being a good client means not expressing
pain to avoid bothering people around them. In addition client may not express
pain because maintaining self-control is important in their culture. The client

216
with high pain tolerance is able to endure periods of severe pain without
assistance. In contrast, a client with low pain tolerance may seek relief before
pain occurs. The client ability to tolerate pain significantly influences the nurse
perception of degree of the discomfort. Often the nurse is willing to attend to the
client whose pain tolerance is high. Yet it is unfair to ignore the needs of the
client who cannot tolerate even minor pain she declared. Typical body
movements and facial expressions that indicate pain include holding the painful
part, bent posture, and grimaces. A client may cry or moan. Often a client
expresses discomfort through restlessness and frequent request to the nurse.
However, lack of pain expression does not necessarily mean that the client is
not experiencing pain. It is equally important to note that unless a client openly
reacts to pain it is difficult to determine the nature and extent of the discomfort.
She submitted that the aftermath phase of pain occurs when it is reduced or
stopped. Even though the source of discomfort is controlled, the client may still
require the nurse’s attention. Pain is a crisis. After a painful experience client
may experience physical symptoms such as chills, nausea, vomiting, anger, or
depression. If there are repeated episode of pain, aftermath responses can
become serious health problems. She therefore concluded that the nurse should
help clients gain control and self-esteem to minimize fear over potential pain
experiences.

Factors in Pain Perception

Perception of pain is individualized and since pain is complex, numerous factors
influence an individual pain experience. Some of these are:
Age – Developmental differences among different age groups can influence hoe
children and older adults react to the pain experience. Infants and young
children have difficulty in understanding pain and those that have not developed
full vocabularies encounter difficulty in verbalizing pain. To help such children,

217
it has been suggested that the nurse employs simple but appropriate
communication techniques to enhance their understanding and description of
pain. The nurse may show a series of pictures depicting different facial
expressions, such as smiling, frowning, or crying and ask the children to point
to the picture that best describes how they feel (White, 1995). School-aged
children and adolescents many times try to brave and not give in to pain.
Adults’ ability to interpret pain may be occluded by the presence of multiple
diseases with varied but similar manifestations. Besides, adult may not report
pain for various reasons ranging from fear of unknown consequences, fear of
serious illness/death, to such erroneous notion as – ‘it is not acceptable to show
pain’. Aging adults may not feel acute pain because of decreased sensations or
perceptions.
Sex/Gender – It is doubtful whether gender by itself is a factor in pain
expression. Results of studies comparing pain tolerance in males and females to
say the least have been at best confusing. As such the only conclusion that could
be safely made is that there are certain cultural factors influencing the effect of
gender on pain perception.
Culture – Culture influences how people learn to react to and express pain.
People respond to pain in different ways, and the nurse must never assume to
know how patients/clients will respond. However, an understanding of the
cultural background, socioeconomic status, and personal attributes helps the
nurse to more accurately assess pain and it’s meaning for patients/clients
(Lipton and Marbach, 1984; White, 1995).
Anxiety – The relationship between pain and anxiety is complex. Anxiety often
aggravates pain sensation and tense muscle reinforces it while pain may induce
feelings of anxiety. White (1995) states that emotionally healthy people are
usually able to tolerate moderate or even severe pain better than those whose
emotions are labile.

218
Meaning of Pain – The meaning that a person attributes to pain affects the
experience of pain. A person will perceive and cope with pain differently if it
suggests a threat, loss, punishment, or challenge (White, 1995).
Fatigue – Fatigue heightens an individual perception of pain i.e. amplifies it
and decreases coping abilities.
Previous Experience – Each person learns from painful experiences. If a
previous experience was very painful, a person may not feel great pain when the
experience is repeated. This probably explains why people who are chronically
ill and have almost constant pain often learn to tolerate it.
Attention and Distraction – The degree to which a patient focuses on pain can
influence pain perception. According to Gil (1990), increased
Attention has been associated with increased pain whereas distraction has been
associated with a diminished pain response. This concept is applied in some of
the pain relieving interventions (relaxation and guided imagery) employed by
nurses.
Family and Social Support – People in pain often depend on family members
for support, assistance, or protection. An absence of family or friends tends to
make pain experience more stressful. The presence of parent is especially
important for children experiencing pain (White, 1995)
Neurological Status – A patient/client neurological function can easily affect
the client’s /patient’s pain experience. For instance any factor that interrupts or
influences normal reception or perception will automatically affect client’s
awareness and response to pain. This explains why patients with spinal cord
injury, peripheral neuropathy, multiple sclerosis e.t.c. may experience pain
differently from patient with normal neurological function.

2.6 Pain Management

219
On a general note nursing interventions at relieving client’s pain can be
summarized as follows: understanding the patient; understanding the nature and
extent of pain; removing the source of pain and decreasing pain stimuli; offering
emotional support; and teaching in relation to pain. Inasmuch as a patient’s
background is very likely to influence his reaction to pain, a good starting point
will be to learn about the patient including his medical history, diagnosis and
the physician’s plan of therapy. The nature of pain and extent to which it affect
physical and psychological well-being is also crucial to determining the choice
of pain relief therapies/measures. This, the nurse can establish through good
observational techniques and adequate history taking. However, since pain is a
complex phenomenon, several treatment options have been developed over the
years and it takes a careful selection of the measure beat suited for every
particular case but in some cases the much-needed relief is only secured through
a combination therapy. The different measures/therapies employed by nurses in
the management of pain are however paraphrased below:
Cutaneous Stimulation: One way to prevent or reduce pain perception is
through cutaneous stimulation, the stimulation of a person’s skin to relieve pain.
A massage, warm bath, and application of liniment, hot and cold therapies,
and transcutaneous electrical nerve stimulation (TENS) are simple measures
that provides cutaneous stimulation. Although the specific way in which
cutaneous application works is not very clear, some authorities have attributed
their action to their inducing the release of endorphins, a naturally occurring
analgesic substance that blocks the transmission of pain (White, 1995). While
others have believed that they relieve congestion or promote circulation and
oxygenation, thereby relieving pain (Cheney-Stern, 1995). Heat for instance, is
said to offer pain relief by increasing blood flow to an area of inflammation or
infection. In addition, heat also reduces joint stiffness, relaxes smooth muscles,

220
and reduces peristalsis. Little wonder that it is being employed in the
management of some abdominal pain painful infiltrated intravenous sites.

Cold when applied, on the other hand, penetrates the muscle thereby helping to
reduce muscle spasm and inflammation. Cold also prevents bleeding and edema
through vasoconstriction. Although not the primary treatment for pain cold
compresses have been shown to be effective in reducing pain after orthopedic
surgery (Bolander, 1994). Massage and back rub are yet other low cost, safe to
use cutaneous stimulation. Massage may lessen pain by relieving congestion
and/or promoting circulation and oxygenation, and enhancing muscular
relaxation. TENS involves stimulation of nerve beneath the skin with a mild
electric current passed through external electrodes. The therapy requires a
physician’s order. TENS unit consist of a battery powered transmitter, lead
wires and electrode which are placed directly over or near the site of pain. Hair
or skin preparations should be removed before attaching the electrodes. When a
client feels pain, the transmitter is turned on. The TENS unit crates a buzzing or
tingling sensation. The client may adjust the intensity and quality of skin
stimulation. The tingling sensation can be applied as long as pain relief lasts.
TENS is effective for postoperative procedure for example, removing drains and
cleaning and repacking surgical wounds (Hargreaves, 1989).

221
Distraction: This technique is more effective with the short, mild pain lasting a
few minutes than severe pain, though can be combined with pain medications to
enhance pain relief. It is achieved by encouraging the person in pain to focus on
a particular image or stimulus other than the painful one. In this way, the
person’s attention becomes drawn away from the painful stimuli with resultant
decrease in perception of such painful stimuli. In some instances, distraction can
make client completely unaware of pain. For example a client recovering from
surgery may feel no pain while watching a football game on television, only for
the pain to resurface when the game is over. An adolescent who feels pain from
a fracture foot bone only after he finished playing a basketball game, is yet
another example. Therefore, distraction does not only decrease one’s
perception of pain but also improve one’s mood while giving a sense of control
over the painful situation.

In what look like a pathophysiologic approach, White (1995) explained that the
reticular activating system inhibits painful stimuli if a person receives sufficient
or excessive sensory input. With meaningful sensory stimuli, a person can try to
ignore or become less aware of pain. She asserted further that pleasurable
stimuli also cause the release of endorphins to relieve pain. This possibly
explains why the most effective distraction techniques are those that the
individual finds interesting and those that stimulate the senses - hearing, seeing,
touching, and tasting. Moving activities are equally useful. For example,
children and even adults that are in pains can be made to watch television or
listen to favorite music or play indoor games. These activities keep the person
occupied leaving no room for boredom, anxiety, loneliness all of which tend to
aggravate pain. Furthermore, disturbing stimuli such as loud noise, bright light,
unpleasant odour, and argumentative visitor can increase pain perception.

222
Therefore the nurse needs to reduce disturbing stimuli. Some distraction
techniques are:
a. Slow rhythmic breathing: - In slow rhythmic breathing (SRB), the
nurse asks the client to stare at an object, inhale slowly through the nose
while the nurse counts 1, 2, 3, and 4. The nurse encourages the client to
concentrate on the sensation of the breathing and to picture a restful screen.
This process continues until a rhythmic pattern is established. When the client
feels comfortable, he or she can count silently and perform this technique
independently.
b. Massage and slow rhythmic breathing: - The client breathes
rhythmically as in SRB but at the same time massages a painful body part
with stroking or circular movements.
c. Rhythmic singing and tapping: - The client selects a well-liked song and
concentrate attention on its words and rhythm. The nurse encourages the
client to hum or sing the words and tap a finger or foot. Loud, fast songs are
best for intense pain.
d. Active listening: - The client listens to music and concentrates on the
rhythm by taping a finger or foot.
e. Guided imagery: - In guided imagery the patient/client creates an image
in the mind, concentrates on that image and gradually becomes less aware of
pain. The role of the nurse is to assist the patient/client to form an image and
to concentrate on the sensory experience. Asking the patient/client to close
his or her eyes and imagine a pleasant scene, and then describing something
pleasurable is one way this is achieved.

Relaxation and Guided Imagery

It is an established fact that patients/clients can alter affective- motivational and
cognitive pain perception through relaxation and guided imagery. Relaxation
per see is mental and physical freedom from tension or stress. However for

223
effective relaxation, the client’s cooperation is needed. The nurse describes the
techniques together with common sensations that the client may experience in
detail. The client uses such described sensations as feedback. The client may sit
in a comfortable chair or lie in bed. A light sheet or blanket for warmth tends to
help the client feel more comfortable and the environment should be free of
noises or other irritating stimuli.
The client may have guided imagery and relaxation exercises together or
separately. The nurse, acting as a coach guides the client slowly through the
steps of the exercise. The nurse’s calm, soft voice helps the client focus more
completely on the suggested image, and it becomes unnecessary for the nurse to
speak continuously. If the client shows signs of agitation, restlessness or
discomfort, the nurse should stop the exercise and begin later when the client is
more at ease. Progressive relaxation of the entire body takes about 15 minutes.
The client pays attention to the body, nothing areas of tension. Some clients
relax better with eyes closed. Soft background music may be helpful. Note that
considerable practice is needed to achieve consistent pain reduction and it may
take five to ten training sessions before clients can efficiently minimize pain.
Progressive relaxation exercise really, involves a combination of controlled
breathing exercises and a series of contractions and relaxation of muscle groups.
The client begins by breathing slowly and diaphragmatically allowing the
abdomen to rise slowly and the chest to expand fully. When the client
establishes a regular breathing pattern the nurse coaches the client to locate any
area of muscular tension, think about how it feels, tense muscle fully and then
completely relax them. This creates the sensation of removing all discomfort
and stress. Gradually the client can relax the muscle without tensing them.
When full relaxation is achieved perception is lowered and anxiety towards the
pain experience becomes minimal. Relaxation technique provides clients with
self-control when pain occurs reversing the physical and emotional stress of

224
pain. The ability to relax physically also promotes mental relaxation. Examples
of relaxation technique include medication, Yoga, guided imagery, and
progressive relaxation exercises. Relaxation with or without guided imagery
relieves tension-headaches, labor pain, anticipated episode of acute pain (for
example a needle stick), and chronic pain disorders.

Anticipatory Guidance
The modifying anxiety directly associated with pain, helps in not only relieving
pain but also enhancing the effect of other pain relieving measures. This is
because knowledge about pain helps client/patient control anxiety and
cognitively gains a level of pain relief (Walding, 1991). White, (1995) asserted
that it is important to give clients/patients information that prevents
misinterpretation of the painful event and promotes understanding of what to
expect. According to her, such information includes:
i. Occurrence, onset and expected duration of pain
ii. Quality, severity and location of pain
iii. Information on how the client’s/patient’s safety is ensured
iv. Cause of the pain
v. Methods that the nurse and client/patient use for pain relief.
vi. Expectations of the client/patient during a procedure.
A typical example of anticipatory guidance is preoperative teaching on
incisional pain and methods used to control it. It has been observed that this
helps the patient to adapt better postoperatively.

Biofeedback
White (1995) paraphrasing the work of Flor et al. (1983) defined Biofeedback
as a behavioral therapy that involves giving individual information about
physiological responses (such as blood pressure or tension) and ways to exercise

225
voluntary control over those responses. This therapy is particularly effective for
muscle tension and migraine headache. The procedure employs electrodes,
which are attached externally. These electrodes measure skin tension in
microvolts. A polygraph machine visibly records the tension level for the client
to see. The client learns to achieve optimal relaxation, using feedback from the
polygraph while lowering the actual level of tension experienced. The therapy
takes several weeks to learn.

Acupuncture
Acupuncture literally means "needle piercing." It began with the discovery that
stimulating specific areas on the skin via insertion of very fine needles affect the
physiological functioning of body’s processes. These specific areas/points on
the skin are called acupoints. These acupoints are in very specific locations and
lie on channels of energy called meridians. It has traditionally been taught as a
preventive form of health care, but has also been found useful in the treatment
of a variety of acute and chronic conditions. Acupuncture has been used for
over 3,000 years in China as a major part of their primary health care system. In
modern times, it is used for the prevention of and treatment of diseases, for the
relief of pain, and as an anesthetic for surgery. There are various painless, non-
needle methods of acupuncture administration, including electrical stimulation,
ultrasound, and laser. Acupressure is based on the principles of acupuncture.
This ancient Chinese technique involves the use of finger pressure (rather than
needles) at specific points along the body to treat ailments such as arthritis,
tension and stress, aches and pains, and menstrual cramps. This system is also
used for general preventive health care. Shiatsu is a Japanese word that means
"finger pressure." Pressure is applied to points in the body using fingers, palms,
elbows, arms, knees, and feet, working on the body's energy system. Different
techniques are used to relieve pain and release energy blockages.

