NSC111 A PDF

NATIONAL OPEN UNIVERSITY OF NIGERIA
COURSE CODE : NSC111
COURSE TITLE:
FOUNDATIONS OF NURSING
NSC111 COURSE GUIDE
COURSE
GUIDE
NSC111
FOUNDATIONS OF NURSING
Course Team Dr. Reuben Fajemilehin (Developer/Writer) - OAU

Mr. Olufemi Ayandiran (Co-developer/Co-writer) - OAU
Mr. Kayode S. Olubiyi (Co-developer/Co-writer) - NOUN
Prof. (Mrs) O. Nwana (Programme Leader) - NOUN
Mr. Kayode S. Olubiyi (Coordinator) - NOUN
ii
NSC111 COURSE GUIDE
National Open University of Nigeria

Headquarters
14/16 Ahmadu Bello Way
Victoria Island
Lagos
Abuja Office
No. 5 Dar es Salaam Street
Off Aminu Kano Crescent
Wuse II, Abuja
Nigeria
e-mail: [email protected]
URL: www.nou.edu.ng
Published By:
First Printed 2010
ISBN:
All Rights Reserved
iii
NSC111 COURSE GUIDE
CONTENTS PAGE
Introduction ……………………………………………………….. 1
What You Will Learn in This Course ……………………………... 1
Course Aim …………………………………………….…………. 1
Course Objectives …………………………………….…....……… 2
Study Units ……………………………………………………….... 3
Textbooks and References ……………………………..………..... 3
Assignment File ………………………………………………….. 4
Assessment ……………………………………….…..………….... 4
Tutor-Marked Assignment ……………………….….…..…..……. 4
How to Get the Most from this Course ……..………….………… 5
Facilitators/Tutors and Tutorials ……..……………………………. 6
Summary ………………………………….……………………….. 7
iv
Introduction
NSC111: Foundations of Nursing course is a two (2) unit credit course

meant for students who are pursuing B.Sc degree. It is one of the courses
meant to lay your desired foundation for choice of nursing as a course of
study and profession. It comprise of the bedrock of
acquisition of necessary elementary skills amidst health care reforms.
The changes in response to social, political, economic factors
as well as health
technology and advances in health care system call for reform in
the delivery of health care have greatly influenced the setting where
nursing
is practiced coupled with the recipient of care itself.
What You Will Learn in this Course
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
concepatients 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.
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.
Course Aim
The aim of the course is to give you an understanding on the

basic concepts and issues necessary for professional practice. This
will be achieved through:
NSC111 FOUNDATIONS OF NURSING
1. Verbal discussion and in writing the fundamental physiological,

psychological, social and environmental factors that contribute to
a state of health or disease in an individual.
2. Demonstrate proficiently all the nursing skills acquired during the
course.
Course Objectives
To achieve the aims set out above, the course sets the overall objective.
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.
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.
On successful completion of the course, you should be able to:
1. Assess the state of health of an individual, either in their homes
or health centers by physical examination.
2. Explain the importance of the Nurse Code of ethics in the
professional practice of a nurse.
3. Educate patients on the basic tenets of a healthy living.
4. Apply pain-relieving measures such as application of heat or
cold, removal of physical agents causing discomfort, proper
alignment of body protection from infusion agents, and
administration of pain relieving drugs.
5. Make the common types of bed used for nursing e.g. simple bed,
admission bed, post operation bed, fracture bed amputation bed
and cardiac bed.
6. Discuss the legal implications of selected issues and problems in
health care.
7. Discuss related legal principles as they affect nursing care and
nursing education.
8. Discuss four (4) models of stress as they relate to nursing
practice.
9. Describe stress-management techniques that nurses can help
patients/clients and use and that can benefit nurses
themselves.
10. Describe sexual development and concerns across the life span.
11. Identify factors influencing sexuality and common illness
affecting it.
12. Explain the cyclical nature of the chain of infection and factors
involve at each stage.
ii
Study Units
This course is made up of the following units:
Module 1
Unit 1 Health and Human Needs I

Unit 2 Health and Human Needs II
Unit 3 Concept of Health and Illness
Unit 4 Promoting Health
Unit 5 Assessing Health I (Vital Signs)
Module 2
Unit 1 Assessing Health II (Vital Signs Contd).

Unit 2 Assessing Health III (History Taking and Physical
Examination)
Unit 3 Diagnostic Measures in Patients Care
Unit 4 Providing Safety and Comfort I
Unit 5 Providing Safety and Comfort II (Pain Management)
Module 3
Unit 1 Infection Control

Unit 2 Ethical Issues in Nursing
Unit 3 Legal Aspects of Professional Nursing I
Unit 4 Legal Aspects of Professional Nursing II
Unit 5 Sexuality and Gender Issues
Module 4
Unit 1 Stress and Adaptation

Unit 2 Nursing and Society
Unit 3 Health Education
Textbooks and References
Cox, C.L. (1995). 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. (1998). Comfort and Sleep. In S. C. Delaune & P.K. Ladner,

(eds.). Fundamentals of Nursing, Standard and Practice.
Albany: Delmar Publishers.
iii
Furest, et al (1974). Fundamentals of Nursing, J.B. Lippincott Co.,

Philadelphia.
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 Jersy: Prentice Hall, Inc.
Assignment File
The assignment file will be the Tutor Marked Assignment (TMA) which
will constitute part of the continuous assessment (CA) of the course.
There are 20 assignments in this course with each unit having an
activity/exercise for you to do to facilitate your learning as an
individual.
Assessment
There are two aspects to the assessment of the course. These are the
Tutor marked assignment and written examination In tackling the
assignments, you are expected to apply information, knowledge and
strategies gathered during the course. The assignments must be turned in
to your tutor for formal assessment in accordance with the stated
presentation schedules. The works you submit to your tutor for
assessment will count for 30% of your total course work.
At the end of the course you will need to sit for a final written
examination of three hour’s duration. This examination will also count
for 70% of your total course mark.
Tutor-Marked Assignment (TMA)
There are 20 tutor-marked assignments in the course. You are advised

in your own interest to attempt and submit the assignments at the
stipulated time in study centre. You will be able to complete the
assignments from the information and materials contained in your
reading and study units. There is other self activity contained in the
instructional material to facilitate your studies. Try to attempt it all. Feel
free to consult any of the references to provide you with broader view
and a deeper understanding of the course. The assignment accounts for
30% of the total assessment pack for the course.
Continuous self-assessment materials will be enclosed with the

instructional materials so that you can monitor your progress through the
course.
iv
How to Get the Most Out of the Course
In distance learning, the study units replace the university lecture. This
is one of the greatest advantages of distance learning. You can read and
work through specially designed study materials at your own pace and at
time and place that suit you best. Think of it as reading the lecture notes
instead of listening to a lecturer. In the same way that a lecturer might
set you some reading task, the study units tell you when to read your
other material. Just as a lecturer might give you an in-class exercise,
your study units provide exercise for you to do at appropriate points.
Here is a list of practical strategy for working through the course:
• Read the course guide thoroughly.

• Organize a study schedule.
• Stick to your own created study schedule.
• Read the introduction and objectives very well.
• Assemble your study materials.
• Work through the unit.
• Keep in mind that you will learn a lot by doing all your
assignment carefully.
• Review the stated objectives.
• Don’t proceed to the next unit until you are sure you have
understood the previous unit.
• Keep to your schedules of studying and assignments.
• Review the course and prepare yourself for the final examination.
v
Course Code NSC111

Course Title Foundations of Nursing
Course Team Dr. Reuben Fajemilehin (Developer/Writer) - OAU

Mr. Olufemi Ayandiran (Co-developer/Co-writer) - OAU
Mr. Kayode S. Olubiyi (Co-developer/Co-writer) - NOUN
Prof. (Mrs) O. Nwana (Programme Leader) - NOUN
Mr. Kayode S. Olubiyi (Coordinator) - NOUN
vi

Headquarters
14/16 Ahmadu Bello Way
Victoria Island
Lagos
Abuja Office
No. 5 Dar es Salaam Street
Off Aminu Kano Crescent
Wuse II, Abuja
Nigeria
e-mail: [email protected]
URL: www.nou.edu.ng
Published By:
First Printed 2010
ISBN:
All Rights Reserved
vii
Module 1 …………………………………………………….. 1
Unit 1 Health and Human Needs I …………….…………. 1

Unit 2 Health and Human Needs II ………………………. 13
Unit 3 Concept of Health and Illness …………………….. 25
Unit 4 Promoting Health …………………………………. 36
Unit 5 Assessing Health I (Vital Signs) ………………….. 48
Module 2 …………………………………………………….. 67
Unit 1 Assessing Health II (Vital Signs Contd).…………. 67

Examination) ……………………………………… 88
Unit 3 Diagnostic Measures in Patients Care …………..… 102
Unit 4 Providing Safety and Comfort I …………………… 121
Unit 5 Providing Safety and Comfort II (Pain Management) 149
Module 3 …………………………………………………….. 167
Unit 1 Infection Control …………………………………. 167

Unit 2 Ethical Issues in Nursing …………………………. 175
Unit 3 Legal Aspects of Professional Nursing I ……….… 184
Unit 4 Legal Aspects of Professional Nursing II …….….. 192
Unit 5 Sexuality and Gender Issues ……………………… 203
Module 4 …………………………………………….……….. 211
Unit 1 Stress and Adaptation ……………………………… 211

Unit 2 Nursing and Society ……………………………….. 220
Unit 3 Health Education …………………………………… 225
viii
MODULE 1
Unit 1 Health and Human Needs I

Unit 2 Health and Human Needs II
Unit 3 Concept of Health and Illness
Unit 4 Promoting Health
Unit 5 Assessing Health I (Vital Signs)
UNIT 1 HEALTH AND HUMAN NEEDS
CONTENTS
1.0 Introduction
2.0 Objectives
3.0 Main Content
3.1 Overview of Individual Needs
3.2 The Basic Human Needs
3.3 Physiologic Needs
3.4 Security and Safety Needs
3.6 Affiliation and Social Needs (Love)
4.0 Conclusion
5.0 Summary
60 Tutor-Marked Assignment
7.0 References/Further Reading/Further Reading
1.0 INTRODUCTION
Health and human needs are inextricably interrelated. Humans need a

number of essentials to survive. The assertion that all individuals
irrespective or age, sex, race or creed have needs that they strive to
satisfy is therefore is no exaggeration. The Cambridge International
Dictionary of English defined ‘Needs’ as things one must have or things
required to live a satisfactory life i.e. things essential to life and quality
living. As a corollary, illness or risk of illness occurs when individuals
are not able to satisfy one or more of their basic needs.
Since the soul of nursing is caring, much of our career is weaved around
helping people to satisfy these needs. This is consistent with the position
of that renowned nurse theorist, Virginia Anderson, who submitted that
Nursing is primarily assisting the individual (sick or well) in the
performance of those activities contributing to health, or its recovery (or
to a peaceful death) which he would have performed unaided if he had
the necessary strength, will, or knowledge, as well as helping the
individual to be independent of such assistance as soon as possible.
Achieving this is however no mean work. This is because human beings
1
are not merely physiological creatures and their needs are multifaceted
and multidimensional. Besides, every individual is a unique being and as
such requires some unique needs in addition to the basic human needs.
This unit therefore takes a detailed look at human needs with a view to
enhancing nurses’ ability to help their clients meet these varied needs.
2.0 OBJECTIVES
At the end of this unit, you should be able to:
• state the basic human needs

• list at least five physiologic needs of all people
• describe relationships among the different levels of needs
• relate the achievement of basic human needs to health status
• discuss the nurses’ role in assessing and meeting patient/client’s
need.
3.0 MAIN CONTENT
3.1 Overview of Individual Needs
Human needs are many. They encompass both physical and non-
physical elements needed for human growth and development, as well as
all those things humans are innately driven to attain. Human needs
therefore can be broadly classified into two major groups viz: Primary
needs and Secondary needs (Rosdahl, 1995).
Primary needs otherwise known as Basic needs, are survival needs.