226
Pharmacological Management of Pain
Quite a number of pharmacological agents provide satisfactory relief from pain.
These agents are generally referred as analgesics ranging from mild to strong
analgesics. They stand out as the most widely employed pain-relieving measure
and are quite potent. Although most, especially the narcotic analgesics, require a
physician’s order, the nurse’s judgment in the use of medications and
management of clients receiving pharmacological therapies help ensure the best
pain relief possible. Analgesics can be broadly classified into four groups viz:
a. Non-narcotic Analgesic – Provides relief for mild to moderate pain.
Example includes Paracetamol.

b. Non-Steroidal Anti-Inflammatory Drug (NSAID) – Just like the Non-

narcotic analgesics NSAID also provides relief for mild to moderate pain
especially those associated with rheumatoid arthritis, surgical and dental
procedure, episiotomies and low back problems. But unlike the Non-
narcotic analgesics Non- steroidal anti-inflammatory drugs (NSAIDS) act
by inhibiting the action of the enzymes that forms prostaglandin. With
less prostaglandin released peripherally, the generation of pain stimuli is
blocked. A reduction in pain sensitivity also occurs.

c. Opioids – Opioids are generally prescribed for severe pain such as

malignant pain. Neurotransmitters and opiate receptors are located in the
dorsal horn of the spinal cord. Administration of opiates such as
morphine results in the opiates binding to receptors and inhibiting the
releases of substances P., as a result, transmission of painful stimuli to the
spinal cords is blocked. In addition to the above, morphine sulphate
and diamorphine hydrochloride raises the pain threshold and at the same

227
 time reduces associated fear and anxiety, thereby reducing pain
perception.

d. Adjuvants or Co-analgesics – These include such drugs as

anticonvulsants, antidepressants, and muscle relaxants. Adjuvant
analgesics are prescribed for those clients/patients whose pain is less
responsive to analgesics alone, usually due to specific co- existing
pathophysiology such as neuropathic pain due to nerve compression. The
administration of tricyclic antidepressants such as amitriptyline and
imipramine creates an analgesic effect, as well as an antidepressant effect.
The tricyclic inhibits the normal reuptake of serotonin at nerve terminals.
With one serotonin present in nerve terminal, pain transmission is
inhibited (Potter, 1993).
Note: As good and effective as the pharmacological management of pain is, it
has its own disadvantages. This is because every drug is a potential poison and
there is no drug without its adverse effect. This therefore calls for a thorough
understanding of the actions, indications, dosages, routes of administration, side
effects, and contraindications of each of these drugs for maximal benefit.

In-text Question 1 (A short question requiring a single sentence answer for quick
reflection over the read topic What are the factors that influence individual’s
perception of pain?

Answer Family and social support, Neurological status, Attention and

distraction, Fatigue, Previous Experiences, Anxiety, Culture, Sex/Gender and
Age.

3.0 Tutor Marked Assignments (Individual or Group)

1. discuss the nature and concept of pain
2. outline factors influencing people’s response to pain
3. discuss pain-relieving strategies.

228
4.0Conclusion/Summary
It is hope that this session has been able to achieved the stated study outcome,
such as identify major causes of pain, differentiate between acute and chronic
pain, outline factors influencing people’s response to pain, discuss pain-
relieving strategies all of which will make us more competent and confidence in
pain management irrespective of disease condition, age and race.

Pain could be physical, chemical or Psychogenic in origin. It comprises the

components of reception, perception, and reaction. Knowledge of these three
components of pain provides the nurse with guidelines for determining pain-
relief measures as pain experience is influenced by a variety of variables such as
age, gender, culture, anxiety, to mention a few. Eliminating sources of painful
stimuli is a basic nursing measure for promoting comfort. The nurse
individualizes pain relief measures by collaborating closely with the
patient/client, using assessment findings and trying a variety of interventions.
Measures that have proven helpful include: verbally acknowledging the
presence of the pain; allowing patients to ventilate their feelings; listening
attentively to what the client says about the pain; providing adequate
information; conveying an attitude that you care; employing distraction,
relaxation and guided imagery, cutaneous stimulation, biofeedback, or analgesic
administration as the case may be. Good judgment and due caution are however
important before utilizing any of these measures. All said and done, the nurse
should not become frustrated when relieve measures fail to fully control pain
while being careful not to offer false reassurance.

229
Pain is not is easy to define and the varied meaning attached to the word pain is
an eloquent testimony of the difficulty inherent in explaining this complex
phenomenon. Much of the difficulty encountered in understanding and precisely
defining the term is attributable to the subjective nature of pain. Pain is a
frequent and important problem in primary care, with far-reaching implications.
Since pain is such a common problem faced in all health care settings, and one
that not only threatens patient’s comfort but also readily incapacitates, no effort
should therefore be spared at procuring potent pain relieving measures. Many
approaches to management are possible, and a multi-dimensional approach, in
discussion with the patient, is the most helpful.

Pain is not is easy to define and the varied meaning attached to the word pain is
an eloquent testimony of the difficulty inherent in explaining this complex
phenomenon. Much of the difficulty encountered in understanding and precisely
defining the term is attributable to the subjective nature of pain. Pain is a
frequent and important problem in primary care, with far-reaching implications.
Since pain is such a common problem faced in all health care settings, and one
that not only threatens patient’s comfort but also readily incapacitates, no effort
should therefore be spared at procuring potent pain relieving measures. Many
approaches to management are possible, and a multi-dimensional approach, in
discussion with the patient, is the most helpful.

5.0 Self-Assessment Questions

1. Mrs. Jones, a known arthritic and ulcer patient reported at your clinic
with complaints of longstanding intermittent pain that is now growing
worse. Attempt a classification of pain. What pain relief measures
would be appropriate for the nurse to use in the management of Mrs.
Jones?

230
6.0References/Further Readings
Anderson, S. et. al. (Ed.). (1987). Chronic Non-Cancer Pain. London: MTP
Press Limited.
Blair, H. S. (2002). Chronic Pain: A Primary Care Condition. Rheumatic
Disease: In Practice (9).
Bolander, V. B. (1994). Sorensen and Luckmann’s Basic Nursing: A
Psychophysiological Approach. Philadelphia: Harcourt Publishers Ltd.
Cheney-Stern, M. A. (1995). Patient Comfort and Pain. In C. B. Rosdahl (ed.)
Textbook of Basic Nursing. Philadelphia: J.B. Lippincott Company.
Fuerst, E.V., Wolff, L.U. & Weitzel, M. H. (Eds.). (1974). Fundamentals of

Nursing (5th Ed.). Toronto: J. B Lippincott Company.

Gil, K. (1990). Psychological Aspects of Acute Pain. Anesthesiology Report
2(2): 246.
Guyton, A. C. (1991). Textbook of Medical Physiology (18th Ed.).
Philadelphia: WB Saunders.
Hargreaves, A. & Lander J. (1989). Use of Transcutaneous Electrical Nerve
Stimulation for Post-Operative Pain. Nursing Research, 38(3): 159.
http://www.alternative-medicine-info.com/alternative-medicine/Acupuncture/
Acupunture.htm
Lipton, J. A. & Marbach, J.J (1984). Ethnicity and Pain Experience. Soc Sci
Med, 19(12): 1279.
Meinhart, N. T. & McCaffery, M. (1983). Pain: A Nursing Approach to
Assessment and Analysis. Norwalk, Conn.: Appleton-Century- Crofts.
Potter, P. A. and Perry, A.G. (2004). Fundamental of Nursing: Concepts,

Progress, and Practice (6th Ed). St Louis: C.V Mosby.

231
White, I. (1995). Controlling Pain. In H. B. M. Heath (Ed.). Potters and Perry’s
Foundations in Nursing Theory and Practice. Italy: Mosby, an imprint of
Times Mirror International.
STUDY SESSION 2A
Infection Control, Sexuality and Gender Issues
Section and Subsection Headings:
Introduction
1.0 Learning Outcomes
2.0 Main Content
2.1- Infection Phases
2.2- Types and Chain of Infections
2.3- Predisposing Factors to Infection
2.4- Infection Control
2.5- Nursing Management of Person with Infection
3.0 Tutor Marked Assignments (Individual or Group assignments)
4.0 Study Session Summary and Conclusion
5.0 Self-Assessment Questions
6.0 Additional Activities (Videos, Animations & Out of Class activities)
7.0 References/Further Readings

Introduction:
Infection is the multiplication of micro-organism/infectious agents within the
body tissue causing a disease in the host (human and animal).What happens
under this circumstance depends on the difference in magnitude between two
opposing forces namely: those of infection and the host’s resistance. The
outcome is determined by the ability of the micro-organism to adhere, invade
and damage the
host versus the

232
hosts defence mechanism. It may be severe or mild.
There are various groups of microorganism that interact with human beings to
cause infection, these include: bacteria, viruses, fungi protozoa and a parasitic
worms. Human beings and animals play host to populations of microorganism
which lives on the skin or mucus membrane. The microorganisms that are
capable of causing disease are termed pathogens or infectious agents.
Certain aspects of bacteria regularly inhabit different parts of the body where
they constitute the normal flora of the area. While some are harmful, others are
not but they ensure their survival and growth.
However, since they are circumstantial, a change in the circumstances can make
them harmful e.g. flora from rectum and vagina when pushed in can cause
infections.
One may then ask if infection control is possible. The answer is simply yes.
In this unit, we shall examine the infection control with the understanding of
infection phases, course and chain of infection, predisposing factors as well as
nursing interventions of infection control.

1.0 Study Session Learning Outcomes

After studying this session, I expect you to be able to:
1. describe the course of infection
2. enumerate the chain of events which link the reservoir of infectious
agents with the susceptible host
3. discuss the factors that predispose one to infection
4. analyze the measures for infection control.

233
2.0 Main Content
2.1 Infection Phases
Infection occurs and extends over three (3) identified phases, these are:
incubation, acute illness and recovery/convalescent phases.
Incubation Phases
This is the period between the entry of microorganism to the body and the initial
clinical manifestation of the infection. At this stage, the microorganism
multiplies while the host defense rises up to the challenge to counter the
infection.
The host is asymptomatic of the disease but sheds off the infectious agents and
may become carriers. When the host overcome the causative organism no
obvious signs and symptoms of the disease is apparent only laboratory
examinations can detect the host.
Acute Illness Phase
Here, the disease reaches its full intensity due to greater force exerted on the
host by the invading microorganism. The duration of the acute illness varies
from few hours to weeks and the disease.
Convalescence Phase
This is the stage when the clinical manifestation of the disease subsides. Most
infectious disease is self-limiting and recovery takes place over a short and
defined period of time. The prognosis depends on the disease and management
while death can occur from some highly virulent diseases or due to
complications.

In-text Question 1 (A short question requiring a single sentence answer for quick reflection
over the read topic) Mention 5 groups of micro- organisms that causes infection?

Answer The 5 group of micro-organism are: bacteria, viruses, fungi, protozoa and parasitic
worms.

234
2.2. Types and Chain of Infections
The following types of infection are explained below to further assist your
understanding of the concept of infection and enhance your practice.
1. Local Infection: when infection is confined to an area or spot.
2. Generalized Infection: infection that is disseminated throughout the body.
3. Focal Infection: when infection spreads from a confined area to other
parts of the body.
4. Mixed Infection: when infection is due to more than one type of
pathogen.
5. Primary Infection: the infection of a host by another type of infection
during the course of an infection.
6. Infection may also be sudden (acute) or manifest later with high resultant
effects (chronic).
In-text Question 1 (A short question requiring a single sentence answer for quick
reflection over the read topic) Who is a carrier?

Answer A carrier is one who has no symptom of a disease but harbours the
infectious agent.

Chain of Infection
Infection results from chain of events which link the reservoir of infection
agents with the susceptible host. These are:
a. Mode of escape from the reservoir.
b. Means or route of transmission.
c. Models of entry into the susceptible host.

235
The chain of event is hereby represented diagrammatically:

Causative agent
Bacteria, viruses, fungi, protozoa,
parasitic worms
Reservoir
Susceptible host Humans, animals/
immune status, insects,
inanimate
nutritional status, objects.
metabolic disorders and other
diseases, immunosuppressive drugs,
trauma or invasive procedure, age.

Mode of entry. Mode of Escape

Respiratory tract, alimentary tract Respiratory
tract Skin and mucus membranes Alimentary tract
Genito- urinary tract, placenta. Genitourinary tract
Skin/mucus membrane
Mode of
Transmission.
Direct personal
contact. Indirect
contact by
conveyor Fomites
or inanimate
objects.

*Chain of
infection

236
2.3 Predisposing Factors to Infection
The manifestation of infection in any host is dependent on the following factors:
Age
Children are more vulnerable to infection than adults due to the compromise of
humoral and cellular immunity. The changes occur with puberty, pregnancy and
menopause which also accounts for diminished resistance to viral infections. The
elderly are more susceptible to autoimmune disease and cancer increased with
advanced ageing.
Occupation
Certain occupation provides increased exposure to infection than o t h e r s . E.g.
industrial, sea and hospital workers
Exposure to Cold
When a man is exposed cold it causes a lowering of the body temperature below
normal. This reduces blood supply to superficial tissues and suppresses natural
defense mechanism.
Nutritional Imbalance
Protein and caloric undernutrition is a prevalent cause of impaired cell media led
immunity. Without the required nutrients and energy the production of antibodies,
lymphocytes and the chemical mediators of the immune response is impaired.
There is a decrease in immuno- competence due to excessive intake of cholesterol
and fats.
Stress
Naturally occurring persistent stress accompanied by poor coping alters the body’s
immune-competence. (See unit 8 on stress and adaptation).
Drug and Other Therapeutic Intervention

237
Some commonly used antibiotics may impair immune functions. All drugs are
capable of initiating a hypersensitivity reaction.
Life Style
Life behaviors/style such as smoking, drinking and indolence can precipitate
infection.
Activity 2
a. Considering the aforementioned factors, did any of the factors applied to you
when last you had an infection?
b. What precautionary measures did you take?

2.4 Infection Control

Infection control is the effort made to maintain a microorganism free environment.
These include:
Improving and supporting the host defaces through intact skin, mucus membrane
and cilia, white blood cells, antibodies and immunizations.
Cilia in the respiratory tract filter the air we breathe in and remove the
microorganism which may cause infection. The secreted mucus like hydrochloric
acid (HCL) from Gastro Intestinal Tract is acidic and protective in nature. Proper
nutrition rich in proteins, carbohydrate, fats and vitamins should be encouraged as
these helps to produce antibodies and enhanced natural resistance against
infections. Adequate rest should be observed while appropriate fluid intake helps
to wash off micro- organism that have been ingested except where
contraindicated, Personal hygiene and environmental care is to be encouraged.
Destruction of causative organism.
This is usually through the use of drugs. Give prescribed drugs to maintain
effective drug concentration. It should be taken as prescribed, find out if the

238
individual is allergic and watch out for side effects as these can throw patient open
to further infection.
Prevention of eh transmission of infective agents to others through isolation,
sterilization, barrier nursing, aseptic techniques, ethical asepsis. Quarantine, bed
spacing, proper waste disposal, health education, hand washing (soap and running
water) to take place before and after carrying out a procedure.
Some of these methods of infection control in bullet three will be explained briefly
as follows:
Barrier Nursing: The patient is not isolated in any room but nursed in an open
ward screened. Every item being used for him/her is strictly kept with there and
used exclusively for him/her.
Isolation: A separate room or cubicle is reserved for the patient where s/he is
nursed. This is usually done in conditions that are infectious like Tuberculosis.
Sterilization: It is a process by which all microorganisms including spores are
destroyed completely. There is no half measure as an item is either sterile or not. It
is achieved by subjecting the material either to heat, chemical, gamma, irradiation
or gases. Sterilization can be physical or chemical.

Physical Sterilization: It is usually accompanied by use of dry heat and radiation.

These alter the internal function of the organism thus rendering them inactive. The
most common method under this is dry and wet heat. Dry heat (as in oven) will kill
organism by oxidation process while moist heat (steam) coagulates protein within
the cell. Sterilization becomes effective when the heat is sufficient to destroy the
micro- organism.
Radiation: Non-iodizing and ionizing radiation are used for physical sterilization
and disinfection. They cause the death of microorganism by altering their essential

239
metabolic processes. The most common type of non-ionizing radiation is the ultra-
violet rays. Ionizing radiation is used for pharmaceuticals, foods, plastic and other
heat sensitive items.
Chemical Methods/Sterilization: Chemical sterilization implores liquid
solutions/gases. Objects to be sterilized are immersed in a solution or exposed to
fumes in a chamber for a specified time. Examples of this include Ethylene Oxide,
Chlorine compounds, Hibitane lotion, Polyvidone Iodine and Methylated spirits.

Assignment: Visit your preceptor/clinical area and

observe the methods of infection control. Find out
who is responsible for the control and at what level.

In-text Question 1 (A short question requiring a single sentence answer for quick
reflection over the read topic) Give 3 examples each of physical and chemical
method of sterilization.

Answer Dry heat, Radiation and Steam. (Physical). Liquid solution/gases e.g. Ethylene Oxide,
Chlorine Compounds, Hibitane Lotion and Methylated Spirits. (Chemical).

2.5 .Nursing Intervention at Every Infective Stage

The nursing intervention at every infective stage stems from assessment, planning
and evaluation. There are five (5)
potential problems relevant to most
patients with infections. These include:
i. physical and social isolation
ii. altered nutrition
iii. alteration in comfort
iv. Maintaining functioning of
others body systems.

240
 v. Alteration in self-management.
Reading Assignment: Read this further in the recommended textbook and discuss
within your study group.

In-text Question 1 (A short question requiring a single sentence answer for quick reflection
over the read topic): What is the major difference between barrier nursing and isolation?

Answer Nursing a patient in an open ward while every item being used for him or her is strictly
Kept and use exclusively for him or her.

3.0 Tutor Marked Assignments (Individual or Group)

1. enumerate the chain of events which link the reservoir of infectious agents
with the susceptible host
2. discuss the factors that predispose one to infection

4.0 Conclusion/Summary
In conclusion, it is believed that our knowledge of infection has been broaden
which shall make us more equip as member of health care team to prevent, and
curtail occurrence of infection to the best of our ability within and outside hospital
setting.

The development of infection of dependent on the nature of the interaction

between the host and microbial agent. The stages of infection are seven fold and
the knowledge of factors influencing the interaction of the host and microbial
agent has led to more effective preventive/control measures.
While remarkable progress is been made to control infection, the place of health
education cannot be overemphasized. Hospital should have in place an infection
control policy for the prevention and transmission of infection.

241
This unit presented an overview of infection control with particular reference to
infection phases, types and chains of infection, predisposing factors and nursing
intervention at every infective stage.
The 5 group of micro-organism are: bacteria, viruses, fungi, protozoa and parasitic
worms.

5.0 Self-Assessment Questions

Self-Assessment Questions (Should correspond to the No of Session Learning
Outcomes & each should relate to the corresponding Learning Outcome)
1. What are nosocomial infections? Identify eight (8) ways of controlling
nosocomial infections?

6.0References/Further Readings
Ingrid Cox (1999). Handbook on Sterilization: Kano.
Joan A.R. & Walsh Mike (1992). Watson’s Medical-Surgical Nursing and Related
Physiology; Butler and Tanner Ltd; Frame, Somerset, ELBS, (4th Ed.).
Jones A.D. et al (1978). Medical-Surgical Nursing: A Conceptual Approach
McGraw-Hill Book Company.
Nwonu A. (1994). ‘’Methods of Infection Control and Nursing Intervention’’
Unpublished, Enugu.

242
 STUDY SESSION 2B
Sexuality and Gender Issues
Section and Subsection Headings:
Introduction
1.0 Learning Outcomes
2.0 Main Content
2.1- Concept of Sexuality
2.2- Sexual Anatomy and Physiology
2.3- Attitudes towards Sexuality
2.4- Sexuality Counselling
2.5- Disorders of Sexuality
2.6- Sexuality and Nursing Process
3.0 Tutor Marked Assignments (Individual or Group assignments)
4.0 Study Session Summary and Conclusion
5.0 Self-Assessment Questions
6.0 Additional Activities (Videos, Animations & Out of Class activities)
7.0 References/Further Readings

Introduction:
Sexuality is the process of becoming and being a man or woman with all its
attending manifestations. Sex as a topic or an issue has long been considered a
“taboo” for proper adult conversation. People hardly want to talk about it openly,
however, in the last two decades, knowledge about sex and discussion of sexuality
have come to be recognized as important and necessary for human development.
Sexuality health has also been recognized as being relevant in the overall
component of wellbeing. In the face of this recognition, there is still lack of

243
knowledge regarding human sexuality among many adults including health care
providers. Clients are often reluctant to raise questions related to sexuality, the
nurse in her bid to provide holistic care must assume the responsibility of initiating
discussion of relevant sexual topics within client’s current developmental and
health status. Acquisition of knowledge and desensitization towards sexual
understanding of the vast range of normal sexual behaviour.

This unit will consider sexuality and gender issues in relation to personal attitudes
and beliefs, sexuality counseling and disorders with the peculiar nursing process
which enables health care provider (nurses) to be non-judgmental and more
effective in working with clients.

1.0 Study Session Learning Outcomes

After studying this session, I expect you to be able to:
1. state the concept of sexuality and gender identity
2. identify various attitudes towards sexuality
3. discuss the nursing intervention in relation to sexuality and gender issues

2.0 Main Content

2.1 Concept of Sexuality
Sexuality is described as the sense of being a female or male. It has biological,
psychological, social and ethical components. It influences and is influenced by
life experiences. The biological aspect of sexuality is the act of sexual activity. Sex
may be used for pleasure and reproduction. The activity can be controlled or
curtailed due to life’s change or a choice for brief or prolonged periods. Being born

244
with female or male genitalia social roles is the main ingredient to the emergence
of sexuality. The adult sexuality has four major divisions:
i. Biological sex
ii. Sexual behaviour
iii. Core gender identity
iv. Sex role imagery

Biological Sex:
This is determined at conception and refers to individual’s physical attributes. This
is based on the inherent genotype X and Y chromosomes. Female foetus receives
two x chromosomes from the mother and a Y Chromosomes from the father.
Initially, the genitalia of the foetus are undifferentiated, when the sex hormones
begin to cue fatal tissues, the genitalia assumes male or female characteristics with
corresponding underlying hormonal, neutral, vascular and physical components.

Core Gender Identity

This refers to one’s sense of being a man or a woman and is established early in
life, usually by 3years of age. Apart from the sex determination in utero with the
aid of C. T. Scan, at this age, the child is known whether he is a boy or a girl. As
children begin to explore and understand their own bodies, they combine this
information with the way that society treats them to create images of themselves as
girls or boys. It is the core gender identity that corresponds to the physical attribute
of the individual and self-concept development.

245
Sex Role Imagery
It refers to the learned behaviour that the particular society subscribes to their men
and women. Sex imagery is complex because it includes the myriad beliefs about
what is labeled feminine or masculine in a society. It also conveys the appropriate
image of sexual conduct for particular social groups. It is important as it represents
much of the learned behaviour which influences human choice and life-style.
In-text Question 1 (A short question requiring a single sentence answer for quick
reflection over the read topic) Mention 3 examples of sex role imagery beliefs for
male and female alike.

Answer

1. Male Female
1.Leadership 1.service
2. Benefactor 2.care-taker
3. Dominance 3.role model

Sexual Behaviour
This is the acting out of sexual expressions, feelings and beliefs. It is a
combination of human behaviour and varies from how one walks to how and with
whom one relays with sexually. These behaviours include promiscuity,
masturbation, sexual preference (oral or genital) and the likes.
1. XY Chromosomes gives rise to ----------- foetus.
2. XX Chromosomes gives rise to ---------- f o e t u s .

In-text Question 1 (A short question requiring a single sentence answer for quick
reflection over the read topic) When does sex role imagery learning begins and
ends?

Answer From 3 years to death

246
2.2. Sexual Anatomy and Physiology Female Sex Organs
The female genitalia
comprise of the external and
internal organs. The external
sex organs, collectively
called the vulva includes the
mons veneris, labia majora,
labia minora, clitoris and
vagina opening. The internal
sex organs include the
vagina, uterus, fallopian
tubes and ovaries. Menstruation and menopause are the main physiological
features of female sex organs.
The male sex organs is made
up of the penis, testicles,
epididymis and ductus
deference, the prostate gland,
seminal vesicles and
Cowper’s glands whose
secretions become part of the
ejaculated semen.

Activity 1
With your background knowledge of Biology / Health Sciences, sketch out the
diagram of the reproductive system of man. (If in doubt check your textbook on
the subject).

247
N.B: You will have an extensive lecture on male and f e m a l e
reproductive system on Anatomy Course at 200 Level.

2.3 Attitudes towards Sexuality

Attitudes towards sexual feelings and behaviours change as people grow older.
These changes become traditional or liberal because of societal changes, feedback
from others, and involvement in religious or community groups. Individuals reveal
themselves as females or males by their gestures, mannerisms, clothing,
vocabulary and patterns of sexual activity.

Factors Influencing Attitudes

Two main factors that help shape sexual attitudes and behaviors are biological
factors and personality. Other powerful factors that are involved include religious
beliefs, society and traditions.
Clients Sexual Attitudes
Everyone has sexual value system which are acquires throughout life. These make
it easy for a client to deal with sexual concerns in a health care setting or it
becomes an obstacle to expressing it.

Nurses Attitudes Towards Sexuality

Nurses should deal with personal
attitudes by accepting their existence,
exploring their sources and finding ways
to work with them. Nurses are part of the
society and her professional behaviour

248
must guarantee that clients receive the best health care possible without
diminishing their self-worth. The promotion of sex education and honest
examination of sexual values and beliefs can help in reducing sexual biases that
can interfere with care. The nurse should give clients information about sexuality
and this does not imply advocacy. Clients require accurate honest information
about the effects of illness on sexuality and the ways that it can contribute to
wellness.
In-text Question 1 (A short question requiring a single sentence answer for quick
reflection over the read topic) Using levels 2 and 3 what will be your guiding
principle in the sexuality counseling of an Acquired Immune Deficiency Syndrome
(AIDS) patient/Client.

Answer Closed monitoring, Provide privacy in management, provide education to

overcome the stigma and offer suitable treatment.

2.4 Sexuality Counseling

Sexuality complains are determined during history taking. An acceptable to open
up makes sexuality an acceptable topic to discuss. Once the nature of the problem
has been identified, treatment commences under the hinges of sexuality
counseling. Sexuality counseling operates at four (4) levels:
a. Permission: this involves letting the client realize or be reassured that the
client realize or be reassured that s/he is normal and may continues doing
what s/he has doing.
b. Limited Information: this involves only providing information specific to
the patients concerns or problem. A closed monitoring by the nurse is made
possible by the assumed change in behaviour or action.
c. Specific Suggestions: these may be a suggested course of action through
more in-depth education and sexual exercise.

249
 d. Intensive Therapy: highly individualized and provided by professionals
who have advanced experience and knowledge in the sex therapy field.

2.5. Disorders of Sexuality

Disorders of sexuality can occur in each of the four areas of sexuality (see 3.1), but
most disorders are psychosexual in origin. These disorders include:
1. Variation in sexual expressions classified by object choice and sexual aim.
2. Tran sexuality in which an individual appears to have a gender identity at
odds with his or her physical self.
3. Ambiguous genitalia which presents a genitalia different from the physical
gender identity on the child.
4. Sexual concerns over performance are also prevalent in which an individual
doubts his or her necessary physical attribute to attract, satisfy and keep a
sexual partner.
5. Sexual dysfunction in the form of impotence, premature ejaculation,
frigidity, dyspareunia and vaginism. It can be as a result of psychological or
physical factors.

2.6 Sexuality and Nursing Process

Sex as a natural, spontaneous act that passes easily through a number of
recognizable physiological stages and culminates in satisfaction for both partners.
Nurses should expect to encounter clients who have problems with one or more of
the stages of sexual behaviour excitement, plateau, orgasm and resolution).
Many nurses are uncomfortable talking about sexuality with clients, but they can
reduce their discomfort using the nursing process which includes assessment,
diagnosis, planning, implementation and evaluation.

250
The assessment level considers the factors affecting sexuality: physical
relationship, lifestyle and self-esteem factors. These assist in eliciting the exact
cause of sexual concerns or problems of the client/patient. As a follow up to the
assessment, altered sexuality patterns and sexual dysfunction are recognized as
approved nursing diagnosis. The difference is in whether the client perceives
problems in achieving sexual satisfaction or expresses concern regarding sexuality.
The planning of nursing care is dependent on client’s needs, and should include
referrals to resources to promote achievement of goals after contact with the nurse
is discontinued.
Nursing interventions (implementation) should address client alterations in sexual
patterns or sexual dysfunction generally to raise awareness, assist clarification of
issues or concerns, and provide information. An acquisition of specialized
education in sexual functioning and counseling may provide more intensive sex
therapy.
Evaluation of the impact of nursing process on sexuality is determined by client or
spouse verbalizations whether achievement of goals and outcomes has been
achieved. Sexuality is felt more than observed and sexual expression requires an
intimacy not amenable to observation. Clients are expected to verbalize concerns,
share activities and satisfaction as well as relate risk factors. Outcomes are
evaluated, the client, spouse and nurse may need to modify expectations or
establish more appropriate time frames to achieve the target goals.
In-text Question 1 (A short question requiring a single sentence answer for quick
reflection over the read topic) What are the four divisions of adult sexuality?

Answer The four divisions of adult sexuality are: Biological sex, Sexual behavior,
core gender identity, sex role imaginary.

251
3.0 Tutor Marked Assignments (Individual or Group)
1. state the concept of sexuality and gender identity
2. discuss the nursing intervention in relation to sexuality and gender issues

4.0 Conclusion/Summary
This unit has consider sexuality and gender issues in relation to personal attitudes
and beliefs, sexuality counseling and disorders with the peculiar nursing process
which enables health care provider (nurses) to be non-judgmental and more
effective in working with clients. Nursing interventions (implementation) should
address client alterations in sexual patterns or sexual dysfunction generally to raise
awareness, assist clarification of issues or concerns, and provide information. An
acquisition of specialized education in sexual functioning and counseling may
provide more intensive sex therapy.
Sexuality is an integral component of personhood and therefore may have an
impact on or be affected by health status. The nurse therefore needs to be clear
about his or her own sexuality and moral beliefs about sex and reproduction before
addressing the needs of the patient. Sex will always remain a controversial issue
because of ethical value systems. Facts of conception, development conception and
sexual diseased transmission may be taught but cannot be totally separated from
ethical issues.
The nurse has many opportunities to be a promoter of good health in the fields of
sex and reproduction which should be utilized at every available opportunity. No
one should be left out (male or female) as the responsibility for sexual health
transcends all boarders. With sensitivity and insight, the nurse can assist client in
assuming responsibility for decisions about sexuality thus enhancing their total
health.

252
This unit on sexuality and gender issues reflected on the concept of sexuality
stressing the four (4) major divisions of adult sexuality, brief anatomy and
physiology of the sexual organs, attitudes towards sexuality and counseling in the
face of sexuality disorders. The levels of nursing intervention were also identified
in order to appropriate the client’s expectation of health care from the nurse.

5.0 Self-Assessment Questions

1. Briefly describe any three (3) aspects of sexuality.

6.0References/Further Readings
Bartscher, PWB (1983). Human Sexuality and Implication for Nursing
Intervention: a Teaching Format, Journal of Nursing Education 22 (3): 123 –
127.
Glover J. (1984). Human sexuality in nursing care: London: Croom Helm.
Joan A.R. & Mike W (1992). Watson’s Medical-Surgical Nursing and Related

Physiology (4th Ed.). London: ELBS.

Katchadourian H.A & Lunde D.T. (1987). Fundamentals of Human Sexuality (3rd
Ed.). New York: Holt Rinehart & Winston.
Potter A.P. & Perry G.A. (1987). Fundamentals of Nursing: Concepts Process &
Practice (3rd Ed.). Philadelphia: J.B. Lippincott Co.