They must be met to sustain life. Put differently, their absence or non-
satisfaction portends great threat to human existence. As such they take
precedence over other needs called secondary needs. The beyond
intractability project (2003) in their write-up on Leadership and Human
Behaviour states that basic needs are physiological, such as food, water,
and sleep; as well as psychological, such as affection, security, and self-
esteem. According to this organization, these basic needs are also called
deficiency needs because if an individual does not meet them, then that
person will strive to make up the deficiency and they are usually listed
in hierarchical order.
Secondary needs or Meta needs (growth needs) as they are sometimes

referred to, are additional higher needs that must be met to maintain the
quality of life. They include justice, goodness, beauty, order, unity, etc.
Basic needs normally take priority over growth needs. For example, a
person who lacks food or water will not normally attend to justice or
beauty needs. Unlike the basic needs, the Meta needs can be pursued in
2
any order, depending upon a person's wants or circumstances, as long as

the basic needs have all been met.
3.2 The Basic Human Needs
There are at least five sets or categories of needs, which we can classify
as Basic Human Needs. They are physiological, safety, love, esteem and
self-actualization needs. These needs are related to each other, being
arranged in a hierarchy of prepotency. This means that the most
prepotent goal will monopolize consciousness and will tend of itself to
organize the recruitment of the various capacities of the organism. The
less prepotent needs are minimized, even forgotten or denied. But when
a need is fairly well satisfied, the next prepotent ('higher') need emerges,
in turn to dominate the conscious life and to serve as the center of
organization of behavior, since gratified needs are not active motivators.
Thus man is a perpetually wanting animal. Ordinarily the satisfaction of
these wants is not altogether mutually exclusive, but only tends to be.
The average member of our society is most often partially satisfied and
partially unsatisfied in all of his wants (Maslow, 1943).
3.3 Physiologic Needs
Undoubtedly the physiological needs are the most pre-potent of all

needs. Why? They are basic biological needs for life sustenance. This
means that in the human being who is missing everything in life in an
extreme fashion, it is most likely that the major motivation would be the
physiological needs rather than any others. A person who is lacking
food, safety, love, and esteem would most probably hunger for food
more strongly than for anything else. Stated differently, if the
physiological needs are unsatisfied, all other needs may become simply
non-existent or be pushed into the background. All capacities are put
into the service of hunger-satisfaction, and the organization of these
capacities is almost entirely determined by the one purpose of satisfying
hunger. The receptors and effectors, the intelligence, memory, habits, all
may now be defined simply as hunger-gratifying tools. Capacities that
are not useful for this purpose lie dormant, or are pushed into the
background. For instance, the urge to write poetry, the desire to acquire
an automobile, the desire for a new pair of shoes are, in the extreme
case, forgotten or become of secondary importance. For the man who is
extremely and dangerously hungry, no other interests exist but food. He
dreams food, he remembers food, and he thinks about food, he emotes
only about food, he perceives only food and he wants only food
(Maslow, 1943).
Perhaps it should be mentioned that any of the physiological needs and

the consummatory behavior involved with them serves as channels for
3
all sorts of other needs as well. That is to say, the person who thinks he
is hungry may actually be seeking more for comfort, or dependence,
than for vitamins or proteins. Conversely, it is possible to satisfy the
hunger need in part by other activities such as drinking water or
smoking cigarettes. In other words, relatively isolable as these
physiological needs are, they are not completely so (Maslow, 1943). In
synopsis, the first need of the body is to achieve homeostasis and this is
achieved through the consumption of food, water and air; elimination of
exogenous and endogenous wastes; sleep and rest; activity and exercise;
and sexual gratification. Let us then take a look at each of these
physiological needs.
Air/Oxygen – This is the most essential of all basic needs. Air is a name
for the mixture of gases present in the earth atmosphere. By volume, dry
air contains approximately 78.1% Nitrogen, 20.9% Oxygen, 0.9%
Argon, and 0.03% Carbon Dioxide. Oxygenation (the delivery of
oxygen to the body cells and tissues) is necessary to maintain life and
health (Christensen, 1998). The brain for instance cannot function
without oxygen for longer than 4 – 5 minutes (Cox, 1995). Oxygen is
needed for internal respiration along side the metabolic processes
occurring in the body. The body meets its oxygen need via external
respiration or what is called gaseous exchange. Variables affecting
oxygenation include age, environmental and lifestyle factors and certain
disease process. Consequently anything that interferes with the airway,
atmospheric oxygen content, human respiration and circulation can
threaten the body’s oxygen supply. Examples of such abound but briefly
they include: some respiratory diseases like emphysema, asthma,
pneumonia; air pollution; blockage of respiratory tract by secretion to
mention a few (Rosdahl, 1995).
Clients with compromised oxygenation status need careful assessment

and thoughtful nursing care to achieve adequate and comfortable level
of oxygenation status (Christensen, 1998). Nursing measures to meet
oxygen needs range from teaching client to rest in position that increases
respiratory volume and thus the level of oxygen, to emergency
cardiopulmonary resuscitation for cardiac arrest and supportive
measures such as administration of oxygen to patients/clients with
pulmonary disease (Cox, 1995).
Water and Fluids – It is no exaggeration that though a man can survive

several days without food could last only a few hours without water.
Water takes many different shapes on earth: water vapour and clouds in
the sky, waves and icebergs in the sea, glaciers in themountain, aquifers
in the ground, to name but a few. From a biological standpoint, water
has many distinct properties that are critical for the proliferation of life
that set it apart from other substances. Water carries out this role by
4
allowing organic compounds to react in ways that ultimately allows

replication. It is a good solvent and has a high, surface tension and thus
allows organic compounds and living things to be transported in it. 60 –
70% of the body cells are made up of fluids.
The body constantly loses fluid to the environment via the various
regulatory systems in the body. Howbeit, body fluid is replenished by
ingestion of liquids and food products such as meats and vegetables,
which contain 65% to 97% water and through the chemical oxidation of
food substances. The healthy existence or otherwise of the cellular
system, indeed the entire body therefore depends on the maintenance of
proper volume, chemical composition, and placement of these fluids.
This balanced internal environment is what is called homeostasis.
Virtually all illness states (unconsciousness, kidney dysfunctions,
gastroenteritis, diabetes mellitus e.t.c) threaten this balance. It is even
threatened in a healthy state, especially when one engages in prolonged
outdoor exercises without adequate fluid intake. Prolonged
administration of certain therapeutic regimen could also alter this
balance, for instance the use of diuretics and corticosteroids.
Dehydration and oedema indicate unmet fluid needs. Dehydration is the

excessive loss of fluid from body tissues; it is accompanied by a
disturbance of body electrolytes. Could follow prolonged fever,
vomiting, diarrhoea, trauma or any other condition that causes a rapid
fluid loss. Oedema is the abnormal accumulation of fluid in the
interstitial spaces of tissues, pericardial sac, intrapleural space,
peritoneal cavity, or joint capsules. Oedema may be caused by decreased
serum protein level, altered functioning of the cardiovascular, renal, or
hepatic system, or drugs. The nurse examines patients/clients for actual
and potential fluid and electrolyte imbalance. Poor skin turgor (normal
skin elasticity becoming lax), flushed dry skin, decreased tears or
salivation, a coated tongue, decreased urine output (oliguria), confusion
and irritability indicate dehydration (Cox, 1995). Pitting bipedal
oedema, facial puffiness, ascites (accumulation of fluids in the
peritoneal cavity), positive shifting dullness are all manifestations of
excessive body fluids. The nurse can assist in conditions of altered fluid
balance through accurate assessment, measuring of intake and output,
weighing of patients and monitoring of intravenous infusions and so on
and so forth.
Food and Nutrients – Food is any substance that can be consumed, be

it of plant or animal origin including liquid drinks, and it is the main
source of energy and of nutrition for man and other animals. The phrase
‘we are what we eat’ is frequently used to signify that the composition
of our bodies is dependent in large measures on what we have consumed
(Latham, 1997). Today there is a greater awareness of the relationship
5
NSS201 FOUNDATIONS OF NURSING
between health and nutrition, nutrition and the onset of illness, nutrition
and wound healing, and nutrition and effective immunity.
Optimal nutrition (intake matches energy expenditure; proper amount of

each essential nutrient) is essential for: Normal growth and
development; maintenance of bodily functions; optimal activities status;
resistance to infection; and repair of injuries to cells and tissues. Lack of
adequate nutrition produces specific identifiable diseases such as
kwashiorkor, marasmus, rickets, e.t.c. Poor nutritional habits, inability
to chew and swallow, nausea and vomiting equally pose a threat to
nutritional status. Over-eating on the other hand also adversely affect
health (results in obesity, hypercholestraemia and other related
problems). Perhaps the point that could be safely made is that while
good nutrition is not synonymous to good health, good health is not
achievable without adequate nutrition.
To determine whether patients/clients are meeting nutritional needs, the

nurse considers body weight and other markers of nutritional deficiency.
These include the physique, body mass index, hair texture and colour,
some laboratory data (e.g. PCV), and food intake patterns. Signs and
symptoms indicating that individuals are not meeting nutritional needs
include failure to thrive, unplanned weight loss, fatigue, pallor and
recurring mouth and gum sores (Cox, 1995). To help individuals meet
their nutritional needs, the nurse must have a good understanding of the
various locally available foodstuffs and their nutritive values as well as
the digestive and metabolic processes of the body. Nursing action
targeted at resolving nutritional problems range from health education to
assuming total responsibility for the planning and feeding of patients.
SELF ASSESSMENT EXERCISE 1
List the basic human needs.
Elimination of Waste Products – This is essential to maintain life and

comfort. The integumentary (the skin and its appendages), respiratory,
urinary, hepatic, and digestive systems are the organs primarily
concerned with elimination of wastes from the body. The skin eliminates
water and salt in form of sweat; the kidney, excess fluids and
electrolytes; the lungs, carbon dioxide and water; the intestine, solid
wastes and fluids; and the liver, detoxified drugs and toxins. Many
conditions (kidney or renal problems, bowel obstruction, diseases of the
respiratory tract e.t.c) impair this process of waste elimination in the
body with grave consequences.
A patient/client whose urinary elimination needs are unmet may become