253
 STUDY SESSION 3A
Ethical and Legal Issues in Nursing I
Section and Subsection Headings:
Introduction
1.0 Learning Outcomes
2.0 Main Content
2.1- History of Nursing Ethics
2.2- Ethics and philosophy of Nursing
2.3- Development of Nursing Codes of Conduct
2.4- Ethical Concepts Applied to Nursing
2.5- Patients’ Bill of Rights
2.6- Interrelationship of Ethics and Law
3.0 Tutor Marked Assignments (Individual or Group assignments)
4.0 Study Session Summary and Conclusion
5.0 Self-Assessment Questions
6.0 Additional Activities (Videos, Animations & Out of Class activities)
7.0 References/Further Readings

Introduction:
In the last unit, we examined sexuality and gender in relation to nursing practice.
Two major factor that influences sexual attitudes are biological and personality
which are determinants of individual sex roles. These are ethics in nursing practice
which provides for confidentiality of care of patient. Ethics is a science of morals.
It stipulate standard of behaviour and values relating to human conduct. It starts
from childhood experiences, taught and learned from home, religious beliefs and
standard of conduct. One is governed by an individual ethical code, professional

254
code and the affirmation duties imposed by the Law. Nursing profession is guided
by both ethical and legal concerns as it is the tool for professional discipline which
gives the nurse a broad idea of what is expected of her as she moves from the
protective atmosphere of school into the society. Ethics of any profession imposes
some responsibilities on its members and consequently the recipient of a
professional service has his/her rights to be protected.
This unit will examine the ethical issues in nursing practice considering the history
of nursing ethic, development of nursing codes of conduct, ethical concepts applied
to nursing, Patients’ Bill of Rights, and the interrelationship of ethics and Law.

1.0 Study Session Learning Outcomes

After studying this session, I expect you to be able to:
1. enumerate the elements in Patients’ Bill of Rights that has ethical concerns
2. identify the differences between ethical and legal concerns of nursing
practice
3. describe clients’ expectation which has implications in the face of
professional negligence

2.0 Main Content

2.1 History of Nursing Ethics
Many books on nursing ethics in the past have in larger part restricted their content
to professional etiquette. In 1900, Robb one of the early nursing leaders wrote on a
breach of etiquette, but her comments reflect the sociology of the situation,
including difference in role, function and status. She remarked that occasionally we
find a nurse who, through ignorance or from an increase of her self – conceit and
an exaggerated idea of her importance, may overstep the boundary in her

255
relationship with the doctor and commit some breach of etiquette. The implication
of this does not rest with the nurse alone, but also her school and the profession
comes under share of criticism and blame. Aikens (1937) observed the nursing
ethics as old-fashioned virtues and this includes truth in nursing reports,
discreetness of speech, obedience being teachable, and respect for authority,
discipline and loyalty. The master and servant relationship between Physician and
Nurses also expresses another angle
of nursing ethics in 1943. Nurses
were subservient to the hospital
which employed them and the
hospital becomes responsible for
her acts. With this arrangement, any
disobedience to the Physician’s order is not only a matter of professional etiquette
but a violation of the employee contract. During such times, even when the
physician is mishandling the patient’s treatment, the nurse must either continue to
carry out his orders or give up the case. This was more private duty nursing
practice.
Many of the early ethics books delved into the private life and morality of nurses,
reflecting the status of nursing students in an apprenticeship system and the
stereotype of the intellectually and morally weak women. Such concerns focused
on the individual’s morality, and the nurses duties, obligations, and loyalties
referred to a situation in which nurses were on the one hand, expected to exhibit a
dedication of almost a religious nature while on the other hand, their morality was
open to suspicion.

256
2.2 Ethics and philosophy of Nursing
There are philosophical forces that make up and direct each nurse’s practice.
Burkhardt and Nathaniel (2008) note philosophy as “the intense and critical
examination of beliefs and assumptions (pp. 27). One incorporates knowledge and
beliefs to make up their philosophical forces. Possessing outstanding philosophical
forces allows one to be respectful, well rounded and possess good character. Some
examples of ways one has been respectful towards another person’s beliefs is:
A nurse encountered an experience with patient from a different religious
background. This particular patient required a blood transfusion, but opted out due
to religious reasons. One had to respect the patient’s wishes and continue to give
them adequate nursing care that was in the scope of their religion. One has also
encountered an experience with a nurse from a different religious background. This
particular nurse’s religion had a prayer ritual that required her to pray at different
times throughout the day. One respected that nurse and watched over her patients
while she was away. As a nurse, one must be respectful and accommodating to
another. One’s philosophical forces go hand-in-hand with their philosophy of
practice.

Ethics and values are incorporated into the philosophy of practice. Burkhardt and
Nathaniel (2008) note that philosophy of practice “focuses on the critical
examination of assumptions about norms or values and includes ethics, social and
psychological aspects.

Nursing Philosophy:
Nursing Philosophy is a system of beliefs, it is often looked at as an effort to define
nursing situations that is observed to exist or happen and serves as the basis for later
theoretical formulations. Florence Nightingale the first nurse theorist, philosophy

257
states that nursing is establishing and environment that allows persons to recover
from illness. The environment in which the patients are in plays a big role in their
healing process. Florence Nightingale founded her nursing theory and philosophy on
enhancing environmental factors to improve the patients overall health, healing and
well-being. Nightingale's attention to environment has added significance to the role
environmental conditions play in human health status (Shaner, 2006).
Nursing has four metaparadigms the client, the environment, health and nursing.

Nursing Code of Ethics

Butts and Rich (2006) point out that effective nursing requires both broad
knowledge and a set of well-developed abilities and skills. The required tasks, are
many and varied and in order to do them properly, care must be taken to respect
each patient's rights and sensitivities. This is why nursing care must be guided by a
code of ethics. As a profession, nurses need to promote the core values and code of
Ethics amongst them. Nurse practitioners are required to understand and practice the
specific knowledge and skills of core values such as nurse caring, advocacy, holism
and professionalism to assist the patients in their critical condition.

Code of Ethics in Nursing

The fundamental responsibility of the nurse is fourfold:
i. to promote health,
ii. to prevent illness,
iii. to restore health and
iv. to alleviate suffering
The need for nursing is universal. Inherent in nursing is respect for life, dignity and
the rights of man. It is unrestricted by consideration of nationality, race, creed,

258
color, age sex, politics, or social status. Nurses render health services to the
individual, the family and the community and coordinate their activities.

Nursing Code of Ethics Provision:

1. The nurse, in all professional relationships, practices with compassion and
respect for the inherent dignity, worth, and uniqueness of every individual,
unrestricted by considerations of social or economic status, personal
attributes, or the nature of health problems.
2. The nurse’s primary commitment is to the patient, whether an individual,
family, group, or community.
3. Value clients Statement
4. Respect clients’ individual values and needs.
5. Respect and promote clients’ autonomy
6. Respect clients’ right to confidentiality
7. Respect and preserve clients’ privacy.
In-text Question 1 (A short question requiring a single sentence answer for quick
reflection over the read topic) List the fundamental responsibility of the nurse?

Answer to promote health, to prevent illness, to restore health and to alleviate

suffering.

2.3. Development of Nursing Codes of Conduct

The code of conduct for nursing practice has spanned from decade to decade with
specific moderations. In order to provide one means of professional self-regulation,
the America Nurses Association (ANA) revised its code of ethics, which had
originally been adopted in 950. The Code of Nurses (1976) indicated the nursing
professions acceptance of the responsibility and trust with which it has been
invested by society. The requirement of the Code may often exceed, but are not

259
less than, those of the law. While violation of the law subjects the nurse to criminal
or civil liability, the Association many reprimand, censure, suspends or expels
members from the Association for violation of the code. The interpretive
statements that accompany the ANA code outline the ethical principles that
underpin each section of the code.

Code of conduct for Nurses

a. The nurse provides services with respect for human dignity and the
uniqueness of the client unrestricted by considerations of social or economic
status, personal attributes or the nature of health problems.
b. The nurse safeguards the client’s right to privacy by judiciously protecting
information of a confidential nature.
c. The nurse acts to safeguard the clients and the public when health care and
safety are affected by the incompetent, unethical, or illegal practice of any
person.
d. The nurse assumes responsibility and accountability for individual nursing
judgments and actions.
e. The nurse maintains competence in nursing.
f. The nurse exercises informed judgments and uses individual competence
and qualifications as criteria in seeking consultation, accepting
responsibilities and delegating nursing activities to others.
g. The nurse participates in activities that contribute to the ongoing
development of the professions’ body of knowledge.
h. The nurse participates in the professions efforts to implement and improve
standards of nursing.

260
 i. The nurse participates in the profession’s efforts to establish and maintain
conditions of employment conducive to high – quality nursing care.
j. The nurse participates in the professions’ efforts to protect the public from
misinformation and misrepresentation and to maintain the integrity of
nursing.
k. The nurse collaborates with members of the health professions and other
citizens in promoting community and national efforts to meet the health
needs of the public.
i. The mother of an AIDS patient knows that her son is seriously ill but does
not know the diagnosis. One day, she asks the nurse if he is dying saying
she’s afraid he has Leukemia. What should the nurse do?
ii. Discuss your opinion with others and check it in line with the code of
conduct for nurse number 2.

2.3 Ethical Concepts Applied to Nursing

The fundamental responsibility of the nurse is fourfold: to promote health, prevent
illness; restore health and alleviate sufferings.
The need for nursing is universal. Inherent in nursing is respect for life, dignity and
rights of man. It is unrestricted by considerations of nationality, race, creed, age,
politics or social status.

2.4 Patients’ Bill of Rights

2 Bill of Rights developed include:
i. A patient’s bill of right developed by the American Hospital Association in
1973.

261
 ii. A Consumer Rights in health Nurses render health services to the individual,
the family, and the community and co-ordinate their services with those of
related groups.
The International Council of Nurses in Geneva updated its code of ethics in 1977
and it includes:
Nurses and People
The nurse’s primary responsibility is to those people who require nursing care, the
beliefs, values, and customs of the individual.
The nurse holds in confidence personal information and uses judgement sharing
this information.

Nurses and Practice

The nurse carries personal responsibility for nursing practice and for maintaining
competence by continual learning.
The nurse maintains the highest standards of nursing care possible within the
reality of a specific situation.
The nurse uses judgement in relation to individual competence when accepting and
delegating responsibilities.

The nurse when acting in a professional capacity should at all times maintain
standards of personal conduct that would reflect credit upon the profession.

Nurses and Society

The nurse shares with other citizens the responsibility with co-workers in nursing
and other fields.

262
The nurse takes appropriate action to safeguard the individual when his care is
endangered by a co-worker or any other person.

Nurses and the Profession

The nurse plays the major role in determining and implementing desirable
standards of nursing practice and nursing education.
The nurse is active in developing a care of professional knowledge.
The nurse, acting through the professional organization, participates in establishes
and maintaining equitable social and economic working conditions in nursing care
published in Canada by the National Consumers Association.

Patient’s Bill of Rights states the following:

a. The patient has the right to considerate and respectful care. He has the right
to an explanation to what is happening.
b. The patient has the right to obtain from his physician complete current
information concerning his diagnosis, treatment and prognosis. When
consider not appropriate tell his/her relation. (see the box below).
c. Patient has the right to receive from his physician information necessary to
give informed consent prior to the treatment of everything to be done on
them except in emergencies.
d. Patient has the right to refuse treatment to the extent permitted by law and be
informed of the medical consequences of his action. He should not be forced
but the authority must be informed.
e. Patient has the right to every consideration of his privacy concerning his own
medical programmes.
f. Patient has the right to expect that all communications and records pertaining
to his care should be treated as confidential.

263
g. Patient has the right to expect that within its capacity a hospital must take
reasonable response to the request of a patient for service.
h. The patient has the right to be advised if the hospital propose to engage in or
perform human experimentation affecting his care or treatment.
i. Patient has the right to expect reasonable continuity of care.
j. Patient has the right to examine and receive an explanation of his bill
regardless of source of payment.
k. Patient has right to be informed of hospital rules and regulations applied to
his conduct as a patient.
l. A disabled person has the right to treatments.
m. A disabled person has the right to economic and social security and to a
decent level of living.
n. A disabled person has the right to live with their families and participate in
all activities.
o. A disabled person shall be protected against all exploitations.
p. A pregnant woman has the right to explanation on any care to be carried out
on her and the risks involve affecting her and the baby in the womb.
q. The pregnant patient has the right to be accompanied during the stress of
labour for and who cares for her.
r. The obstetric patient has the right to be informed in writing of the name of
the person who actually delivered her baby.

In given out information to patient as stipulated in the Rights consideration

should be given to?
Answer
1. Who gives what information?
2. To whom is the information given.
3. When is it appropriate to give it? 3marks

264
Activity 1
Quickly recap eight (8) of the Bill of Rights off hand. Of what use is information to
the nurse and patient?

2.5 Interrelationships of Ethics and Law

Ethics and Law interface in any nursing practice and administration. Smith and
Davis (1980) identified four (4) situations in which ethics and law interface.
1. That which is ethical is legal e.g. informed consent.
2. That which is ethical is illegal e.g. euthanasia (see unit 14).
3. That which is unethical is legal e.g. abortion.
4. That which is unethical is illegal e.g. involuntary medical treatment in non-
emergency situations.
Two of the situations are congruent and two are conflict.
N.B. If you are in doubt, check for the meaning of Congruent and Conflict in the
Advanced Learners Dictionary (ALD) before attempting the exercise.
The following statement serves to put the four situations in proper perspectives:
a. The conflict between ethical and illegal and unethical and legal will
probably always be with us. Ethical cannot be bound by the law when
ethical considerations override legal ones. Law cannot be held hostage to
ethics in the sense that a law cannot be enhanced to control every immoral
act. Therefore the nurse as patient care administrator must expect this
tension between ethics and law.
b. The role of the institutional lawyer and that of the nurse as patient care
administrator may conflict. A nurse care administrator can recommend that a
health care institution hire additional lawyers as advocates for patients. This
option provides a balanced perspective.

265
 c. Lawyers use basic tenets in formulating laws, and ethicist use laws or court
decisions as part of their database in arriving at morally justified decisions.
Ethics is not the final determinant of law, and the law is not the final
determinant of ethics.
d. A reasonable compromise or acquiescence to a majority decision by the
nurse and lawyer may be in the overall best interest of all.
The standards of care and of professional performance help nurses as patient care
administrators ensure that they are creating and maintaining a professional nursing
system within their health care settings. Standards of professional performance are
not static; they reflect changes in society, technology and the professions.
Nursing’s reflection of these changes, however, must always be a responsible one
that ultimately is accountable to ethics, law and the society contract between
nursing and society.
In-text Question 1 (A short question requiring a single sentence answer for quick
reflection over the read topic) Mention 2 congruent situations and 2 congruent
situations

Answer congruent situation are 1 and 4 while conflict situation are 2 and 3.

3.0 Tutor Marked Assignments (Individual or Group)

1. enumerate the elements in Patients’ Bill of Rights that has ethical concerns
2. describe clients’ expectation which has implications in the face of
professional negligence

4.0 Conclusion/Summary
Both nursing and ethics are in state of profound transition. Regarding nursing, the
scope of nursing practice and the ways in which nurses are reimbursed for their
care are changing with ethics. During the past several decades, classical ethical

266
theories and associated principles dominated. Today, feminist ethics and the ethics
of care are coming into their own. Both are transformative ethics which are best
articulated and developed from the outset with a keen awareness of multicultural
and global perspectives in a search for and an understanding of a common
humanity. A detailed lecture on Nurse and the Law in this course will further shed
light into the legal implications of nursing practice and consequences of neglect or
negligence since the code of nursing practice maintains that the primary ethical
obligation is to the patient.
This unit has examined extensively the Ethical issues in Nursing with clear
definition of nursing codes of conducts, ethical concepts applied to nursing,
Patients’ Bill of Rights, and the interrelationships of ethics and the Law to guide
the nurse in the discharge of her nursing roles to the clients and society in general.

5.0 Self-Assessment Questions

1. List the fourfold fundamental responsibility of ethical concepts for
nurses.
2. Briefly state the International Council of nurses’ code of ethics.

6.0References/Further Readings
Davis, A.J. et al (1996). Ethical Dilemmas Nursing Practice: Appleton and Lange,
Stamford, (4th Ed.).
Nwonu, E.I. (1994). Concepts in Professional Nursing Practice: Unpublished
Handbook at UNEC, Enugu.
Theresa, S.D. et al (1996). “Selected Ethical Approaches: Theories and Concepts
in Ethical Dilemmas Nursing Practice, Appleton and Lange, Stamford, (4th
Ed.).
American Nurses Association: Nursing Position Statements on Ethics and Human
Right

267
 STUDY SESSION 3B
Legal Aspects of Professional Nursing I
Section and Subsection Headings:
Introduction
1.0 Learning Outcomes
2.0 Main Content
2.1– Nature of Law
2.2– Sources and Types of Nigerian Law
2.3– Functions of Law in Nursing and the Legal Responsibilities of
Professional Nurses
2.4– Regulation of Nursing Practice in Nigeria
2.5- Contractual Arrangements in Nursing
3.0 Tutor Marked Assignments (Individual or Group assignments)
4.0 Study Session Summary and Conclusion
5.0 Self-Assessment Questions
6.0 Additional Activities (Videos, Animations & Out of Class activities)
7.0 References/Further Readings

Introduction:
We live in a changing world and nothing is really static. Indeed the only thing that
is permanent in life is change. It is therefore an open truth that the wind of change
is blowing over every aspect of life including nursing professional practice. There
are changes in orientation and standards of practice. The present unit therefore
aims at introducing learners to the legal framework of nursing with a view to
broadening the learner’s horizon on legal intricacies in nursing practice.

268
1.0 Study Session Learning Outcomes
After studying this session, I expect you to be able to :
1. describe the legal framework and how laws are adapted
2. discuss the impact of law on nursing practice
3. enumerate legal responsibilities of nurses in delivering client care
4. explain legal concepts that apply to nurses.

2.0 Main Content

2.1 Nature of Law
Right from creation, every society, primitive or civilized, is governed by a body of
rules which members of the society regard as standards of behaviour. It is when
such rules involve the idea of obligation that they become law. As such laws can
be defined as those standards of human conducts established and reinforced by the
authority of an organized society through its government. Bern Zweig (1996)
defined it as ‘those rules made by human, which regulate social conduct in a
formally prescribed and legally binding manner’.

2.2 The Sources of Nigerian Law

Nigeria laws have its origin primarily from two sources namely:
Nigerian Legislation, which consist of:
1. Customary Laws – This consist of customs accepted by members of the
community as binding among them. Can be broadly classified into Ethnic
(i.e. Non-Moslem) customary law and Moslem or Sharia law.

2. The Constitution – This is an embodiment of principles upon which any

state (i.e. nation) is governed. A document written or unwritten containing a

269
 body of rules that specifies the functions of different organs of government
and their interrelationship with each other for the purpose of good
governance. All other laws take their validity from the constitution. As such
the constitution is believed to be supreme to all other laws.

3. Judgments of Courts (Judicial Precedents) – Decisions of the court of

law. Judgments passed by courts of law usually serve as precedent for
deciding similar cases in future (Decisional Laws). This principle of
following precedent in settling legal tussles is known as the doctrine of
‘Stare Decisis’ meaning to stand as decided or previous decision stands.

4. Statutes (Statutory Law) – Decisions made by legal democratic institutions

whether at National, State or Local level. They are laws enacted by the
legislative arm of government and are usually politically inclined. Nigerian
statutes include: (i) Ordinances (ii) Acts (iii) Law (iv) Decrees (v) Edicts.

5. Rules and Legislation (Administrative Law) – These are promulgated by

groups who are appointed to governmental administrative agencies, and who
are entrusted with enforcing the statutory laws passed by the legislature.
Received English Law, which encompasses:
1. Common Law – Historically, these are laws made common to the whole of
England and Wales after the Norman Conquest of 1066 and which following
its full establishment was imported to all British colonial territories, Nigeria
inclusive. With the passage of time the common law became so stringent,
harsh and crafty so much that justice could not be done in all cases. This
inability of the common law to render fair decisions in all cases provoked
the emergence of Equity.

270
 2. The Doctrine of Equity – Body of rules or principles laid down in the court
of Chancery before 1873 that are intended to supplement the common law
by providing new rights and new remedies and by ameliorating the common
law where this was too rigid, harsh and inflexible. Its emergence
tremendously contributed to the fairness of court decisions in England and
her colonial territories.

3. Statutes of General Application in force in England on January 1, 1960.

4. Statutes and subsidiary legislation on specified matters.

Types of Nigerian Laws/Classification of Nigerian Laws

Nigerian laws can be broadly classified into three main categories viz:
Public Law – Public law refers to the body of law that deals with relationships
between individuals and the government and governmental agencies. The different
types of public law are outlined below:
Constitutional Law – The laws of the federal republic of Nigeria is set forth in the
Nigerian constitution.
Administrative Law – The Nurse Practice Act, The Pharmacy Law, Food and
Drug Administration and Control Act e.t.c, are all examples of administrative laws.

Criminal Law – These are sets of rules or statutes, which deals with how a society
as a whole should behave. Criminal law addresses acts against the safety and
welfare of the public. That is criminal offence is against the state. Prosecution is
therefore by the state represented by the Commissioner of Police or Director of
Public Prosecutions or Attorney General. Note that an individual can occasionally

271
institute a criminal action in the court. The objective is to convict by the way of
fine, imprisonment or both or
death. The prosecutor however
has to prove the guilt of the
accused beyond all reasonable
doubt. Perhaps it should be
added that an accused cannot agree with the state to withdraw a criminal case
already in court but the Attorney General can enter ‘Nolle Prosequi’ and thereby
withdraw the case from court (Babajide, 2001).

Civil Law – The phrase ‘civil’ has several meanings. It may be taken to mean a
branch of the law of a country that governs the relations that exist between citizens
themselves i.e. concerned with the protection of individual rights of members of
society. It may even be viewed as laws made to direct the affairs of workers and
government functionaries i.e. Government Order. Call it civilian law and one may
not be wrong as the word civil to those in the armed forces denotes anything that is
not peculiar to the military. Civil laws therefore encompass all laws that deals with
crimes against a person or persons in such legal matters as contracts, torts,
mercantile law, and protective/reporting law. Most cases of malpractice fall within
the civil law of torts. Civil wrong is a breach of individual’s right (Martin, 1998;
Flight, 1993).

The individual who brings a civil action in court is called a plaintiff while the
person for whom action is brought against is known as the defendant. The whole
essence of civil suit is to compensate the victim of the civil wrong complained
about. The standard of proof in civil cases is based on balance of probabilities. And

272
unlike the criminal case, civil suit can be withdrawn from the court by the parties
and be settled out-of- court.

Customary Law – As earlier mentioned these are customs (written or unwritten)

that are accepted by members of the community as binding among them. Can be
broadly classified into Ethnic (i.e. Non-Moslem) customary law and Moslem or
Sharia law. The ethnic customary law is indigenous and applies to members of a
particular ethnic group. The Sharia law on the other hand is a religious law. It is
based on Islamic injunction or Islamic doctrine and has its own principles which
are Islamic oriented. It is basically applicable to members of the Islamic faith.

2.3 Functions of Law in Nursing and Legal Responsibilities of Professional

Nurses
Functions of the Law in Nursing: Kozier, et.al. (2000) declared the following as
the functions of law in nursing:
a. It provides a framework for establishing which nursing actions in the care of
clients are legal.
b. It differentiates the nurse’s responsibilities from those of other health
professionals.
c. It helps establish the boundaries of independent nursing action.
d. It assists in maintaining a standard of nursing practice by making nurses
accountable under the law.
e. It serves as a professional update of client’s/patient’s legal right.

273
Legal Roles of Professional Nurses
Nurses have three separate, interdependent legal roles, each with associated rights
and responsibilities as provider of service, employee or contractor for service, and
citizen (Kozier, et.al. 2000)

Provider of Service – The nurse is legally responsible to ensure that the client
receives competent, safe, and holistic care. To ensure this and to avert possible
liability nurses are expected to:
i. Render care based on their education, experience and circumstances. The
standard of care by which a nurse acts or fails to act are legally defined by
the nurse practice acts and by the rule of reasonable and prudent action i.e.
what a reasonable and prudent professional with similar preparation and
experience would do in similar circumstances.
ii. Discuss with the client the associated risks and outcomes inherent in the plan
of care as well as alternate treatment modalities.
iii. Maintain clinical competence and refuse to carry out orders that would be
injurious to client.
iv. Document the care the client receives and other significant events affecting
the client. (Kozier, et.al. 2000; Martin, 1998).

Employee or Contractor for Service – In all nurse-patient relationships, the nurse

holds the patient/client a duty of care. Personal inconvenience and personal
problems are not legitimate reasons for failing to fulfill this contract whether as an
independent practitioner or as an employee. The nurse employed by a hospital
functions within the policies of the employing agency. According to Kozier, et.al.
(2000), this type of legal relationship creates the ancient legal doctrine known as

274
respondent superior (‘let the master answer’). In other words the master assumes
responsibility for the conduct of the servant (employee) and can also be held
responsible for malpractice by the employee. This doctrine does not however
imply that the nurse cannot be held liable as an individual nor does it exonerate her
in cases where her actions are extra-ordinarily inappropriate, that is beyond those
expected or foreseen by the employer. In a nutshell, the nurse has obligation to her
employer, the client, and other personnel.

Citizen – The rights and responsibilities of the nurse in the role of citizen are the
same as those of any individual under the legal system. Rights are privileges or
fundamental power to which an individual is entitled unless they are revoked by
law or given up voluntarily; responsibilities are obligations associated with these
rights. An understanding of these rights and responsibilities associated with them
will therefore promote legally responsible conduct and practice by nurses (Kozier,
et.al. 2000).

2.4 Regulation of Nursing Practice in Nigeria

The Nursing and Midwifery Council of Nigeria established by decree 89 of 1979
and variously amended by decree 54 of 1988, decree 18 of 1989 and decree 83 of
1992, is saddled with the
responsibility of regulating nursing
practice in Nigeria. This specifies
the functions and administration of
the nursing and midwifery council
of Nigeria. The major functions
include: Registration, regulation of

275
professional standard, training and disciplines in Nursing

2.5 Nature of a Contract:

A contract may simply be defined as a legally binding agreement (oral or written)
between two or more competent persons, on sufficient consideration
(remuneration), to do or not to do some lawful act. Implicit in this definition is that
an agreement between two or more parties is of the essence of a contract.
Consequently the general principle is that no party can derive any benefit from a
contract or have any obligation imposed on him by it unless he is a party to the
contract. A contract then, is the basis of the relationship between a nurse and an
employer. Contract may be implied or expressed. A contract is considered to be
expressed when the two parties discuss and agree orally or in writing to its terms,
for example, that a nurse will work at a hospital for a stated length of time and
under stated conditions. An implied contract on the other hand, is one that has not
been explicitly agreed to by the parties but that the law nevertheless considers to
exist. For instance in the contractual relationship between the nurse and the
patients, the patients have the right to expect that the nurse caring for them have
the competence to meet their needs. The nurse also has the associated right to
expect the patient to provide accurate information as required (Kozier, et.al. 2000).
It is important to mention at this juncture that it is not all agreement that one enters
into that is legally binding.
The following are few examples:
i. A gentle man’s agreement.
ii. Agreement between family and friends relating to purely social or domestic
matters.
iii. An agreement to marry commonly known as engagement.

276
iv. Agreement made under duress.

Essentials of a Contract: A valid contract requires the following five elements

i. Offer
ii. Acceptance – the assent of the parties/persons involved.
iii. There must be a valid consideration or something of value, in most cases
financial compensation for fulfilling the terms of the contract.
iv. The parties to the contract must have contractual capacity i.e. must be of
legal age and must possess mental capacity to understand the requirement of
the contract.
v. Intention to enter into a legal relationship which in most cases is presumed
by the parties’ conducts must be manifestly seen.
In-text Question 1 (A short question requiring a single sentence answer for quick
reflection over the read topic) mention four (4) types of Nigerian law

Answer The four types of Nigerian law are 1: public law, 2: customary law, 3: civil
law, 4: and criminal law.

3.0 Tutor Marked Assignments (Individual or Group)

1. Describe the legal framework and how laws are adapted
2. Discuss the impact of law on nursing practice
3. Explain legal concepts that apply to nurses.

4.0 Conclusion/Summary
In the end, this study session has successfully described the legal framework and
how laws are adapted, as well as how this relate to nursing profession and nursing
practice particularly in deliverance of client care. More so, public also becomes
better informed than ever about their rights.

277
The unit opens with a succinct background to the need for nurses to become
conversant with legal conceptions affecting the practice of nursing. It portrays laws
as rules made by human, which regulate social conduct in a formally prescribed
and legally binding manner. That is law defines and limit relationships among
individuals and the government. The unit contends that Nigerian laws are from two
major sources: Nigerian legislation and Received English laws, and they can be
classified into three broad groups namely: Public law, Civil law and Customary
law.
Furthermore, the unit presents a synopsis of the functions of law in nursing which
include providing a legal framework.
5.0 Self-Assessment Questions
1. Outline the legal responsibilities of a professional nurse.
2. Discuss the concept of contractual agreement in Nursing.

6.0 References/Further Readings

Babajide, L.O. (2001). The Nigerian Nurse on the Scale of Law. Ile-Ife: Samtrac
Publishers.
Bernzweig, E. P. (1996). The Nurse’s Liability for Practice: A Programmed
Course (6th Ed.). St. Louis: Mosby.
Caulfield, H. (1995). Legal Issues. In H. B. M. Heath (ed.) Potters and Perry’s
Foundations in Nursing Theory and Practice. Italy: Mosby, An Imprint of
Times Mirror International
Creighton, H. (1975). Law Every Nurse Should Know (3rd Ed.).
Philadelphia: W.B Saunders Company.

Flight, M. (1993). Law, Liability, and Ethics (2nd Ed.). Albany, NY: Delmar
Publishers.

278
Kozier, B.; Erb, G.; Berman, A.U. & Burke, K. (Eds.). (2000). Legal Aspects of
Nursing. Fundamental of Nursing: Conceptions Process and Practice (6th
Ed.). New Jersey: Prentice Hall, Inc.
Lowe, S. C. (1995). Legal and Ethical Aspects of Nursing. In C. B Rosdahl (ed.)
Textbook of Basic Nursing. Philadelphia: J.B. Lippincott Company.
Martin, J. (1998). Legal Responsibilities. In Delaune & Ladner (Eds.).
Fundamentals of Nursing, Standards and Practice. Albany: Delmar
Publishers.
Obilade A.O. (1979). The Nigerian Legal System. London: Sweet and Maxwell.
Zerwekh, J. & Claborn, J. C. (1994). Nursing Today: Transitions and Trends.
Philadelphia: Saunders.

279
 STUDY SESSION 3C
Legal Aspects of Professional Nursing II
Section and Subsection Headings:
Introduction
1.0 Learning Outcomes
2.0 Main Content
2.1- Selected Legal Aspects of Nursing Practice
2.2- Liability in Nursing Practice
2.3- The Nurse and the Criminal Law
2.4- Legal Safeguards for Nursing Practice
3.0 Tutor Marked Assignments (Individual or Group assignments)
4.0 Study Session Summary and Conclusion
5.0 Self-Assessment Questions
6.0 Additional Activities (Videos, Animations & Out of Class activities)
7.0 References/Further Readings

Introduction:
One of the direct consequences of the changes in life patterns talked about in the
preceding unit is that, the employers and clientele now expects a level of
excellence of practice from the professional. The public also becomes better
informed than ever about their rights. This in addition to the subtle but complex
legal relationship that is in existence in many countries of the world therefore
demands that a nurse has an understanding of basic legal concepts as they affect
the practice of her profession.