incontinent or develop urinary tract infection. Unmet urinary elimination
6
needs also results in fluid and electrolyte imbalances. A patient unmet

need for bowel elimination may lead to changes in pattern of elimination
or diet intake (Cox, 1995). Nursing measures at helping clients/patients
meet their elimination needs may be as simple as providing privacy or
changing diet or giving enema or as complex as inserting a urethral
catheter, conducting peritoneal dialysis or haemodialysis, or assisting
with surgery to relieve bowel obstruction or administering medication to
relieve constipation.
Sleep and Rest – Sleep is a recurrent, altered state of unconsciousness

that occurs for sustained periods, during which the body experiences
minimal physical activity and a general slowing down of physiological
processes with resultant restoration of energy and well-being. It provides
time for the repair and recovery of body systems for the next period of
wakefulness. Rest refers to a state of relaxation and calmness (Coy,
1998). Like sleep it reduces physical and psychological demands on the
body. Activities during rest periods range from lying down to taking a
quiet walk. While it is very true that the much of sleep required by
individuals depends to a large extent on such factors as age, pregnancy,
state of health; sleep deprivation has been implicated in the worsening of
certain mental disorders. Although the length of time that can be
considered as adequate sleep is still controversial, there is a general
belief that about 6 to 8hours of sound sleep is sufficed for healthy living.
Rest and sleep habits of persons entering the hospital or other health
care facility can easily be changed by illness, the strange hospital
environment culminating in fear and anxiety, and hospital routines. The
nurse must be aware of patient/client’s need for rest and sleep as lack of
it aggravates the existing deteriorating state of health of the clients. As
nurses, we can assist our clients to get enough rest and sleep by
providing safe, comfortable, and quiet environment, maintenance of
proper anatomical alignment or positioning, provision of adequate
ventilation, giving of warm tub bath, soothing back rub, and prescribed
sleep enhancing medications (Rosdahl, 1995). Any bedtime habits, such
as reading, walking, bathing or drinking milk should be incorporated
into the care plan.When possible the nurse should plan care to fit the
patient’s/client’s usual sleep-wake-cycle (Cox, 1995).
Activity and Exercise – Mobility or movement is an activity most

people have taken for granted but the ability to move and be active
brings about positive benefits to one’s health status (Brillhart 1998).
Mobility though not absolutely essential for survival is needed to
maintain optimum health. According to respiration Rosedale (1995)
activity stimulates the mind and body while exercise helps in
maintaining body’s structural integrity and health by enhancing
circulation and respiration. Mobility enhances muscle tone, increases
energy levels, and is often associated with psychological benefits such
7
as independence and freedom. Functional mobility is governed by body

mechanics, the purposeful and coordinated use of body parts and
positions during activity. Use of proper body mechanics maximizes the
effectiveness of the efforts of the Musculoskeletal and neurological
systems and reduces the body’s exposure to strain or injury during
movement (Brillhart 1998).
The nurse can assist her client to obtain needed exercises in the
following ways: (a) Through the teaching of pre-operative breathing
exercises; (b) Encouraging early ambulation post surgery; (c)
Conduction of passive range of motion exercises; (d) Turning of
immobilized patients (non-ambulant patients) to mention but a few.
Sexual Gratification – Everyone is a sexual being regardless of health

status (Hodge, 1995), and sexual integrity is an integral part of a
person’s well-being. Even though there are no universal values about
sexuality, individuals do experience sexual needs but unlike other
physiologic needs, sexual gratification may be sublimated (Rosdahl
1995). This to an extent underscores the fact that the sex need is not vital
to survival of individuals but it is vital to the survival of the species.
Nurses often encounter clients whose sexuality is threatened. Some

illnesses such as diabetes mellitus, chronic pain, some disabilities,
certain surgeries and some medications like certain antihypertensives,
and even hospitalization may impair a person’s sexual integrity
(Delaune & Ladner, 1998). The nurse can be of great help in managing
client’s sexual problems by demonstrating understanding, creating an
atmosphere that communicates consideration, and making the patient
feel comfortable. In addition clients and sexual partner need to be
informed about the cause of the problem. Medications reducing sexual
libido could be substituted while clients with chronic pain could be
taught methods of increasing their comfort level (e.g. relaxation
techniques). However, as Rosdahl (1995) rightly suggested, when a
client present with major sexual problems such should be referred for
professional counseling.
3.4 Security and Safety Needs
Once the physiological needs are relatively well gratified, there then
emerges a new set of needs, which we may categorize roughly as the
safety needs. All that has been said of the physiological needs is equally
true, although in lesser degree, of these desires. They may equally well
wholly dominate the organism. They may serve as the almost exclusive
organizers of behavior, recruiting all the capacities of the organism in
their service, and we may then fairly describe the whole organism as a
safety-seeking mechanism. Again we may say of the receptors, the
8
effectors, of the intellect and the other capacities that they are primarily
safety-seeking tools. Again, as in the hungry man, we find that the
dominating goal is a strong determinant not only of his current world-
outlook and philosophy but also of his philosophy of the future.
Practically everything looks less important than safety, (even sometimes
the physiological needs which being satisfied, are now underestimated).
A man, in this state, if it is extreme enough and chronic enough, may be
characterized as living almost for safety alone (Maslow, 1943).
Whereas the physiological drive have certain limit to their satisfaction,

security needs seems to be infinite in nature. For example excessive
indulgence in eating could be harmful to people. Characteristics of
safety include: predictability, stability, familiarity, as well as feeling safe
and comfortable and trusting other people (Rosdahl 1995). Inherent in
the above statement is that safety needs contains both physical and
psychological components. Freedom from harm, danger and fear,
financial security, need for shelter and warmth all are therefore
subsumed under safety and security needs.
Physical Safety – Maintaining physical safety involves reducing or

eliminating threats to body or life. The threat may be illness, accident,
danger, or environmental exposure, lack of shelter and warmth. The
threat could even be orchestrated by medical or surgical complications
following a protracted illness or surgical intervention. Although lack of
shelter may not create an immediate threat to life, its cumulative effect
may eventually squeeze out life out of people. Furthermore, it will
thwart the ability of an individual to progress towards a higher level
needs. The need for warmth is however predicated on the fact that the
human body functions in a relatively narrow range of temperature and
any deviation from this narrow range will spell doom for the whole body
(Cox, 1995; Rosdahl 1995). The nurse may assist in removing threats
from patient’s environment through keen observation and continual
assessment, ensuring adequate bed spacing, Keeping wards well
illuminated and aerated, scrupulous hand-washing, aseptic wound
dressing, locking up of poisons at home to safeguard children, to
mention but a few.
Psychological Safety – According to Cox, 1995 ‘To be safe and secure

psychologically, a person must understand what to expect from others,
including family members and healthcare professionals, and what to
expect from procedures, new experiences, and encounters within the
environment’. Cox asserted that everyone feels some threat to
psychological safety with new and unfamiliar experiences. By
extension, a newly hospitalized patient may feel threatened by the
strange hospital environment and a patient/client about to undergo a
diagnostic test may equally feel threatened by the technology involved.
9
The fact that people rarely open up that their psychological safety is
threatened makes assessment of psychological safety often difficulty. To
this end, the nurse will have to interpret the patient/client language and
behaviour. The nurse may assist in alleviating psychological threat
through explanation of procedures to patients before actual intervention,
health education e.t.c.
3.5 Affiliation and Social Needs (Love)
These encompass the need for friendship, love, belongingness, and

acceptance. When both the physiological and the safety needs are fairly
well gratified, then the affiliation needs will emerge and dominate the
behaviour of human being. Now the person will feel keenly, as never
before, the absence of friends, or a sweetheart, or a wife, or children. He
will hunger for affectionate relations with people in general, namely, for
a place in his group, and he will strive with great intensity to achieve
this goal. He will want to attain such a place more than anything else in
the world and may even forget that once, when he was hungry, he
sneered at love (Maslow, 1943).
The drive to belong and be accepted by other people stems from the
gregarious nature of human. Everyone needs to feel that they are wanted
and belong to a group. Non-fulfillment of these needs may affect the
mental health of the individual and indeed has implicated in the etiology
of maladjustment and more severe psychopathology. For instance, a
usually mild-tempered person may become easily irritated; an outgoing
person may suddenly become withdrawn from friends and coworkers;
could even affect a person’s work habits leading to increased
absenteeism or over commitment to the job.
For this reason, the nursing care plan for an ill hospitalized patient
should include means by which love and belonging needs can be met.
Some of the ways by which this need could be met include: getting
patient/client actively involved in the development of their care plan;
giving nursing care in friendly and empathetic manner; encouraging
presentation of greeting cards to patient and visits by friends and
relatives; and short social visits by members of the health care team.
Itemise your physiological and psychological needs.
4.0 CONCLUSION
Since the attainment of highest level of health by any individual is

predicated upon a complex maze of needs achievement, no effort should
10
be spared at ensuring that individuals meet their basic human needs.

Nurses, the set of health workers that spend the longest hours with the
patients, therefore need to be equipped with knowledge and skill of
assessing and meeting the multifaceted needs of their clients.
5.0 SUMMARY
This unit has taken a broad look at the relationship between health and
human needs. It noted that all human need a number of essentials to
survive and that all human beings are driven by physiologic and
psychological needs. It classified human needs into two broad groups –
Primary needs and Secondary needs noting that the first level needs
(physiologic needs) must be met before a person can address higher
level needs. Employing simple illustrations, the unit shows that
physiological needs can control thoughts and behaviors, and can cause
people to feel sickness, pain, and discomfort. In addition, the unit
buttressed the view that ‘as illness or injury can interfere with a person’s
ability to meet needs, the duo could also cause an individual to regress
to a lower level of functioning’. Lastly, the unit emphasized that nurses
can do a lot in identifying and assisting patients/clients to meet their
basic human needs.
6.0 TUTOR-MARKED ASSIGNMENT
Classify the basic human and physiological needs. Describe the

relationship among the different levels of needs.
ANSWER TO SELF ASSESSMENT EXERCISE 1
Physiological, Safety, Love, Esteem and Self actualization.
Physiological: Food, Water, Sleep, Psychological: Affection, Security

and self esteem.
7.0 REFERENCES/FURTHER READING/FURTHER

READING
Brillhart, B. (1998). Mobility. In S. C. Delaune & P.K. Ladner, (eds.).