280
1.0 Study Session Learning Outcomes
After studying this session, I expect you to be able to:
1. explain legal conceptions that apply to nursing
2. identify areas of potential liability in nursing practice and actions nurses can
implement to avoid these problems
3. differentiate between unprofessional conduct and negligence
4. distinguish between tort and crime
5. explain the role of the nurse in the informed consent process.
6. discuss how privileged communication applies to the nurse-client
relationship
7. discuss advance directives and differentiate between living will, directive to
physicians, and durable power of attorney.

2.0 Main Content

2.1 Selected Legal Aspects of Nursing Practice
Confidential Communication
Medical and nursing practice is built on a relationship of trust and confidence in
which the patient might disclose many things of confidential nature, which this
undertakes to regard as a professional secret. It is not uncommon to find such
privileged information to be given to a professional nurse who is forbidden by law
not to divulge without the consent of
the patient who provided it This
relationship is imperative if the
patient is not going to be afraid to
seek advice from the nurse and if
nurses are to be free to ask any

281
question that they consider to be germane to the management of the patient. This
rule is also entrenched in the nurses’ code of ethics, which states that – The nurse
safeguards the individuals’ right to privacy by judiciously protecting information
of a confidential nature, sharing only that information relevant to his care.
There are however exceptions to this rule. And that takes us to the question – when
can we divulge such information?
i. When compelled by the law: – Courts
ii. Notifiable diseases
iii. Vital statistics such as births and deaths
iv. With the consent of the patient.
v. Where there is a public duty of disclosure, for example armed robbery cases
or in a forensic case; an epileptic patient who may be a driver; or in a case of
child or elder abuse.
vi. Where the interest of the health personnel requires it, for instance patients
refusal to pay bill.

Informed Consent
The law has long recognized that individuals have the right to be free from bodily
intrusions. This perhaps informs the inculcation of informed consent into medical
practice. The doctrine of informed consent not only requires that a person be given
all relevant information required to reach a decision regarding treatment but also
that the person be capable of understanding the relevant information regarding
various treatment modalities so that the consent can be truly an informed process.
Therefore, informed consent can be described as an agreement by a client to allow
a course of treatment or a procedure to be carried out on him after complete

282
information, has been provided to him by a health care provider, including the risks
of such treatment and facts relating to it.
There are basically two types of consent: express and implied Express consent
may either be oral or verbal. Implied consent is an assumed consent and it exist
when the individual’s non-verbal behavior indicates agreement. Examples of
implied consent include:
i. Tubal ligation in a grand multiparous woman whose attitude suggest
acceptance of procedure.
ii. During surgery when additional procedures are needed that are consistent
with the procedure already consented to.
iii. When clients continue to participate in therapy without removing previous
consent.
Obtaining an informed consent for a medical or surgical procedure is the
responsibility of a physician although this responsibility is delegated to nurses in
some agencies. The nurses’ responsibility is to witness the giving of informed
consent for medical procedure. This involves the following:
i. Witnessing the exchange between the client and the physician
ii. Establishing that the client really understands i.e. was really informed.
iii. Witnessing the signature.
In addition, nurses may play a role in decision-making through teaching,
counselling, and clarifying issues with the patient but should not be made to
provide medical information. This said, there are instances where the nurses
themselves have to assume the responsibility of obtaining informed consent,
especially when the procedure to be performed is purely nursing like passing a
nasogastric tube, medication administration, and so on and so forth.

283
There is a common misconception that only written consent is legal or valid. On
the contrary, oral consent is equally binding. Furthermore, the fact that consent is
written is not the proof that the consent is informed or valid, but it can be a useful
evidence that a discussion between the nurse/doctor and the patient/client took
place. In fact written consent can give a false sense of reassurance especially when
the wordings of such consent are vague and meaningless. Therefore the legal issue
in litigation is precisely what the client was told and not the procedural aspects of
signing the form. What then are the essential elements of an informed consent?
1. The consent must be given voluntarily, not coerced.
2. The client must be of age of maturity and must be mentally competent.
3. The client must be given enough information to be ultimate decision maker.
Sometimes, the amount and type of information required for a client to make an
informed decision can be challenging. Kozier et.al. (2000) gave the following as
general guidelines:
i. The purposes of treatment
ii. What the client can expect to feel or experience
iii. The intended benefits of treatment
iv. Possible risks or negative outcomes of the treatment
v. Advantages and disadvantages of possible alternatives to the treatment
(including no treatment).
It should also be noted that it is not in all cases that consent is required. Outlined
below are instances when consent may not be required:
i. Prisoners – No legal right in court
ii. On a court order – If the court orders that certain procedures be carried out
on a client.
iii. Immigrants – Screening procedure to ensure safety of citizens.

284
iv. Milk and Food Handlers- Screen procedures for the health of the generality
of people.
In-text Question 1 (A short question requiring a single sentence answer for quick
reflection over the read topic) List two (2) examples of exception to confidential
information

Controlled Substances
In Nigeria like any part of the world, the law of the nation regulates the distribution
and use of controlled substances such as narcotics, stimulants, e.t.c. Misuse of
controlled substances therefore attracts criminal penalties. The law also requires
that record be kept on dispensing narcotics. Hence the wisdom behind keeping
these substances in double locked cupboards in most hospitals with special
logbook for documenting their administration?

Advance Directives
Lowe (1995) expressed that to preserve a patient’s rights, all healthcare workers
need to be aware of patient’s wishes regarding continuing, withholding, or
withdrawing treatment in the event the patient cannot make these decisions for
himself or herself. Caulfield (1995) quoting the Omnibus Reconciliation Act of
1990 tagged Patient Self Determination Act defines an advanced directive as a
written instruction such as a living will or durable power of attorney for health
care, that is recognized under state law and is related to the provision of such care
when individual is incapacitated. Consequently, there are three types of advance
directives viz:
i. A living Will – This a written and legally witnessed document prepared by a
competent adult instructing health workers to withhold or withdraw life-

285
 sustaining procedures in a person in event of the person’s incapacitation or
becoming unable to make decisions personally.

ii. Durable Power of Attorney (Health Care Proxy) – This is an

authorization that enables a competent individual to name someone to make
medical decisions for him/her in the event the individual is unable to make
those decisions. This designated person does not necessarily be a relative.

iii. Advance Care Medical Directive – This is also a document made by the
client in consultation with the physician and other advisors that authorizes
the physician to be the decision maker in matters concerning his/her medical
care. The physician must also agree in writing, to accept to be the client’s
agent.
What are the nurses’ responsibilities in advanced directives?
i. Understand the different types of advanced directives.
ii. Know the laws relating to the patient Self-Determination Act.
iii. Obtain assistance if the patient wishes to change an advanced directive, as
the person’s health or desires change.
iv. Teach patient so informed decisions can be made.
v. Inform patients that they have the right to refuse treatment or can refuse life-
prolonging treatment but still receive palliative care and pain control.
(Caulfield, 1995).

2.2 Liability in Nursing Practice

The term liability actually connotes a sense of obligation or legal responsibility one
incurs for one’s acts (or inaction) including financial restitution for harms resulting
from negligent acts, deliberate commission of a forbidden act or omission of an act

286
required by law. We live in an
information age and the public are not
only better informed now than ever
before about their rights, but do seek
redress/damages (legal claims) where
such rights are infringed upon. As such
tort liability (intentional and unintentional torts) has become the subject of most
litigations against nurses and other health care providers. A tort is a civil wrong
committed against a person or a person’s property. Legally, it connotes
wrongful doings by one citizen against another; serious enough to merit the award
of compensation to the person affected (the victim). Intentional torts include
malicious prosecution, invasion of privacy, defamation, assault and battery, and
false imprisonment. Unintentional torts include: Negligence and Malpractice.

Negligence – This is one of the most common lawsuits instigated by patients.

Because the society attaches great weight to a determination that conduct is or is
not negligent, it is clear that an objective and fair a standard as possible must be
established for measurement of such conduct. A search for the above culminated in
the emergence of “the reasonably prudent man concept”, whose hypothetical
conduct is the standard against which all other conduct is judged. Negligence
therefore is defined as ‘the omission to do something which a reasonable man
guided upon those considerations which ordinarily regulate the conduct of human
affairs, would do, or doing something which a prudent and reasonable man would
not do’.
A more lucid definition is – ‘the failure of a professional person to act in
accordance with the prevalent professional standards or failure to foresee

287
possibilities and consequences that a professional person having the necessary
skills and training would note in her area of knowledge and practice. Potential
areas of negligence include: performing nursing procedures that you have not been
taught; failing to meet established standards for the safe care of the patient; failing
to prevent injury to patients, hospital employees and visitors; to mention a few.
Parameters for Negligence: For negligence to be established there are four things
otherwise called element of negligence that must be critically looked at. They are:
i. Owe a duty of care (contractual engagement)
ii. Breach of the duty of care
iii. The client suffers an injury or loss
iv. The breach is the proximate cause of harm/loss
The general rule is that the plaintiff must be able to establish the aforementioned
points before negligence can be ascertained. The ultimate goal of law in negligence
is to compensate the person who was injured by the wrongful conduct of the other
person. It is not to penalize or punish the other person even though that is what is
indirectly done.

Malpractice The term malpractice refers to behavior of a professional person’s

wrongful conduct, improper discharge of professional duties or failure to meet the
standards of acceptable care, which result in harm to another person (Zerwekh &
Claborn, 1994). Stated differently, malpractice constitutes any professional
misconduct, unreasonable lack of skill or fidelity in professional duties, evil
practice, or illegal or immoral conduct which results in injury or death to the
patient. To hold a nurse responsible in damages, it must be proved that the
defendant failed to exercise the degree of skill and care required by the law.

288
2.3 Liability of Hospitals for Negligence of Nurses (Vicarious Liability)
Although it is possible for a patient to sue a nurse directly in action for negligence,
in practice this is often not the case. Generally, the patient/client will sue the
hospital or employing institution where the nurse works under the principle of
vicarious liability/respondent superior literarily translated as ‘let the master
answer’. This is because it is assumed that an employer should ensure the
competency of its staff. As such the employing institution is held liable for
negligent actions of its staff. This however does not totally exonerate the nurse
from litigation as she can be added as a second defendant.
Exemptions to this rule are:
a. Where the nurse commit clear cut professional mistakes.
b. In the case of a private hospital, where the hospital obtain the services of
competent hands (nurses and physicians) and provides proper apparatus for
treatment of clients.
c. In cases of visiting nurses who have been selected with due care but are not
servants of the hospital governor.
d. Where the nurse is operating independently; not an employee of a hospital
probably engaged and paid by the patient.

Defamation – This is the act of discrediting the reputation of someone else i.e. an
act of creating wrong or false impression of somebody – negative connotation or
giving wrong picture of another individual. Defamatory statements, whether oral
or written, pictured or otherwise communicated therefore are those which tend to
expose a person to hatred, contempt, aversion, disrespect and the likes. The most
common examples of this tort are giving out inaccurate or inappropriate
information from the medical record; discussing clients, families or visitors in

289
public places or speaking negatively about co-workers (Zerwekh & Claborn,
1994; Caulfield, 1995).
Defamation can occur in two ways namely: Slander and libel. Slander is the term
given to malicious verbal statements or defamatory statements made in a non-
permanent form e.g. during a conversation, a gesture, sign language. Libel on the
other hand is defamation by means of prints, writing, pictures, cartoons, broadcast,
or telecast from a prepared print that are of more permanent nature. Since libel
can be broader in its application, it is generally actionable without the plaintiff’s
need to show special damages. There to avoid incessant litigations secondary to
defamation, every member of the health team should refrain from idle
conversations, gossips and inaccurate reports.

Assault and Battery – These two terms are often used together but each has a
separate meaning. Assault is described as an intentional and unlawful offer or
threat to touch a person in an offensive, insulting, or physically intimidating
manner. For instance, a nurse who threatens a client with an injection after the
client has refused oral medication may be committing assault. Battery is the willful
touching or intentional harmful or offensive contact with another person without
consent or with consent exceeded or fraudulently obtained. The term embraces
such things as striking and beating another person but excludes accidental bumping
of persons. In nursing care, giving an injection against the patient’s will; forcing a
patient out of bed; and wanton use of physical restraints, all constitute battery.
The legal issues arising from assault and battery are usually based on consent, in
terms of whether the client agreed to the touching that occurred. In order not to be
held liable for assault and battery, the nurse must respect the clients/patient’s
cultural values, beliefs, and practices and ethnic orientation. In the U.S, as a

290
safeguard against assault and battery, adults are asked to sign a general permission
for care and treatment on admission while additional written consent are obtained
for special procedures.

False Imprisonment – Illegal detention as it is sometimes called means unlawful

detention or intentional confinement without authorization. It occurs when clients
are made to wrongfully believe they cannot leave a place. The most common
example is telling a client not to leave the hospital until the bill is paid. Other
examples are the use of physical or chemical restraints and threats of physical or
emotional harm without legal justification. Note that restraints are legal only if
they are necessary to protect the client or others from harm. The law mandates that
the use of restraints or seclusion must have a physician order. False imprisonment
must however not be confused with statutory authority which permits hospitals to
quarantine for a limited time patients suffering from contagious diseases.
Of course occasions may arise in health care relationships that necessitate the
extension of period of admission. In such situations, nurses should only counsel
with the patient on the need to stay rather than detaining patients against their will.
The point to be made is that patient has the right to insist on leaving even though it
may be detrimental to their health. The only rational and lawful thing that could be
done is to make the patient to sign an absence without authority form (AWA) or
discharge against medical advice (DAMA) form.

Invasion of Privacy – The right to privacy is the right of individuals to withhold

themselves and their live from public scrutiny. Encroachment upon this right
without a person’s consent constitutes an invasion of privacy and it is actionable.
Medical instances where privacy laws may be violated include photographing a

291
patient without consent, revealing a patient’s name in a public report, allowing an
unauthorized person to observe the patient’s care. To this end, nurses must always
obtain patient’s permission before disclosing any information regarding the patient,
going through patient’s personal belongings, performing procedures, and
photographing the patient.

2.4 The Nurse and the Criminal Law

As earlier stated a crime is an act committed in violation of public law and is
punishable by fine and/or imprisonment in a state or federal penitentiary. Crimes
are mainly of two types: a felony (a crime of serious nature, such as murder and
manslaughter, arson and armed robbery, usually punishable by imprisonment) and
misdemeanors (crime of less serious nature punishable by imposition of fines or
imprisonment for less than a year).
Murder is defined as direct and deliberate killing of an innocent person (a person
who has not forfeited his right to life); death is intended as end or means. It is an
unjust killing, done without legitimate authority. It excludes killing criminals on
authority of the state; the soldier killing the enemy in war; and killing in self-
defense (excusable homicide). Because murder is morally wrong, the practice of
Euthanasia (mercy killing) whether active or passive euthanasia, has come under
great criticism over the years and the moral argument is that it violates the right of
God who has exclusive full ownership over human life.
Manslaughter is an unintentional killing (accidental killing). Manslaughter in the
first degree include cases where the victim is killed while the defendant was
engaged in the commission or attempt to commit a misdemeanor affecting the
person or property of the killed person or another. This embraces cases where there
is willful killing of a viable fetus by injury inflicted on the mother, as in abortion

292
deaths. Manslaughter in the second degree involves culpable negligence of a
drunken doctor or nurse.

In-text Question 1 (A short question requiring a single sentence answer for quick
reflection over the read topic) What are the two (2) basic types of Informed
consent?

Answer There are basically two types of consent: Expressed and Implied Consent.