Fundamentals of Nursing, Standard and Practice. Albany:
Delmar Publishers.
Christensen, B. (1998). Oxygenation. In S. C. Delaune & P.K. Ladner,

(eds.). Fundamentals of Nursing, Standard and Practice. Albany:
Delmar Publishers.
11
Cox, C.L. (1995). 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. (1998). Comfort and Sleep. In S. C. Delaune & P.K. Ladner,

(eds.). Fundamentals of Nursing, Standard and Practice. Albany:
Delmar Publishers.
Hodge, A. L. (1995). Addressing Issues of Sexuality with Spinal Cord
Injured Persons. Orthopaedic Nursing, 14 (3): 21 – 24.
Latham, M.C. (1997). Human Nutrition in the Developing World. Rome:

Food and Agriculture Organization of the United Nations.
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
Rosdahl, C. B. (ed.). 1995. Optimum Health for All People; Textbook of

Basic Nursing. Philadelphia: J.B. Lippincott Company.
12
UNIT 2 HEALTH AND HUMAN NEEDS II
CONTENTS
1.0 Introduction
2.0 Objectives
3.0 Main Content
3.1 Esteem and Self-Esteem Needs
3.2 Self Actualization Needs
3.3 Theories of Human Needs
3.4 Criticisms of Maslow’s Theory of Needs
3.5 Application of Basic Needs Theory
4.0 Conclusion
5.0 Summary
6.0 Tutor-Marked Assignment
1.0 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 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.
2.0 OBJECTIVES
• differentiate between the esteem needs and self-actualization

needs
• discuss the Maslow hierarchy of needs
• describe what is meant by hierarchy of needs
• discuss Maslow Hierarchy of Needs and other Needs Theories
• examine the flaws of Maslow Hierarchy of Needs
• discuss the clinical and other applicability of Basic Needs
Theory.
13
3.0 MAIN CONTENT
3.1 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 (1995)
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 (1995)
stressed further that it is not the magnitude of the change or role that
affects self-esteem, but rather 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 1995). 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. In Cox (1995)
words, 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
14
total responsibility for meeting those other needs while taking steps to
increase self-esteem (Rosdahl 1995; Cox, 1995).
3.2 Need for Self-Actualization
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, 1995).
However, 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, 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 tends to
15
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,
1995).
What is the positive link of esteem and self esteem needs?
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) Maslow Hierarchy of Needs
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:
• Needs are hierarchical in nature. That is, each need has a specific
ranking or order of obtainment.
• 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.
• 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.
• When one set of needs is satisfied, it seizes to be a motivator.
• Lower level need must be satisfied in general, before higher level
needs are activated sufficiently to drive behavior.
• 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:
16
• Physiological: hunger, thirst, bodily comforts, etc.;

• Safety/Security: the need for structure, predictability, out of
danger, free from harm, feel safe and secure;
• Belongings and Love: the need to be accepted by others and to
have strong personal ties with one's family, friends, and identity
groups;
• Esteem: the need to achieve, be competent, gain approval and
recognition; and
• 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 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
17
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 needs that influence workers’ behavior;
existence, relatedness, and growth. These three needs categories are:
• 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.
• 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.
• 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 regress to relatedness needs, and socialize more
with co-workers. The relevance of this on the job is that even when the
18
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
Existence Growth
Needs Needs
Satisfaction / Progression
Frustration / Regression
Satisfaction / Strengthening
Source: Adapted from

http://www.valuebasedmangement.net/methods_alderfer_erg_theory.ht
ml
(c) 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 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 autonomy,
19
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.
3.3 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 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
counterpositions suggest that satisfaction which Maslow viewed as a
20
major motivator has been found not to be directly related to production

which is main goal of the manager.
3.4 Application of Basic Needs Theory
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 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 (1995) 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 (1995) 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
pressing/life threatening needs while simultaneously addressing the
higher level needs.
21
Sketch a diagrammatic representation of Abraham Maslow’s Hierarchy

of needs.
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, 1995). 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 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.
4.0 CONCLUSION
The human needs theory, no doubt, is a set of concepatients important

for the nurse understanding of health and illness and the
patient’s/client’s position on the health-illness continuum. Nonetheless,
the nurse must as a necessity consider the uniqueness of each individual,
their need References/Further Reading/Further Reading and the
significance of each need in prioritizing nursing care.
22
5.0 SUMMARY
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.
A person feels self confident and useful to himself and community.
Show your representation to your colleague.
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?

READING
Alderfer, C. P. (1969). Existence, Relatedness, and Growth; Human

Needs in Organizational Settings. Retrieved from,
http://www.valuebasedmangement.net/methods_alderfer_erg_the
ory.html
Boeree, C. George (2004). Abraham Maslow. Available on

http://www.ship.edu/∼cgboeree/maslow.htm
Cox, C.L. (1995). 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.
23
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.
24
UNIT 3 CONCEPT OF HEALTH AND ILLNESS
CONTENTS
1.0 Introduction
2.0 Objectives
3.0 Main Content
3.1 What is Health?
3.2 Concepatients of Wellness
3.3 Illnesses and Disease
3.4 Etiology of Illnesses and Diseases
3.5 Classification of Illnesses and Diseases
3.6 Theoretical perspectives of health and wellness
3.7 The Health-Illness Continuum
4.0 Conclusion
5.0 Summary
1.0 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,
1995) 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 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.
2.0 OBJECTIVES
• differentiate health, wellness and illness

• describe five dimensions of wellness
25
• differentiate between acute, chronic and terminal illnesses;

primary and secondary illnesses; and hereditary, congenital, and
idiopathic illnesses.
• distinguish between the terms illness and disease
• outline the etiology of illnesses and diseases
• describe the health-illness continuum.
3.0 MAIN CONTENT
3.1 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 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
• 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.
• Places health in the context of environment. It takes cognizance
of the fact that people’s live, and therefore their health, are
26
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.
• 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.
• Health therefore in its global/broadest sense encompasses:
• Physical health – physical fitness, the body fixing at its best.
• Emotional health – feelings and attitudes that make one
comfortable with oneself.
• Mental health – a mind that grows and adjusts; in control, free of
serious stress.
• Social health – a sense of responsibility and caring for health and
welfare of others.
• 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.
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.
27
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.
3.2 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 ones 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

concepatients 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.
28
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: Concepatients, Process and Practice.
Let us examine these factors one by one:
• 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.
• 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.
• 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.
29
• Intellectual – The ability to learn and use information effectively

for personal, family, and career development. It includes striving
for continued growth and learning to deal with new challenges
effectively.
• 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.
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.
List the five (5) factors that contribute to wellness?
3.3 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.
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
30
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.
3.4 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:
• Inherited genetic defects

• Developmental defects/Congenital malformations. Example –
Atria Septal Defect
• Biological agents or toxins
• Physical agents such as temperature extremes, chemicals, or
radiations
• Generalized response of tissues to injury or irritation
• Physiological and psychological reactions to various stressors
• 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.
3.5 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
31
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.
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.
List the two main classification of illness?
3.6 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.
32
Fig 4 – 2 Illness–Wellness Continuum
Wellness axis
Premature High-level
Death * * * * wellness
Critical illness Illness Normal health Good health
Illness axis
Excellent health
Source: Adapted from Rosdal, 1995: Textbook of Basic Nursing &

Kozier, Erb, Berman and Burke 2000: Fundamentals of Nursing:
Concepatients, 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 changes that illness produces in every
dimension of functioning, the nurse must understand all the
aforementioned dimensions.
4.0 CONCLUSION
This unit 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
33
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.
5.0 SUMMARY
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.
1. Physical 2. Social 3. Emotion 4. Intellectual 5. Spiritual
1. Acute (Primary) 2. Chronic (Secondary).
Is health static or changing? Explain with particular reference to the

health-illness continuum.

READING
Anspaugh, D. J., Hamrick, M. H. & Rosata, F. D. (1991). Wellness:

Concepatients 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.
Dubos, R. (1978). Health and Creative Adaptation. Human Nature,

74(1), Entire Issue.
34
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 (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.

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
Concepatients 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.
35
UNIT 4 PROMOTING HEALTH
CONTENTS
1.0 Introduction
2.0 Objectives
3.0 Main Content
3.1 Factors/Variables Affecting Health
3.2 Defining Health Promotion and Illness Prevention
3.3 Health Promotion Goals
3.4 Behaviours that Promote Health (Healthy Habits)
3.5 Nurses Role in Health Promotion and Illness Prevention
4.0 Conclusion
5.0 Summary
1.0 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. 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 unit.
36
2.0 OBJECTIVES
• identify variables affecting health and explain the relationship

between such and health
• define health promotion and distinguish it from illness prevention
• enumerate health promotion goals and discuss the levels of
preventive care
• describe the behaviours that promote health
• discuss theoretical models of health and illness together with their
assumptions
• differentiate health preventive or protective care from health
promotion
• discusses the nurses’ role in health promotion and illness
prevention.
3.0 MAIN CONTENT
3.1 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. 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
37
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 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 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.
4. 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.
3.2 Defining Health Promotion
The concepts of health promotion, self-care and community

participation emerged during 1970s, primarily out of concerns about the
38
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.
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, 1995).
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
39
promotion and illness prevention activities are important to both the

consumer and the health care provider (Cox, 1995).
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.
3.3 Health Promotion Goals
Delaune & Ladner (1998) submitted the following as health promotion

goals:
• Respect and support clients right to make decisions.

• Identify and use clients’ strengths and assets.
• Empower clients to promote own health or healing.
Levels of Preventive Care
The three levels of prevention are:
• 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, 1995). 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.
• 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
40
severity and enabling the patient/client to return to normal health

at the earliest possible time (Edelman & Mandle, 1990; Cox,
1995). Secondary prevention includes screening techniques and
treatment of early stages of disease to limit disability or delay the
consequences of advanced disease (Cox, 1995; Delaune &
Ladner, 1998).
• 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).
3.4 Behaviours 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 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, 1995). 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).
41
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 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, 1995).
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, 1995).
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 comfortable. Clothes should be clean, well
fitting and comfortable too. They should be appropriate for the type of
42
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, 1995).
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 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.
3.5 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
43
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 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.
• Promote understanding of health promotion, preventative care,

health education and healthy living.
• 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.
• Facilitate responsibility and choice among clients for healthy
living, and their ability to determine their own lifestyles.
• Develop and implement strategies for health care based on
understanding of the impact of health trends on resources.
• Consequently, Watkinson (2002) illustrated the many sided roles
of the nurse in health promotion with this schematic diagram (Fig
3 – 1).
44
Fig 3.1 The Role of the Nurse in Health Promotion
Evaluation 1 Needs Identification

Students’ identification of
Health their own needs
Promotional Skills Self and self-awareness, Value base
Prejudices, Resources
Co-workers
Communication
Skills
1
8 Practice Based 2
Outcomes and Structural influences
Process Empowerment
measurement Anti-discrimination
Monitoring Gender, Poverty
Race
Advocacy
Implementation
7 Health Achievement 3
Planning Health
Gain Epidemiology Methods
in needs assessment of Research
Targeting effectively Skills of enquiry
Planning services. and analysis of
qualitative and
quantitative data
6 Project Management 4 Psychosocial issues

Theory and skills Social construction of health
Report-writing Stress and health
Planning Assessment
5
Choosing the appropriate models and approaches
Educational principles
Making alliances and ethical considerations
Source: Watinson (2002) Promoting Health. In R. Hogston & P. M.

Simpson (eds.) Foundations of Nursing Practice; Making the Difference
(2nd ed.)
4.0 CONCLUSION
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
45
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.
5.0 SUMMARY
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.
Genetic, Personal life style, Environment, Technological advancements.
These are activities that help an individual to achieve and maintain a

healthy status.
Examples are: elimination, personal hygiene, sleep and rest, exercise,

posture and body mechanisms.
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
attack. How would you begin to design the program? What resources do
you need?
46

READING
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. (1995). Health and Illness. In H. B. M. Heath (ed.). Potters

and Perry’s Foundations in Nursing Theory and Practice. Italy:
Delaune, S. C. & Ladner, P.K. (eds.). (1998). The Individual, Health and
Holism. Fundamentals of Nursing, Standards and Practice.
DiMartino, C. (1999). Healthy Living: A Combination of Diet,

Nutrition, and Exercise. In Motion, 9(6).
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,

Watkinson, G. (2002). Promoting Health. In R. Hogston & P. M.