3.0 Tutor Marked Assignments (Individual or Group)

1. Differentiate between unprofessional conduct and negligence
2. Distinguish between tort and crime
3. explain the role of the nurse in the informed consent process

4.0 Conclusion/Summary
It is hope that, the treated topic in this study session ranging from, Selected Legal
Aspects of Nursing Practice, Liability in Nursing Practice, The Nurse and the
Criminal Law, to Legal Safeguards for Nursing Practice will make us more to be
conscious of rights, duty and obligation in all ramifications of our profession while
striving to maintain excellence in nursing education/practice.

5.0 Self-Assessment Questions

1. What is negligence and how does it differ from malpractices? Identify
and explain the key legal issues in professional negligence that will
assist the court to award damages.

293
6.0References/Further Readings
Babajide, L.O. (2001). The Nigerian Nurse on the Scale of Law. Ile-Ife: Samtrac
Publishers.
Bernzweig, E. P. (1996). The Nurse’s Liability for Practice: A Programmed
Course (6th Ed.). St. Louis: Mosby.
Caulfield, H. (1995). Legal Issues. In H. B. M. Heath (Ed.). Potters and Perry’s
Foundations in Nursing Theory and Practice. Italy: Mosby, an Imprint of
Times Mirror International.

Creighton, H. (1975). Law Every Nurse Should Know (3rd Ed.) Philadelphia: W.B
Saunders Company.

Flight, M. (1993). Law, Liability, and Ethics (2nd Ed.). Albany, NY: Delmar
Publishers.
Kozier, B.; Erb, G.; Berman, A.U. & Burke, K. (Eds.). (2000). Legal Aspects of

Nursing. Fundamental of Nursing: Conceptions Process and Practice (6th

Ed). New Jersey: Prentice Hall, Inc.
Lowe, S. C. (1995). Legal and Ethical Aspects of Nursing. In C. B Rosdahl (Ed.).
Textbook of Basic Nursing. Philadelphia: J.B. Lippincott Company.
Martin, J. (1998). Legal Responsibilities. In Delaune & Ladner (eds.)
Fundamentals of Nursing, Standards and Practice. Albany: Delmar
Publishers.
Obilade A.O. (1979). The Nigerian Legal System. London: Sweet and Maxwell.
Zerwekh, J. & Claborn, J. C. (1994). Nursing Today: Transitions and Trends.
Philadelphia: Saunders

294
 STUDY SESSION 4A
Stress and Adaptation, Nursing and Society
Section and Subsection Headings:
Introduction
1.0 Learning Outcomes
2.0 Main Content
2.1- Concept of Stress
2.2- Models of Stress and Stressor
2.3- Factors Influencing Response to Stressors
2.4- Sources of Stress
2.5- Adaptation Responses
2.6- Management of Stress
2.7- Nursing Intervention of Stress
3.0 Tutor Marked Assignments (Individual or Group assignments)
4.0 Study Session Summary and Conclusion
5.0 Self-Assessment Questions
6.0 Additional Activities (Videos, Animations & Out of Class activities)
7.0 References/Further Readings

Introduction:
Modern man is faced with the paradox
of stress. Everyone experience stress
from time to time and normally a
person is able to adapt to long- term
stress or cope with short term stress
until it passes. Stress places heavy

295
demand on a person, and if the person is unable to adapt, illness can result.
Stress is an essential part of our lives providing us with the impetus for vitality,
drive and progress. Stress is the body response to the daily or everyday pressure of
the body reaction to excessive demand by the trying to maintain equilibrium
among its internal process. Conversely, it is also stress which is the root of a
multitude of sociological, medical and economic problem. Stress can be mild,
moderate and severe with behaviours that decrease energy and adaptive responses.
The leading Cayuse of death today involves life-style stressor which precipitates
stress with resultant effect on health-illness continuum. It is this cause and effect
that this unit intends to examine stress and adaptation considering its concept,
models of stress and stressor, factors influencing response to stress, adaptation and
stress management for improved patients’ care.

1.0 Study Session Learning Outcomes

After studying this session, I expect you to be able to:
1. explain the concept of stress and stressor
2. discuss four (4) models of stress as they relate to nursing practice
3. describe stress-management techniques required for clients care.

2.0 Main Content

2.1 Concept of Stress and Stressor
There can be no stress without a stressor.
Stress is any situation that can upset and
prevent an individual from relaxing
naturally. Stressor is the stimuli that
precipitate the change in a man. Stress as a

296
stimulus, do tax the adaptive capacity of the organism to its limits and which in
certain condition can lead to a disorganization of behaviour and maladaptation
which may lead to diseases.
Stress is common denominator of the adaptive reaction in the body. It is any
situation in which a non-specific demand requires an individual to respond
physiologically and psychologically as well as taken an action. Stress can lead to
negative or counterproductive feelings or threaten emotional wellbeing; threatens
the way a person normally perceives reality, solves problems or think; threatens
relationship and sense of belonging and a person’s general outlook on life, attitude
towards loved ones, job satisfaction, ability to problem solve and health status.
Response to stress is initiated by the individual’s perception or experience of the
major change.

The stimulus precipitating the response is called the stressor which may be
physiological, psychological, social, environmental, developmental, spiritual, or
cultural and represent unmet need. Stressors may be internal such as (fever,
pregnancy, menopause and an emotion such as guilt; and external which originates
outside a person such as marked change in environmental temperature, a change in
family or social role or peer pressure.

Activity 1
1. Have you ever been faced with stress? Yes or No
2. If yes, what is/are the cause?
3. How did you recognize that you were under stress?
4. What did you do?
5. What other sources of stress do you know?

297
In-text Question 1 (A short question requiring a single sentence answer for quick
reflection over the read topic) List any five (5) types of stressor you know

Answer Physiological, psychological, social, environmental, developmental,

spiritual, cultural and unmet need.

2.2 Models of Stress and

Stressor
Models of stress refers to
classes of stress which are
used to identify the
stressors for a particular
individual and predict that
persons responses to
them. These models are
useful for planning
individualized nurse care plan to help a client cope with unhealthy, non- productive
response to stressors.
There are four (4) models of stress namely:
1. Response Based Model (RBM)
2. Adaptive Based Model (ABM)
3. Stimulus – Based Model (SBM)
4. Transaction- Based Model(TBM)

*Please follow as we discuss these models in relation to nurse client therapeutic

care.

298
Response Based Model (RBM)
RBM special the particular response or pattern of responses indicating a stressor.
Selye, S. (1976) in his classic research into stress identified two physiological
responses to stress namely: The local adaptation syndrome (LAS) and the general
adaptation syndrome (GAS).While LAS is a response of a body tissue, organ or
part of the stress of trauma, illness, or other physiological change, the GAS is a
defense response of the whole body to stress. Individual response to stress is purely
physiological and never modified to allow cognitive influences, but RBM does not
allow individual differences in response patterns (No flexibility).

Adaptation Based Model (ABM)

ABM states that there are four (4) factors that determines whether a situation is
stressful or not. These are: ability to cope with stress; practices and norms of the
person’s peer groups; impact of the individual to adapt to a stressor; and the
resources that can be used to deal with the stressor.
ABM is based on the fact that people experience anxiety and increased stress when
they are unprepared to cope with stressful situation.

Stimulus-Based Model (SBM)

SBM focused on distributing or disruptive characteristics within the environment.
The classical research of Holmes and Rahe (1978) identified stress as a stimulus
resulting in the development of the social readjustment scale which measures the
effects of major life events on illness. The following verdicts have been summed
up for:
1. Life changes events are normal.
2. People are passive recipients of stress and their perceptions of the events are
irrelevant.

299
 3. All people have a common threshold of stimulus, and illness results at any
point after the threshold.
4. Transaction Based Model (TBM)

TBM views the person and environment in changing, reciprocal, interactive,

relationship. It was developed by Lazarus and Folkman (1984) with a focus on the
stressor as an individual perpetual response rooted in psychological and cognitive
process.

2.3 Factors Influencing Response to Stressors

The response to any stressor is dependent on physiological functioning,
personality, behavioural characteristics and the nature of the stressor. The nature
of the stressor involves the following factors:
i. Intensity: minimal, moderate or severe.
ii. Scope: limited, medium, extensive.
iii. Duration: time lag
iv. Number and nature of other stressors

Activity 2
As a following to activity I, briefly comment in not more than a page, how the
above underlined influences your response to the identified sources of stress.

2.4 Sources of Stress

The common sources of stress are classified under the following headings:
A) Stress problems at home: these includes
1.Problem with co- tenants or neighbours
2.Fear of attack by armed robbers

300
 3.Looking after dependants
 4.…………………………………
5.………………………………… (complete the last two)

B) Stress provoking situations in the society:

1.Erratic supply of electricity water and fuel
2.Reckless driving and traffic hold ups
3.Insecurity
 4.………………………………………….
 5.……………………………………………. (complete the rest)

C) Stress provoking situation at work:

1.having too much to do
2.too much pressure and repeated deadlines
3.poor physical working conditions
 4……………………………………..……………………………

Activity 3
Now recap on the sources of stress above and compare with your write up in
Exercise 1.

2.5 Adaptation to Stressors

Adaptation is the process by which the
physiological dimensions change in response
to stress. The focus therefore in health care
is on a person’s family’s or community’s
adaptation to stress because many stressors
cannot be avoided. It involves reflexes,

301
automatic body mechanisms for protection, coping mechanisms and instincts.
Adaptation is an attempt to maintain optimal functioning. To do this, persons must
be able to respond to such stressors and adapt to the required demands or changes.
It requires an active response from the whole person (physical, developmental,
emotional, intellectual, social and spiritual). Adaptation response can be
physiological or psychological.

Physiological Response
This model of stress response can be either Local Adaptation Syndrome (LAS) or
General Adaptation Syndrome (GAS). See Exercise 1 in 3.2. An example of LAS
is reflex (pain) and inflammatory response. The GAS consists of alarm reaction,
resistance and the exhaustion stage.
1st Stage Alarm Stage
Mobilization of the defence mechanisms of the body and mind to cope with the
stressors.
2nd Stage Resistance Stage
Stabilization is attempted and success if achieved the body repairs damaged tissue
that may occur if not exhaustion is the next stage.
3rd Stage: i) Recovery Stage
Repairs done, the body goes back to full functioning
ii) Exhaustion Stage:
The body can no longer resist stress and if it continues, death may
occur.

302
Psychological Response
Exposure to stress threatens ones basic needs. The threat whether actual or
perceived, provides frustration, anxiety and tension. The psychological response
otherwise referred to as coping mechanisms is adaptive behaviors which assist the
person’s ability to cope with stressors. These behaviors are directed at stress
management and are acquired through learning and experience as a person
identifies acceptable and successful behaviors. The behavior includes:

Task Oriented Behavior

Use of cognitive abilities to reduce stress, solve problems, resolves conflicts and
gratify needs. The 3 types of task-oriented behaviors are attack behaviour,
withdrawal behaviour, compromise (by substitution or omitting the satisfaction
of needs to meet other needs or to avoid stress).

Ego Defense Mechanism

These are unconscious behaviors that offer psychological protection from a
stressful event. It is used by everyone and helps protect against feelings of
unworthiness and anxiety.

2.5 Management of Stress

The management of stress is classified into 3 headings for easy assimilation and
understanding.
Reducing stressful situation through:
a. Habit formation
b. Change avoidance

303
 c. Time blocking
d. Time management
e. Environment modification.
Decreasing physiological response through:
a. Regular exercise
b. Humour
c. Nutrition
d. Rest
e. Relaxation
Improved behavioural and emotional responses to stress through:
a. Support systems: family, friends, colleague, to be included in the stress
management.
b. Crisis intervention
c. Enhancing self-esteem.

2.7 Nursing Intervention in Stress

The nurses understanding of the physiological and psychological indicators of
client management easier. Since each client has specific perceptions and responses
to stress, the nurses ability to assess, individual needs, diagnose in relation to
stress, plan the levels of care, implement and evaluate will assist greatly in
determining the effectiveness of stress management technique for the overall
benefit of the client.

Conclusion
Each person reacts to stress differently according to perception of the stressor,
personality, prior expectations with stress and use of coping mechanism.

304
The stages of illness development in stress-related diseases are 7 in all.
Stage 1: short stress situation (no risk)
Stage 2: moderate stress situation (at risk)
Stage 3: severe stress situation
Stage 4: early clinical sign
Stage 5: symptom
Stage 6: disease or disability
Stage 7: death

At any of this stage, there may be physical complaints such as nausea, vomiting,
diarrhea or headache. Physical appearance also changes. The identification of the
mind-body interaction is crucial for predicting the risk of stress-related illness. A
nurse by mere studying the effects of a stressful lifestyle or event in a client can
also assess the coping mechanism required by the client.

In-text Question 1 (A short question requiring a single sentence answer for quick
reflection over the read topic) What are the support systems roles in alleviating
stress in an expectant mother who is due to put to bed in a weeks’ time?

Answer Family (social, economic, emotional) friends, colleagues, acquaintances

and the family nurse.

In-text Question 1 (A short question requiring a single sentence answer for quick
reflection over the read topic) Identify 3 physiological changes in the body that
goes for local Adaptation syndrome

Answer Trauma, Illness and physiological change.

In-text Question 1 (A short question requiring a single sentence answer for quick
reflection over the read topic) Identify the physiological changes in the body that
goes for general Adaptation syndrome

305
Answer Alarm reaction, Resistance and exhaustion stage.

3.0 Tutor Marked Assignments (Individual or Group)

1. explain the concept of stress and stressor
2. discuss four (4) models of stress as they relate to nursing practice

4.0 Conclusion/Summary
This unit has examined the concept of stress and its relationship to health and
illness. The various models of stress were also highlighted to help the nurse
understand the causes and response to stress. Stress management techniques
directed at changing a person’s reaction to stressors were also discussed to assist
the nurse in helping client manage stress carefully.

5.0 Self-Assessment Questions

1. What is your concept of stress?
2. Identify and discuss the four (4) models of stress as they relate to
nursing practice.

6.0References/Further Readings
Danlami, A.R. (1998). A Handbook on Stress Management: Lafiya Health
Associates.
Dorothy et al. (1980). Medico-Surgical Nursing; a Conceptual Approach McGraw:
Hill Book Company.
Hoffmann-La, F. (1991). Stress: Sign, Symptoms, Sources Solution. Switzerland:
Editions Roche, Basel.
Potter & Perry (1987). Fundamentals of Nursing; Concepts, Process and Practice
(3rd Ed.). Philadelphia: J.B. Lippincott Co.

306
 STUDY SESSION 4B
Nursing and Society
Section and Subsection Headings:
Introduction
1.0 Learning Outcomes
2.0 Main Content
2.1- Demographic Changes
2.2- Technological Advances
2.3- Increasing Consumer Knowledge
2.4- Human Rights Movement
2.5- Women Liberation Movement
2.6- Professionalism in Nursing
3.0 Tutor Marked Assignments (Individual or Group assignments)
4.0 Study Session Summary and Conclusion
5.0 Self-Assessment Questions
6.0 Additional Activities (Videos, Animations & Out of Class activities)
7.0 References/Further Readings

Introduction:
The society is a system whereby people live together in organized community. It
is dynamic with its attending challenges.
In the last lecture, the relationship of Nursing to other sciences and technology was
established thus as the society is changing so much nursing. Throughout history,
nursing has responded to society needs and ceases to remain static/practicing solely
on tradition with threats to her existence and relevance.

307
In this unit, we shall examine Nursing and the Society with the trends influencing
Nursing practice. The overall effect will be considered vis-à-vis Nursing adaptation
to the challenges posed by the societal trends.