Simpson (eds.) Foundations of Nursing Practice; Making the
World Health Organization (1986). Geneva: Ottawa Charter for Health

Promotion.
47
UNIT 5 ASSESSING HEALTH I – VITAL SIGNS
CONTENTS
1.0 Introduction
2.0 Objectives
3.0 Main Content
3.1 What are Vital Signs?
3.2 Times to Assess Vital Signs
3.3 Factors Affecting Body Temperature
3.4 Alterations in Body Temperature
3.5 Assessing Body Temperature
4.0 Conclusion
5.0 Summary
1.0 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 understand and interpret the values,
communicate findings appropriately and begin interventions as needed.
2.0 OBJECTIVES
• identify the measurements that comprise the vital signs

• identify when to assess vital signs
• define body temperature
• describe the thermoregulatory mechanisms
• identify the variations in normal body temperature that occur
from infancy to old age
• discuss factors affecting body temperature
48
• describe how to measure body temperature using various routes

stating the advantages and disadvantages associated with each
route.
3.0 MAIN CONTENT
3.1 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 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.
3.2 Times to Assess Vital Signs
• On admission to a healthcare agency to obtain baseline data.

• When the patient’s/client’s general physical condition changes
(as with loss of consciousness or increased intensity of pain)
• Before and after surgery or an invasive diagnostic procedure.
• Before and/or after administration of certain medication that
affect the cardiovascular, respiratory, and temperature control
function.
• 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)
• When the patient reports non-specific symptoms of physical
distress (such as feeling ‘funny’ or ‘different’)
49
• (Webster, 1995; Kozier, et. al., 2000).
3.3 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.
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
50
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).
51
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 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).
52
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.
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
53
temperature is abnormally high, the nurse can lower it by tepid sponging

thereby taking advantage of conductive heat loss (Webster, 1995).
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.
3.4 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
54
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).
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/noradrenaline 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).
55
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).
List out the factors that can influence body temperature.
3.5 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 – 38.30C - Low Pyrexia

38.4 – 39.40C - Moderate Pyrexia
39.5 – 39.50C - High Pyrexia
Over 40.50C - Hyperpyrexia
Source: Adapted from Ross and Wilson Foundations of Nursing and

First Aid (6th ed.).
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).
56
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 pathphysiologic 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 production
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
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
57
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.
Table 5 – 2 Clinical Signs of Fever
Onset (cold or child stage) Glassy-eyed appearance

Increased heart rate Increased pulse and
respiratory rates
Increased respiratory rate Increased thirst
and depth
Shivering Mild to severe dehydration
Pallid, cold skin Drowsiness, restlessness,
delirium, or convulsions
Complaints of feeling Herpetic lesions of the fever is
cold prolonged
Cyanotic nail beds Loss of appetite (if the fever is
prolonged)
“Gooseflesh” appearance Malaise, weakness, and
of the skin aching muscles
Cessation of sweating
Course Effervescence(fever abatement)
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
58
Nursing Management of Clients with Fever
Nursing interventions for clients with fever could be summarized as

follows:
• Monitor vital signs

• Assess skin color and temperature
• Monitor white blood cell count, hematocrit value, and other
pertinent laboratory reports for indications of infection or
dehydration.
• Remove excess blankets when the client feels warm, but provide
extra warmth when the client feels chilled.
• 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.
• Measure intake and output.
• Reduce physical activity to limit heat production, especially
during the flush stage.
• Administer antipyretics (drugs that reduce the level of fever) as
ordered.
• Provide oral hygiene to keep the mucous membranes moist. They
can become dry and cracked as a result of excessive fluid loss.
• Provide a tepid sponge bath to increase heat loss through
conduction.
• 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 lost
(b) 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 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)
59
Clinical Signs of Hypothermia
• Decreased body temperature, pulse, and respirations

• Uncontrolled severe shivering (initially)
• Feelings of clod and chills
• Pale, cool, waxy skin
• Hypotension
• Cardiac dysrhythmias
• Decreased urinary output
• Lack of muscle coordination
• Disorientation
• 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:
• Provision of warm environment (room temperature)

• Provision of dry clothing
• Application of warm blankets
• Keeping of limbs close to body
• Covering the client scalp with a cap or turban.
• Supplying warm oral intravenous fluids.
• Application of warming pads.
3.5 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.
60
Table 5 – 3 Advantages and Disadvantages of the four Sites for

Body Temperature Measurement
Site Advantages/Merits Disadvantages/Demerits/Flaws

Oral Most accessible and Mercury-in-glass thermometers
convenient can break if 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.
Rectal Most reliable Inconvenient and more unpleasant
measurement for clients; 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
61
on neonates.
Axillary Safest and most non- Requires the nurse to hold the
invasive thermometer in place for a long
time; is less accurate.
Tympanic Readily accessible; Can be uncomfortable and involves
Membrane reflects the core risk of injuring the membrane if
temperature. Very the probe is inserted too far.
fast. Repeated measurement may vary.
Right and left measurements can
differ. Presence of cerumen can
affect the reading.
Guidelines for Taking body Temperature
Preparation
• 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.
• Equipment/Environment: Clinical mercury thermometer;
Disposable cover for the thermometer or alcohol swab for
cleaning it; & Observation chart.
• 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.
Oral
4. 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.
62
5. Ask the patient to close their lips, but not their teeth, around the
thermometer to prevent cool air circulating in the mouth.
6. Leave in position for 2-3 minutes (see PPP).
7. 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
8. Holding the thermometer horizontally at eye level, note the level
of the mercury.
Axilla
9. Do not use a disposable cover as this is not necessary and

interferes with skin contact.
10. Ask/assist the patient to expose his/her axilla, for an accurate
recording, the axilla must be dry.
11. 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.
12. Leave in position for five minutes.
13. Holding the thermometer horizontally at eye level, note the level
of the mercury
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.
63
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.
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.
64
4.0 CONCLUSION
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.
5.0 SUMMARY
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.
ANSWER TO SELF ASSESSMENT EXERCISE
Age, Environment, Stress, Hormonal level and Exercise.
Explain the thermoregulatory mechanism and discuss the various factors

influencing body temperature.
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.
65
7.0 REFERENCES/FURTHER READING
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.
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

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: Mosby, An Imprint of Times Mirror International.
66
MODULE 2
Unit 1 Assessing Health II (Vital Signs Contd)

Examination)
Unit 3 Diagnostic Measures in Patients Care
Unit 4 Providing Safety and Comfort I
Unit 5 Providing Safety and Comfort II (Pain Management)
UNIT 1 ASSESSING HEALTH II – VITAL SIGNS

(CONTD)
CONTENTS
1.0 Introduction
2.0 Objectives
3.0 Main Content
3.1 Respiration
3.2 Mechanics and Regulation of Breathing
3.3 Altered Breathing Patterns and Sounds
3.4 Assessing Respiration
3.5 Heamodynamic Regulation
3.6 Assessing Pulse
3.7 Blood Pressure and its Determinants
3.8 Assessing Blood Pressure
4.0 Conclusion
5.0 Summary
7.0 References/Further Reading
1.0 INTRODUCTION
This unit examines the other components that make up the vital signs,
which are respiration, pulse and blood pressure.
2.0 OBJECTIVES
• describe the physiological mechanisms governing pulse,

respiration, and blood pressure
• identify normal ranges for each vital sign
• identify the variations in pulse, respirations, and blood pressure
that occur in a normal healthy state from infancy to old age
67
• select appropriate equipments needed for measuring each vital

sign
• identify the different sites for assessing pulse and list the
characteristics that should be included when assessing pulses
• explain how to measure the apical pulse and the apical-radial
pulse
• describe the mechanics of breathing/the mechanism that controls
respiration and demonstrate the ability to count the respiration of
a patient accurately
• discuss characteristics that should be included in a respiratory
assessment
• explain how to measure a blood pressure and differentiate
between systolic and diastolic pressure.
3.0 MAIN CONTENT
3.1 Respiration
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.
68
3.2 Mechanics and Regulation of Breathing
Regulation of Breathing
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.
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.
69
3.3 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.
(A) Normal Respiration
Normal respiration is quiet, rhythmical (regular), comfortable, being

neither too deep nor too shallow and of 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 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 Average
Range
Newborns 30 – 40
Early Childhood 25 – 30
Late Childhood 20 – 25
Teens 18 – 22
Adults 16 – 20
Aged 16 – 18
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.
List the factors that could influence respiratory rate.
70
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.
• 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
inhaled and exhaled, following a full expansion of the lungs with full
71
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 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 breath 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.
72
What are the requirements for observing a patients respiration, pulse and
temperature?
(B) Abnormal Pattern/Dysfunctional Respiration
Rate:
• 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.
73
• Orthopnea – When difficulty becomes so marked that the patient

can breath 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:
• Stridor – A shrill, harsh sound heard during inspiration with

laryngeal obstruction.
• Stertor – Loud snoring or sonorous respiration, usually due to
partial obstruction of the upper airway.
• 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.
• Whoop – This long drawn-out noisy inspiration occurring after a
paroxysm of coughing in whooping cough.
• Grunting – Grunting at the end of respiration is sometimes
noticed in pneumonia.
• Sighing – Sighing or air hunger, is characterized by slow
inspiration and rapid expiration. This occurs in shock following
hemorrhage.
• Bubbling – Gurgling sounds called bronchi are heard as air
passes through moist secretions in the respiratory tract.
Chest Movements
• Intercostal Retraction – Indrawing between the ribs.