1.0 Study Session Learning Outcomes

After studying this session, I expect you to be able to:
1. to examine the societal changes and nursing practice
2. to discuss the current societal trends and influence on nursing practice
3. to identify the place of Nursing in the society

2.0 Main Content

2.1 Demographic Changes
Demography is the statistical description of population using: birth, death,
migration, emigration, life expectancy, and marriage and divorce rates. Population
in every society increase daily, which accounts for more people in need of health
services with greater demand on health practitioners (Nurses inclusive). Urban
shifts, peculiarities in the health care of older persons and youths which forms 75%
of the population, increased divorce rates and weakened family ties requires
nursing assistance to family and other social problems with health implications.
These include incidence of chronic long-term illness, e.g. AIDS, Cancer, mental
disorders and alcoholism, epidemics,

308
Nurses therefore have to explore new methods for providing care and establish
practice standards in new areas.
In-text Question 1 (A short question requiring a single sentence answer for quick
reflection over the read topic) List three (3) problems of over population.

Answer Increased divorce rates

Weakened family ties
Incidence of chronic long-term illness, e.g. AIDS, Cancer, mental disorders
and alcoholism, epidemics, etc.

2.2. Technological Advances

The ongoing scientific research has continued to uncover new knowledge at a
faster pace. With the advent of computer
and other management information
systems, societal values and quest for
services have been tailored towards this
e.g. canned food, drinks and additives.
Scientific advances closely associated
with health illness, organ transplants,

309
family planning methods and sophisticated diagnostic sets such as C. T. Scan
machine, Ultra sound machines and Electrocardiograph machines. In the social
sciences, great strides have been made in attempting to understand and predict
human behaviour, which is an important area for nursing.
Nurses as agent of change uses the knowledge of values, attitudes and prejudices,
social mobility, ethnic, social and cultural backgrounds to design patient care.
Empirical knowledge of practice is no longer adequate as nursing programs are
increasingly teaching scientific principles that will guide the practice for all
possible circumstances.

2.3 Increasing Consumer Knowledge

There has been an increase in health information on consumable items thereby
encouraging consumer movement aimed at getting quality health to the worth of
their money. The society made up of consumers is demanding health care with
high quality. Nurses as consumer of someone’s product in the society with high
expectations, is expected to support the clients right in the quality and cost of
health care being offered.

2.4 Human Rights Movements

Human Rights movements is a non-governmental organization which seeks to
address outright violation/negation of human rights to life, expression, association
and religion that is considered as morally right or wrong in our relationship with
others. The movement is concerned for the poor, lonely, neglected and oppressed.
Nursing respects the rights to good care for all and recognizes the right to life,
advocates clients rights with recognitions of special needs of some groups: the
dying, hospitalized, pregnant women, to ensure that quality care is provided

310
without sacrificing their rights. Nursing holds the key to maintenance of human
individualistic concern for people and their health problems hence it must be
zealously enlarged.

2.5 Women Liberation Movement

Women today are taking steps to free her for independent action. Nursing traces its
origin in the society to orders with unquestioned obedience to superiors. Nursing is
predominately made up of women and this reveals the role of a nurse as a mother
surrogate to nurture those who were ill and helpless.
Women in the society today seek for social, economic, political and educational
quality with men. The Women-In-Nursing (WIN) is one of such group which
joining forces with non-nurses strives for equality in the society and changing
nursing care practices.

2.6 Professionalism in Nursing

Nursing in Nigeria has evolved through several philosophical eras in the last
decade. Having passed through the Nurses’ Ordinance of 1947/1959, Registration
of Nurses Regulation of 1962 and the legal status of as a professional cum trade
union organization, trade Union Decree 21 and 22 of 1978, Decree 54 of 1989 and
recently amended decree 54 of 1992. One common phenomenon that prevailed in
all these has been that of uplifting the image of nursing.
This progress is attributed to the recognition accorded nursing by the society due to
unique and essential contributions made. The emergence of professionalism in
nursing has produce a self-regulatory, self-determining and a body of scientific
knowledge of a group of people who can assume responsibility and accountable for
their action.

311
In-text Question 1 (A short question requiring a single sentence answer for quick
reflection over the read topic) Who is the mother of modern Nursing?

Answer Florence nightingale

In-text Question 2 (A short question requiring a single sentence answer for quick
reflection over the read topic) When was she born?

Answer 1820

In-text Question 3 (A short question requiring a single sentence answer for quick
reflection over the read topic) What was her major role?

Answer A researcher, a caring nurse of a the sick and well. She gave birth to
professionalism in nursing.

3.0 Tutor Marked Assignments (Individual or Group)

1. Mention four (4) advancement in communication/technology that can
facilitate nursing care in a hospital set up
2. Answer 1. C T scan, Ultra sound machines, Electrocardiography

4.0 Conclusion/Summary
It is believed that this study session has refreshed our memory on demographic
changes, technological advances, increased consumer knowledge, women
liberation movement and professionalism in Nursing. Also, examined was Society
with the trends influencing Nursing practice with its overall effect on nursing
adaptation to the challenges posed by the societal trends. All of the above will
make us standout as nurses with a difference
The scope and range of nursing responsibilities in meeting the needs of society
mean assuming increasing responsibility for patient care, developing collaboration

312
with other health practitioners, supporting and embracing new and promising
methods for delivery health care service more effective.
Nursing has demonstrated interest in caring for society’s unfortunates. The
emphasis of the care is on compassion and understanding, sympathy and empathy
in accepting the patient who is a member of the society as the nurse. Nursing is a
member of the society as the nurse. Nursing as a profession holds the key to the
holistic client care.
In this unit, we have identified and examine concisely nursing and society with six
(6) changes in the society that has positively influenced nursing practice. A
dynamic society requires understanding and commitment on the part of service
providers that will not be compromised Demographic changes, Technological
changes, Increasing consumer knowledge, Human Rights movement, Women
Liberation movement and Professionalism in Nursing.

5.0 Self-Assessment Questions

1. Discuss in details the Technological Advances that have come on
Nursing and its influence on the practice.

6.0References/Further Readings
Akinsola H. A. (1993). “A to Z of Community Health and Social Medicine in
Medical Nursing Practice” 3. A. M. Communications.
Furest, et al. (1974). “Fundamental of Nursing; The Humanities and The Sciences

in Nursing (5th Ed). Toronto, Philadelphia: J. B. Lippincott Co.

Potter and Perry (1993). Fundamentals of Nursing: Concepts, Process and

Practice, (3rd Ed.). St. Louis: J. B. Lippincott Co.

Royle and Walsh (1980). Watsons Medical-Surgical Nursing and Related

313
 Philosophy (4th Ed.). Toronto, Philadelphia: J. B. Lippincott Co.
Smith, R. G. (1984). “Nursing in the Community. New York: Wiley Medical
Publications.
School Craft V. (1984). Nursing in the Community. London: Wiley Medical
Publication

314
 STUDY SESSION 5
Health Education
Section and Subsection Headings:
Introduction
1.0 Learning Outcomes
2.0 Main Content
2.1- Definition of Health Education
2.2- Growth of Health Education
2.3- Purposes of Health Education
2.4- Process of Health Education.
2.5- Principles of Heath Education.
2.6- Health Education in Nursing.
3.0 Tutor Marked Assignments (Individual or Group assignments)
4.0 Study Session Summary and Conclusion
5.0 Self-Assessment Questions
6.0 Additional Activities (Videos, Animations & Out of Class activities)
7.0 References/Further Readings

Introduction:
You will recall that we explored the concept and components of Primary Health
Care in the Nature of nursing course of which Health education was one. Health
education is a process by which individual or group of persons learn to prevent
diseases, promote and maintain or restore health through voluntary adaptation of
health behaviour.
The importance of health education was strongly highlighted by Alma Ata
Conference. It was pointed out that community participation is crucial to ensure

315
optimum utilization of health resources. It was also stressed that health is an
individual responsibility and every individual need to be health conscious so that
he may observe healthy living practices.
You know already that preservation of good health is dependent on following good
health practices. Health education and communication about healthy practices
bring about a change in health behaviour so that harmful; health practices can be
given up and good health practices can be reinforced.
This unit presents to you the definition, growth, principles, practices, and levels of
health education. The interrelationship of health education with communication is
already dealt with in Nature of Nursing. (Please check up).

1.0 Study Session Learning Outcomes

After studying this session, I expect you to be able to:
1. explain his/her own concept of health education
2. list the objectives of health education
3. describe how health education can be planned and methods of delivery

2.0 Main Content

2.1 Definitions of Health
Health: It is a state of complete physical, mental, social and spiritual wellbeing
and not merely the absence of diseases or infirmity (World Health Organization,
1948).
Education: It is the process by which there is a behavioural change resulting from
an experience undergone.
Health Education: A process that informs motivates and helps people to adopt
and maintains health practices for a healthy lifestyle, advocates environmental

316
changes as needed to facilitate this goal
and conducts professional training and
research towards the same end (National
Conference on Preventive Medicine,
U.S.A). This is working definition that is
more of practical value.
Health education is a process of known information which has the purpose of
promoting health (Pearce, 1980).
Health education is also described as a process by which habits, attitudes and
knowledge are changed to choose the path leading to better health. Success in
health education depends on a great deal on the skills of communicating with the
community (WHO, Health Panel).
It is also seen by many as a process of positively changing or influencing peoples’
health knowledge, attitudes and behaviour through their own actions (Ewles and
Simnelt, 1985 and Tones, 1990).
It is an all-round process which involves the whole life thereby helping people to
help themselves live a healthful life.
In-text Question 1 (A short question requiring a single sentence answer for quick
reflection over the read topic): What is your concept of idea health education?

Answer The answer is to incorporate all round process/procedure which

contributes to healthy living.

2.2. Growth of Health Education

Health education has begun with people being systematically interested in general
sanitary progress, social and material causes which can impede their health.
In 1875, Maryland State of Health emphasised that the health of the public is
dependent on the public conviction about health. Health education initially was the

317
responsibility of Public Health personnel until the 2nd quarter of the century when
it became formally recognized as a speciality and a major function of Public
Health.
The development of newer interpretation of public bought about the need to do
things with people and to get people accept an increasing responsibility for their
own health.
Clair Turner at the Massachusetts Institute of Technology later recognised health
education academically with the development of specialized graduate curriculum
in 1922. Its global acceptance for knowledge acquisition and practice has brought
its operation beyond the hospital setting to community, schools, churches, mosques
and the public at large.

2.3 Purposes of Health Education

Health education is a process that
informs, motivates and helps people to
adapt and maintain healthy practices
and lifestyles. The three main purposes
of health education will be discussed
below:
Informing people
Informing people is the right of an individual. It is prerequisite to proper awareness
and assessment of one’s duties and rights. Health is a basic right of all human
beings, so is health information. Only informed community will aspire, work,
demand and fight for its right, that is, health. Health information helps people in
becoming aware of their health problems and guides them to appropriate solution
for the same.

318
Motivating people
Only information is not enough. Information that alcohol or tobacco is harmful for
health does not ensure that people will leave them. Besides informing, it is also
necessary to motivate people to adopt certain behaviour. Health education must
provide learning experiences, which favourably influence habits, knowledge and
attitude. Consumers should make choice and decisions about health matters.

Guiding people into action

Motivation must be accompanied by guidance to achieve the expected behaviour.
People need to adopt and maintain healthy practices and lifestyle.

2.4 Process of Health Education

The process involved in health education as identified by Books (1980) includes:

GOAL ACHIEVED STAGE STAGE STAGE

I II
Assessment Setting of Setting of
Obj i
STAGE IV
Reassessme
t
Evaluation STAGE
Implementation
assessment, objectives setting, readiness, implementation and evaluation.

Note that a similar process is involved in nursing care. See unit 17 in Nature of
Nursing for details. The nurse is expected to identify, plan, implement, and
evaluate in relation to the patients knowledge and behaviour.

319
2.5 Principles of Health Education
Health education brings together the art and science of Medicine and the principle
and practice of general education. It involves teaching, learning and inculcation of
habits concerned with healthful living. The guiding principles are:
i. Issues to be discussed must be interesting (or made interesting) to the
people.
ii. Personal involvement in f o r m o f group discussion, p a n e l discussion
and workshops.
iii. Start health education from what the people knew before the unknown.
iv. Study the people’s level of understanding, literacy and education to ensure
prompt comprehension.
v. Reinforcement and repetition at intervals is useful.
vi. Motivation: incentives must be incorporated for good and bad habits.
vii. The education should role model any issue being taught. Consider this
Chinese proverb. “If I hear it, I forget it. If I see it, I remember it. If I do it, I
know it.”
viii. Make the whole exercise attractive, palatable and acceptance with necessary
methods.

2.6 Health Education in Nursing

Health education is a continuous
professional activity in nursing at all
levels. It places on the nurse a sense of
responsibility to:
1. Supply relevant, accurate
information about general and
specific health matters to patients and relatives.

320
 2. Teach patients and relatives on self-care, avoidance of complication and
reduction of consequences of ill health.
3. Teach patient and relatives how to cope effectively with disability both in
hospital and after discharge.
4. Communicate effectively, appropriately and sensitively with patients and
relatives.

In-text Question 1 (A short question requiring a single sentence answer for quick
reflection over the read topic) Health education involves the following?

Answer No clarity of purpose, inappropriate methods, Wrong audience and Wrong

evaluation

In-text Question 1 (A short question requiring a single sentence answer for quick
reflection over the read topic) Why do you need to health educate

Answer To provide information that will bring about a desired change in behavior.

3.0 Tutor Marked Assignments (Individual or Group)

1. What do you understand by the word ‘health’?
2. What is education?
3. Mention 4 problems in health education. (If in doubt study 3.5 again)

4.0 Conclusion/Summary
In this unit, we have examined health education in relation to the definition,
growth; principles purposes and processes. We also considered its relationship to
nursing and exercises to check your progress on the unit, knowing well that
preservation of good health is dependent on following good health practices.
Health education and communication about healthy practices bring about a change

321
in health behaviour so that harmful; health practices can be given up and good
health practices can be reinforced by Nurses as an health educator desirous to
affect the people for good with sympathy and friendliness, knowledgeable and one
who practices what he teaches (role model) talks the language of the people, uses
different methods of health education, uses audio-visual and proper medium of
communication to be an effective communicator and achieve the desired result
(change of life style for healthful living.

Nurses have limitless opportunities to practise health education regardless of the

nursing speciality. Health education can occur at both formal and informal settings
whenever and wherever the nurse fulfils her professional function). The only
limitation is when the nurse fails to appreciate or recognized those occasions and
opportunities which are favourable.

An health educator desirous to affect the people for good must be sympathetic and
friendly, knowledgeable and one who practices what he teaches (role model) talks
the language of the people, uses different methods of health education (as
identified by you in Exercise 4), uses audio-visual and proper medium of
communication to be an effective communicator and achieve the desired result
(change of life style for healthful living.

In this unit, we have examined health education in relation to the definition,

growth; principles purposes and processes. We also considered its relationship to
nursing and exercises to check your progress on the unit.

322
5.0 Self-Assessment Questions
1. Briefly discussed the principles of health education.
2. Discuss the three (3) specific objectives of health education.

6.0 References/Further Readings

Ashonibare, J. B (2001). Administration and Supervision of School Health
Education Programme: Unpublished Paper: University of Ado Ekiti (Centre
for Higher Studies, COED, Ilorin)

Brooks Health Education in A general textbook of Nursing, (13th Ed.). London:

EBLS.
Ewles and Simnett (1985). Health Education and Patient Teaching in Watsons
Medical Surgical Nursing and Related Physiology Pg. 23.
Ezeduka, E. O. (1993). Health Education: Its Trends and Challenges: Unpublished
Paper: University of Nigeria, Enugu Campus.
Lucas A. O. and Guiles H. M. (1984). Preventive Medicine for the Tropics. Kent:
Hodder and Stoughton Ltd.
Otun, Kalu (1994). Workshop Paper on “The Role of the Media in Information
Dissemination on Family Planning and Population Issue”.

Pearce, E. (1980). A General Textbook of Nursing, (12th Ed.). London: EBLS.

Santhosh, M. (2000.) Primary Health Nursing (PHN) Indira Gandhi National Open
University, New Delhi: Berny Art Press.
UNICEF (1999). Publications on Health Communications

323