• Substernal Retraction – Indrawing beneath the breast bone.
• Suprasternal Retraction – Indrawing above the clavicles.
• 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.
(Webster, 1995; Roark, 1995; Timby, 1996; Usman, et. al. 2000; Kozier,
et. al. 2000)
3.4 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.
74
Table 7 – 2 Procedure for Assessing Respiration
Suggested Action Rationale
Assessment
Determine when and how Demonstrate accountability for
frequently to monitor the patient’s making timely and appropriate
respiratory rate. assessments.
Review the data collected in Aids in identifying trends and
previously recorded assessments of analyzing significant patterns.
the respiratory rate and other vital
signs.
Read the patient’s history for any Demonstrate an understanding of
reference to respiratory, cardiac, or factors that may affect the
neurologic disorders. respiratory rate.
Review the list of prescribed drugs Helps in analyzing the results
for any that may have respiratory assessments findings.
or neurologic effects.
Planning
Arrange the plan for care so as to Ensures consistency and accuracy.
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 respirations at rest rather than
rate after a 5-minute period of under the influence of activity.
inactivity.
Suggested Action Rationale
Implementation
Introduce self to patient if this has Demonstrates responsibility and
not been done during earlier accountability.
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.
75
Choose a time when the patient is Prevents conscious control of

unaware of being watched; it may breathing during the assessment.
be helpful to count the respiratory
rate while appearing to count the
pulse.
Observe the rise and fall of the Determines the respiratory rate per
patient’s chest for a full minute, if minute.
breathing is 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 patient care, safety and comfort.
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 Alerts others to monitor the patient
respiratory rates or any other closely and make changes in the
unusual breathing Care. 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.)
3.5 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 of
blood vessels (arteries, arteriole, capillaries, venules and veins), and the
76
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, 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:
77
• Age – As the age increases, the pulse rate decreases. See Table 7
– 3 for specific variation in pulse rate from birth to old age.
Table 7 – 3 Normal Age Related Variations in Pulse
Age Normal Range Average Rate/Minute

Newborn 80 – 180 130
1 – 3yrs 80 – 140 120
6 – 8 yrs 75 – 120 100
Teen years 50 – 90 70
Adult 60 – 100 80
Older Adult 60 – 70 65
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.
• Sex – After puberty, the average female have a slightly higher

pulse rate than male.
• Exercise – Pulse rate normally increases with activities.
• 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.
• 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.
• 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.
• 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.
• Fever – The peripheral vasodilation that occurs concomitantly
with elevated body temperature and increased metabolism
associated with fever results in an increase in pulse rate.
3.6 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
78
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:
• Radial – At the wrist, just above the base of the thumb (postero-
inferior), where the radial artery run along the radial bone.
Readily accessible
• 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.
• 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.
• 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.
• 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.
• 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.
• 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.
• 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.
• 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.
79
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 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
80
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.
3.7 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 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.
81
• 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
• Sympathetic Stimulation/Cardiac Accelerator (Adrenalin) –

Increases peripheral resistance and heart rate and consequently
increases the Bp.
• Parasympathetic (Vagal) Stimulation – Cardiac inhibitor;

reduces Bp.
• 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.
• 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
82
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.
• 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).
3.8 Assessing Blood Pressure
Since blood pressure can vary considerably, it is expedient for the nurse
to know a specific clients baseline Bp.
83
Preparation
• 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
1. Assess the patients knowledge of the procedure and explain as

necessary
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.
3. When applying the cuff, no clothing should be underneath it if
clothing constricts the arm remove the arm from the sleeve (see
PPP)
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.
5. The arm should be positioned so that the cuff is level with the
hear and may be more comfortable resting on a pillow
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.
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.
8. If using a communal stethoscope clean the earpieces with an
alcohol-impregnated swab. Curving the ends of the stethoscope
slightly forward, place the earpieces in your ears. Check that the
tubes are not twisted
9. Check that the stethoscope is turned to the diaphragm side by
tapping it with your finger.
10. Palpate the brachial artery, which is located on the medial aspects
of antecubital fossa.
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.
84
12. Position yourself so that the column of mercury in the

sphygmomanometer is clearly visible.
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).
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.
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.
4.0 CONCLUSION
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
85
controlled for comfort, and the nurses well armed with knowledge and
skills for assessing vital signs.
5.0 SUMMARY
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, 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.
Exercises, Body position, Emotion, Stress, Diseases, Certain drugs, and

acute pain.
Thermometer, Sphygmomanometer, Stethoscope, Spirit swabs and

Observation chart for record.
1. A 65-year-old known hypertensive patient was brought into your

clinic with complaint of slurred speech and labored breathing.
2. You have been assigned to check the vital signs. How will you
take his pulse and his blood pressure? What things should you
pay particular attention to while assessing the pulse? Differentiate
between normal and abnormal breathing patterns stating their
implications.
86
Donovan, J.E.; Belsjoe, E.H., and Dillon, D.C. (1968). The Nurse Aide.
Estes, M. E. Z. (1998). Vital Signs and Physical Examination. In S. C.

Delaune & P.K. Ladner (eds.). Fundamentals of Nursing,

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.

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

Timby, B.K. (ed.). (1996). Vital Signs. Fundamental Skills and


(ed.). Potters and Perry’s Foundations in Nursing Theory and
87
UNIT 2 ASSESSING HEALTH III – HISTORY

TAKING/PHYSICAL EXAM
CONTENTS
1.0 Introduction
2.0 Objectives
3.0 Main Content
3.1 Types of Assessment
3.2 Indications for Health Assessment
3.3 Data Collection
3.4 Interviewing/History Taking
3.5 Health History and Nursing History
3.6 Physical Examination
4.0 Conclusion
5.0 Summary
1.0 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.
88
2.0 OBJECTIVES
• explain the purpose, components, and techniques related to the

health history and physical examination
• differentiate between health history and nursing history
• identify information to collect from nursing history before an
examination
• describe the appropriate use and techniques of inspection,
palpation percussion, and auscultation
• identify some of the equipments needed to perform a physical
examination
• conduct physical assessments correctly in the right sequence and
in an organized fashion.
3.0 MAIN CONTENT
3.1 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 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
89
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.
3.2 Indications for Health Assessment
The purposes of health assessment include to:
• Collect data about the client through observation, interview and

physical examination.
• Assess the patient’s current physical condition.
• Establish a database for future comparisons.
• Continuously update database.
• Detect early signs of developing health problems
• Evaluate responses to medical and nursing interventions.
• Make clinical judgments about a client’s changing health status
and management.
3.3 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
90
instance, only the patient can tell you that he/she is afraid or has pain or
experiencing itching.
Methods of Data Collection
The basic methods employed in data collection or data gathering are:
• Observation
• Interview, and
• Physical Examination.
List the indications for patient’s assessment.
3.1.1 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 breath odour which might indicate Gamalin poisoning,
alcohol intoxification, poor hygiene, diabetic ketoacidosis e.t.c.
91
3.4 Interviewing/History Taking
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
• 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.
• Appropriate Timing – Schedule interviews with client at a time
when the client is physically comfortable and free of pain, and
when interruptions by friends, family, and other health
professionals are minimal.
• 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.
92
• 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.
3.5 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 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, surgeries,
93
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.
• 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.
Nutritional-Metabolic Pattern – Assesses food and fluid intake, food

References/Further Reading and taboos, cultural factors relating to food
94
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 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).
95
3.6 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 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 plexor). The stroke should be delivered from the
wrist and finger joints, not from the elbow, and the percussing finger
(the plexor) should be held perpendicular to the pleximeter. Tap lightly
and quickly, removing the plexor 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).
96
• 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.
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.
97
Fig 7 – 1 Regions of the Abdomen
1. Right hypochondrion 6. Left lumbar

2. Epigastruium 7. Right Iliac
3. Left hypochondrion 8. Hypogastrum 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 (pfannenstiel)
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
98
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.
What is the use of the five (5) special senses in observation/physical

examination?
4.0 CONCLUSION
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 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.
99
ANSWER TO SELF-ASSESSMENT EXERCISE 1
i. For evaluating the patient’s current physical condition

ii. For detecting early signs of developing health problems
iii. To establish a data base for future comparisons.
iv. To evaluate responses to medical and nursing interventions.
ANSWER TO SELF-ASSESSMENT EXERCISE 2
Eye (Sight) for visual clues e.g. patient’s appearance, mannerisms,

mode of dressing.
Touch (Tactile) for palpating any part of the patient to provide
information such as coldness, swelling etc.
Auditory (Ear) - use of hearing aids to collect information
(stethoscope).
Olfactory (Nose) an offensive smell when perceived around a patient
can be suggestive of an underlying problem.
You are asked to make an initial assessment on a woman entering the

nursing home. Describe the methods/techniques you will use in making
the assessment and identify types of data you will collect.
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.
100
Moffett, B. S. (1998). Assessment. In S. C. Delaune & P.K. Ladner

(eds.). Fundamentals of Nursing, Standards and Practice.

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

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


(ed.) Potters and Perry’s Foundations in Nursing Theory and
Wilkinson, J. (2000). Assessing. In Kozier, et. al. (eds.). Fundamental of

Nursing: Concepts Process and Practice (6th ed.). New Jersey:
Prentice Hall, Inc.
101
UNIT 3 DIAGNOSTIC MEASURES IN PATIENTS CARE
CONTENTS
1.0 Introduction
2.0 Objectives
3.0 Main Content
3.1 Preparing a Client for Diagnostic Investigations
3.2 Common Laboratory Tests
3.3 Lumbar Puncture
3.4 Sputum Studies
3.5 Urinalysis
3.6 Radiological Studies
4.0 Conclusion
5.0 Summary
1.0 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.
2.0 OBJECTIVES
• describe common invasive and noninvasive diagnostic

procedures
• explain to patient what is involved to allay anxieties
• discuss the relevant client teaching guidelines for care of client
before, during and after diagnostic testing
102
• identify specific physical preparations (such as bowel

preparation, fluid deprivation e.t.c.) needed for certain diagnostic
procedures
• describe accurately sample collection techniques and means of
ensuring delivery to right places
• 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.
3.0 MAIN CONTENT
3.1 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 facilitate instrumentation, promotes reliability of test
and efficient utilization of time, and above all, increases cost
effectiveness.
• Ensure proper identification of clients. This promotes client’s
safety.
• 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.
• Assess the presence, location, and characteristics of physical and
communicative limitations or preexisting conditions.
• Assess vital signs of clients scheduled for invasive investigations
to establish baseline data. Establish intravenous access if
necessary for procedure.
• Adequate physical preparation such as bowel preparation, fluid
deprivation e.t.c. Clarify with practitioner if regularly scheduled
103
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.
• Evaluates client’s knowledge of what to expect, client’s anxiety
and client’s level of safety and comfort.
3.2 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 solute) are present in a specimen. Laboratory tests
are ordered by the practitioners to:
• Detect and qualify the risk of future disease

• Establish and exclude diagnoses
• Assess the severity of the disease process and determine the
prognosis
• Guide the selection of interventions
• Monitor the progress of the disorder
• 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 40% – 54% for men and from 37% – 47% for women. High
hematocrit suggests polycythermia or hemoconcentration caused by
blood loss; low hematocrit may indicate anemia or hemodilution.
104
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 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.

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
105
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.
Purpose
• To assess renal function (primarily glomerular filtration)

• To monitor the progression of renal insufficiency.

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 veinpunctcre, 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
106
elevated creatinine clearance rate usually has little diagnostic

significance.
Erythrocyte Sedimentation Rate
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
• To aid in diagnosing occult disease such as tuberculosis and

connective tissue disease
• To monitor inflammatory and malignant disease.

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 accerelating 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.
107
Purpose
• 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

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 venipunctcre 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.
List out the purpose of glucose fasting plasma.
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 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.
108
Hyperglycemia can also stem from chronic hepatic disease, brain

trauma, chronic
3.3 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.
Purpose
• To measure CSF pressure and to detect possible obstruction of

CSF circulation.
• To aid in diagnosing viral or bacterial meningitis, and
subarachnoid or intracranial hemorrhage, tumors, and abscesses.
• 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. Make sure the patient has signed a consent
form. 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
109
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
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:
110
Element Abnormal Result Possible Causes

CSF Pressure - Increase - Increased Intracranial Pressure
- Decrease - Spinal subarachinoid obstruction
above puncture site.
Appearance - Cloudy - Infection

- Xanthochromic - Elevated protein level or RBC
breakdown.
- Bloody - Subarachinoid, intracerebral, or
intraventricular haemorrhage;
spinal cord obstruction; traumatic
puncture
- Brown - Meningeal melanoma
- Orange - Systemic carotenemia
Protein - Marked increase - Tumor, trauma, haemorrhage,

Diabetes mellitus, polyneuritis,
blood in CSF.
- Marked decrease - Rapid CSF production
Gamma globulin - Increase - Demyelinating disease (such as

Multiple sclerosis),neurosyphilis,
Guillain-Barre′ syndrome
Glucose - Increase - Systemic hyperglycemia

-Decrease - Systemic hypoglycemia, bacterial
or fungal infection, meningitis,
mumps, postsubarachinoid
hemorrhage.
Cell count - Increase in WBC count - Meningitis, acute infection, onset

of chronic illness, tumor, abscess
infarction, demyelinating disease
-RBC present - Hemorrhage or traumatic puncture
Source: Cynthia, Breuninger, Ginnona,, & Mintzer, 1994.
Nurse’s Pocket Companion.
3.4 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 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.
111
3.5 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:
• Completely immerse all reagent areas of the strip in fresh, well-

mixed, uncentrifuged urine and remove immediately.
• 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.
• 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.
112
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
(i) Benedict’s Qualitative Test
Equipment: Bursen 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
(ii) Fehling Test
Equipment: Bursen burner, test tube, fehling solution A & B.
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
(i) 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
113
degree of cloudiness gives some idea of the relative protein

concentration.
(ii) 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: Bursen 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 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 bursen 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
(i) Acetest Reagent Tablets
Equipment: Acetest tablets (Acetest tablets contain sodium

intropusside, 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
114
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.
(ii) 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
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
(i) 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.
(ii) 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
115
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.
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
116
specimen. Collect a random urine specimen preferably in the morning,

label it (including the time), and send to laboratory.
24 Hours Urine Collection
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).
3.6 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.
Indications: Chest films can indicate the following alterations and

diseases:
• 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.
117
• Air accumulation in the lungs (chronic obstructive pulmonary

disease, emphysema); and pleura (pneumothorax).
• 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 (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.
Mention at least five (5) abnormalities which chest examination can

reveal.
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.
118
4.0 CONCLUSION
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 SUMMARY
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
.
• 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
• 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
119
Discuss you’re the nursing roles before, during and after the following
diagnostic investigations: (a) Lumber puncture (b) Fasting blood sugar,
and (c) Sputum studies.
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,
Roper, N. (1984). Churchill Livingstone Pocket Medical Dictionary

(13th ed.). New York: Churchill Livingstone Inc.
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
120
UNIT 4 PROVIDING SAFETY AND COMFORT I
CONTENT
1.0 Introduction
2.0 Objectives
3.0 Main Content
3.1 General Safety Rules and Practices
3.2 The Role of the Nurse in Moving and Handling Patients
3.3 Control of Infection
3.4 Commonly Employed Comfort Measures in the Hospital
4.0 Conclusion
5.0 Summary
1.0 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 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.
2.0 OBJECTIVES
• outline the general safety rules and practices in the health care
setting
• describe the role of the nurse in moving and handling patients
including principles underlying moving and lifting of patients
121
• give examples of risks in a health care setting and suggest

preventive measures
• describe the role of the nurse in infection control
• describe the different comfort measures employed in patient’s
care in the hospital and explain their underlying principles.
3.0 MAIN CONTENT
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:
• Walk rather than run – especially on stairs and along corridors.

• Open doors slowly. Do not open a door by pushing on the glass
part.
• 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.
• Installing safety devices, wherever practicable including cautious
use of bedside rails.
• Ensure adequate lighting by illuminating areas in which people
move and work.
• 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.
• Do not engage in horseplay or practical jokes.
• 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.
• Remember the elderly and the very young are more accident-
prone than the adult. Protect them as much as possible.
• 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.
• Provision for refuse collection and proper waste disposal to
maintain hygienic condition.
• Ensure proper bed spacing is maintained.
• Maintaining aseptic technique for all invasive procedures.
122
• Appropriate institution of isolation techniques and barrier nursing

in infectious cases.
• Periodic fumigation of hospital ward and surgical theatres.
• Never overload an electric socket and avoid using defective
electric equipments.
• 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.
• Obey all NO SMOKING signs. Never smoke or permit anyone to
smoke in the vicinity of oxygen equipment that is in use.
• When smoking in designated areas, see that cigarettes are
completely extinguished in receptacles provided.
• Report any injury to self or to others immediately and secure first
aid.
• 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.
• 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.
• 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)
Activity 1
Quickly recap some of the safety rules and practices in the hospital.
3.2 The Role of the Nurse in Moving and Handling Patients
In professional nursing practice there will always be the need to move

patients or heavy equipments 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,
123
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:
• Keep as close as possible and safe to the object to be lifted.

• Maintain a good base of support.
• Keep the back as vertical as possible.
• 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.
Here are additional safety tips or precautions that must be observed in

the health care setting:
• 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.
• 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.
• When going down an incline, guide the stretcher from the foot
and proceed slowly.
• Check restraining straps for proper fastening.
• Never lift a patient who is too heavy without assistance.
• Never leave a paralyzed patient alone in the bathroom or in bed
with the side rails down.
• Never leave a paralyzed or helpless patient sitting in a chair
without a protective restraint around the waist.
• 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).
124
3.3 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
inapparent/symptomatic/subclinical infection. It could be 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 large-particle
aerosols (droplets) like measles, mump and other acute
125
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, equipments 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.
• Others are: Adequate Bed-Spacing; Proper Waste Disposal;

Health Education e.t.c.
3.4 Commonly employed Comfort Measures in the Hospital
(a) Bedmaking
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).
126
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.
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 Bedmaking
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
127
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 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 bedmaking. 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 Bedmaking
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 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.
128
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.
Bedmaking: 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 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.
129
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
Important Steps Reasons for Action

1. Wash your hands before Unclean hands may spread
selecting linens; then take disease germs to clean linen, and
everything needed next to to patient who is to be to and
patient's unit. pillowcase.
2. Place linen on straight chair Stacking linens in this manner
near foot of bed. Stack the saves time and effort later on.
items in order 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 The higher level will cause less
position and is flat and that strain on back and leg muscles.
wheels are locked.
4. Place the folded quilted Lifting and shaking any item of
mattress pad on near side of linen may stir up dust and lint
bed and unfold it without which may which may carry and
lifting or shaking it out disease-causing organism.
5. Place folded sheet on near Also lifting and flapping linen at
side of bed and unfold it shoulder level to unfold it causes
lengthwise in the same unnecessary strain and fatigue on
manner described above, that the back, shoulder, and arm
is without shaking or flapping muscles.
130
it out.
Arrange sheet in this way:
(a) With bottom hem even Placing the bottom sheet

with foot of mattress, correctly is the most important
depending on length of sheet. step in bedmaking.
(b) Allow 15 to 18 inches at The Foundation sheet should be

head of bed tuck under secure against anything that
mattress. 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 Covering foot of mattress is far

center of bed, fanfold the far less Important.
half of sheet beyond the center
of bed. The sheet is doubled back on
itself in folds of several inches -
like a fan.
Placing this foundation sheet

straight on the bed is also
important. A sheet that is even
just a little crooked, on the base,
will always have wrinkles.
6. Lift the head of mattress with If you face in the direction of
one hand and pull sheet under your work and move along in this
the mattress with the other position, you will Avoid twisting
hand. See that material is groups of muscles, thus reducing
smooth after tucking under. strain and fatigue.
7. Make a mitered corner at
head of mattress.
8. Continue tucking sheet under Move along with your work,
side of mattress from head to facing side of mattress as you
foot. tuck sheet from head to foot of
bed. Keep feet slighty separated.
9. If rubber draw sheet is used, Where plasticized mattresses are
place it about 12 to 15 inches used, it is often the policy to omit
from head of mattress. Tuck a waterproof sheet. It is
smoothly under mattress on sometimes placed over the
near side. mattress and under the quilted
mattress pad.
10. Cover rubber sheet with Lying directly on even a small
cotton draw the sheet or a strip of rubber sheet will be
large sheet folded once may uncomfortable and cause skin
131
cross-wise. Place this irritation to patient.

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 You may be taught to make on
tuck bottom sheet smoothly entire side of the bed before
under head of mattress. Make going to the other side. If careful
a mitered corner. attention is given to unnecessary
motion and energy there may not
be much difference.
13. Grasping bottom sheet with By keeping your feet slightly
both hands, tuck under separated and your back straight,
mattress along side of bed, you will reduce strain.
tightening and smoothing it,
as you Move from head to
foot of bed.
14. Pull rubber draw sheet (at When holding the sheet with
center of bed) toward you and palms downward, the strong
smooth it out. Grasp with both muscles of the shoulders and
hands, holding palms arms are used. Keep one foot in
downward on level with front and rock backward on the
mattress; tighten the sheet and other, as you tighten the sheet.
tuck 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:
16. Continue on same side of bed. If wrong side of them is up, when
Place the folded top sheet on the top edge of the sheet is turned
near side of bed and unfold it down over the edge of bedspread,
in the manner described the right side of hem will show.
earlier. Arrange it this way:
(a) with upper edge of sheet

even with head of mattress.
132
(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 Allow the top covers to hang
mattress at foot of bed. Make free at side of bed.
a corner on 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.
21. Rest the pillow on foot of bed
If pillowcase is considerably
and draw on pillowcase - in wider than the pillow, tuck the
this way: and grasp the inside
excess material into a smooth
seam at end of case. fold on one side, making the case
fit well over the pillow. Keep this
(a) Slip your hand inside tuck in place when placing on
pillowcase and grasp the bed.
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
133
23. If you wish to "open" this bed, Opening the bed, that is, turning
here is one of various ways it the covers down, makes it look
might be done: more inviting to the patient
sitting for a time in a chair. If
(a) With both hands grasp the your patient has gone to a
upper edge of the top covers; treatment room or X-ray
carefully bring your arms Department, it will be easier to
toward foot of bed, until the assist him back in bed.
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.
24. If you wish a "closed" bed for The steps of this procedure lend
a patient not yet admitted, the well to learning good body
upper edge of bedspread is left mechanics. There is a certain
even with the head of rhythm that can be developed
mattress. 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.
134
Equipments 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.
135
Important Steps Reasons for Action

1. Wash your hands before If this procedure follows the
selecting linens. Take patient's bath, start with step 5 and
everything needed to loosen all the lower sheets. The
patient's unit and stack items reason is that the clean linen will
on chair in order of use. 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 If patient is not familiar with this
on near side of bed and step for removing sheet, tell him
unfold it over top sheet If what you will do, so that he can be
patient is not too ill, ask him sure that he will not be exposed.
to hold the top edge of bath
blanket.
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.
9. Bring the top and bottom Shaking and flapping linens
hems together and fold the (especially used linen) stirs up dust
sheet on lower part of bed and lint which carry disease-
without shaking it out. causing organisms into the air.
10. Place folded top sheet on This top sheet will be used again as
back of chair. a bottom sheet or to cover rubber
136
draw sheet.
11. Go to other side of bed and It is much easier to remove sheets
help patient move toward and replace them if there are no
you, then turn him to side- pillows on the sheets. However,
lying position, facing you. one pillow can be managed, if
Position him in good patient is uncomfortable without it.
alignment without pillow, if
this is not too uncomfortable
for him.
12. Raise the side rail on that If patient is turned away from you
side of bed before returning to his side, he may just keep on
to your 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 These sheets are folded separately
sheet smoothly to the back Because each will be removed later
of patient. (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.
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 mattress with it. Face the direction of your work
and move Keep back straight but
(b) Allow 15 to 18 inches at not rigid; bend at hips. Knees
head of mattress. should be slightly flexed and feet
apart throughout action.
(c) With bottom hem even
with foot of mattress.
This sheet will be placed under the
patient later. Do not wrinkle or pull
(d) Fanfold far half of sheet
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
137
the other hand.

18. Make a mitered corner at
head of mattress.
19. Tuck sheet smoothly under
mattress along side 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.
21. Straighten the rubber sheet Make sure that rubber sheet will
in place and tuck it under never be next to patient's skin,
mattress at 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 Try to keep the patient's body in as
and lower legs in your arms good ' alignment as possible. It will
and move towards you over be much - less strain on him. Also,
the "bump" of folded line it will cause you less strain and
(Keep edges of the bath fatigue, if you keep your back
blanket folded up on the straight your knees slightly flexed.
patient so it will be out of Keep one foot a little in front of the
the way of patient's other. This allows you to use the
movements and your long strong thigh muscles rather
action). 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.
138
26. Reach over the patient and If patient has a drainage tube of
push folded sheets away any kind, see that there is enough
from patient's back toward slack in tube for turning.
the far side of bed.
27. Raise the side guard on your Use these side guards if available
side, then go the other side because the patient may misjudge
of bed. the width of bed and move to near
edge.
28. Lower side guard. Starting Hold linens away from uniform
with soiled bottom sheet, and drop in laundry hamper.
fold and bunch it as you
remove it from the bed.
29. Remove and discard cotton If patient is becoming
draw sheet in the same uncomfortable Without a pillow,
manner. 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 along side 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 tugging in place over rubber sheet.
at this step. it with both If you lift the draw sheet up higher
hands (palms down), hold it than mattress level, you may cause
at level with mattress. Pull it the patient to roll out of bed. The
tightly, but without lifting it cause and effect of this is
up, and tuck under side of something like using crowbar to
mattress. pry up a heavy object.
33. Place clean top sheet on near
side of bed and unfold it on
blanket top of bath blanket
34. Have patient hold upper This is done to prevent exposing

edge of sheet while you fold patient. At the same time, folding
bath blanket to foot of bed the blanket toward the foot of bed
and remove it. under the top sheet does not stir up
dust.
139
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 Tight top covers not only are
blanket, if used) under foot uncomfortable for patient's feet but
of mattress, make a toe pleat may cause a serious condition. If
to allow room for patient's the feet are restrained in a forward
feet. When blanket is used, position over a period of time, the
make the pleat in sheet and muscles of he soles of the feet are
blanket together. The toe weakened. Th1s results in a serious
pleat may be made in this deformity called drop foot.
way.
Note: The other types of bed making will be discussed in some other
units.
(B) 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 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
140
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.
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:
• Cleansing Bath: - Tub bath or showers

- Partial bath
- Complete bed bath
• Therapeutic Bath: - Sitz bath
- Emollient bath or medicated bath
141
Cleansing Bath: The Objectives of cleansing bath are to:
• promote hygiene and comfort for the patient

• observed the patient’s skin condition
• assess the patient’s range of motion.
• encourage the patient to be as independent as possible on allowed
• assess the patient’s physical and mental status
• establish a communication pattern between patient and nurse that
promotes health teaching and expression of patient concerns.
Providing a Tub Bath or shower
Equipments: - 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
consciousness, orientation, patient’s ability to carry out
strength, and mobility hygiene practices independently.
• Check for gauze dressings, Contraindicates taking a tub bath

plaster cast, or electrical or or shower.
battery 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
cleanliness of the tub or shower care.
(b) Planning
• Clean tub or shower if it Reduces the potential for spreading
appears to need it microorganisms.
• Consult with patient about a Facilitate cooperation between the
convenient time for tending to patient 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 Show concern for the patient’s
142
or bathroom safety
• Demonstrate how to operate Ensures the patient’s safety and
water faucet and drain comfort.
• 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 temperature.
• Place a DO NOT DISTURB or Ensures privacy
IN 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.
• 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 &
room on completion of the bath welfare.
or shower.
• Clean the tub or shower with Reduces the spread of
antiseptic/antibacterial agent and microorganism and demonstrate a
dispose off the soiled linen in its conscientious concern for the
designated location. person who will use the tub shower
or.
• Remove the IN USE sign from Indicates that the bathing room is
the door. unoccupied.
(d) Evaluation
Patient is clean; Patient remains
143
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. 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
• Following a vaginal delivery or gynecologic or rectal surgery, so

that the impaired skin is kept as clean as possible.
• 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
1. Prevents direct contact between the nurse and the secretion or

excretion that may be present, and
2. 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
144
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).
Quickly recap the indications for perineal care.
Indication
• The sitz bath is used to relieve discomfort, congestion, or

inflammation in the pelvic and rectal regions.
• Promotes phagocytosis through increased peripheral vasodilation.
• Stimulate formation of new tissue through increased blood
supply.
• Promote relaxation of local muscles.
• 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 the genital and rectal Provides data for determining if
areas of the patient. perineal care is necessary.
(b) Planning
• Explain the procedure to the Reduce anxiety and promote

patient. cooperation
• Wash your hands. Reduces spread of
microorganisms.
• Gather equipments. Demonstrate organization and time
management.
• Place the patient in dorsal Provides access to the perineum.
recumbent position and cover
145
with a bath blanket.

• With gloved hands remove soiled Soiled dressing are contaminated
dressings and disposed off
properly.
• Consult the patient’s folder for Engenders accuracy and enhances
prescribed water temperature. maximal Benefits from treatment.
(c) Implementation
• Check the temperature of the Facilitates bath and prevent

water with your bath possible one-third full with warm
thermometer as you fill the tub water.
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 his Promotes safety.
bathrobe and have him sit on the
bath towel.
• Take the bath blanket and drape Helps in avoiding chilling which
it around vasoconstriction. may cause the patient. Pin the end
together at the back.
• If indicated, place rubber ring in Sitting the patient on rubber ring
bathtub. will relieve Pressure and
discomfort if he has rectal or
Perineal sutures or pain.
• Help the patient get into the tub. Reduces the risk of falling and
Take the towel the patient was sustaining injury.
sitting on and place it under his
buttocks.
• Check the water temperature Fluctuations in water temperature
from time to time and add warm can cause cardiovascular stress.
water as required.
• After the prescribed time for Maximum benefit is obtained
treatment has elapsed, usually 20 within the first 20 minutes.
– 30 minutes, help the patient out Prolonging the procedure tires the
of the bath tub. patient and increases chances of
cardio-vascular stress.
• If necessary or requested by the Demonstrate concern for welfare.
patient, help him to dry himself
and put on a clean gown.
• Help the patient to return to bed. Promotes comfort.
See that the bed is dry and warm.
Arrange the bedding for patient’s
comfort.
146
• Return to bathroom. Wash the tub, disinfect Reduces

the spread of microorganism
it, if necessary.
• Return to bathroom. Wash the Reduces the spread of
tub, disinfect it, if necessary. microorganism and demonstrate a
Place used towels/washcloths in conscientious concern for the next
the hamper. Treat rubber rings as person who will use the tub.
instructed and return it to
designated storage.
(d) Evaluation
• Note and document the patient’s total reaction Helps in monitoring
patients response to treatment, including the colour of skin, therapy.
The write-up serves as a vehicle pulse and respiration. In addition note
the of 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.
4.0 CONCLUSION
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 is going to be a recurring theme throughout the period of
your training and beyond.
5.0 SUMMARY
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
147
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.
Following a vaginal delivery or gynecologic or rectal surgery, so that the

impaired skin is kept as clean as possible.
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
Describe the different comfort measures employed in patient’s care in

the hospital and explain their underlying principles.
Fuerst, E.V.; Wolff, L.U. & Weitzel, M. H. (eds.). (1974). Fundamentals

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,
Parboteeah, S. (2002). Safety in Practice. In R. Hogston & P. M.

Simpson (eds.). Foundations of Nursing Practice; Making the
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.
148
UNIT 5 PROVIDING SAFETY AND COMFORT II –

PAIN MANAGEMENT
CONTENTS
1.0 Introduction
2.0 Objectives
3.0 Main Content
3.1 Nature and Concept of Pain
3.2 Prejudices and Misconceptions
3.3 Types of Pain
3.4 Causes of Pain
3.5 Pain Perceptions and Reaction or Response
3.6 Pain Management
4.0 Conclusion
5.0 Summary
1.0 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 discusses pain
in its entirety with particular focus on pain management strategies.
149
2.0 OBJECTIVES
• discuss the nature and concept of pain

• identify major causes of pain
• differentiate between acute and chronic pain
• discuss common misconceptions about pain
• outline factors influencing people’s response to pain
• discuss pain-relieving strategies.
3.0 MAIN CONTENT
3.1 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 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
150
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.
3.2 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:
• Drug abusers and alcoholics overreact to discomfort.

• Patients/Clients with minor illnesses have less pain than those
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.
• Health care personnel are the best authorities on the nature of the
patient’s/client’ pain.
• 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.
List out the prejudices and misconceptions people have about pain.
3.3 Types of Pain
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
151
(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 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
152
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 promote patient’s 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)
3.4 Causes of Pain
There are many causes of pain. According to Cheney-Stern, (1995) these

causes can be broadly grouped into three viz:
153
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. Can be as severe as pain from a physical
cause.
3.5 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-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.
154
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 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.
155
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 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 In 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, it has been suggested that the
nurse employs simple but appropriate communication techniques to
enhance their understanding and description of pain. The nurse may
156
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.
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
157
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.
What are the factors that influence individual’s perception of pain?
3.6 Pain Management
On a general note nursing interventions at relieving clients 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, application of liniment, hot and
158
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, 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).
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
159
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. Therefore the nurse
needs to reduce disturbing stimuli. Some distraction techniques are:
• 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, 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.
• 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.
• 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.
• Active listening: - The client listens to music and concentrate on
the rhythm by taping a finger or foot.
• 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.
160
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 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 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.
161
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:
• Occurrence, onset and expected duration of pain

• Quality, severity and location of pain
• Information on how the client’s/patient’s safety is ensured
• Cause of the pain
• Methods that the nurse and client/patient use for pain relief.
• 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 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
162
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.
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:
• Non-narcotic Analgesic – Provides relief for mild to moderate

pain. Example includes Paracetamol.
• 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.
• 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
163
hydrochloride raises the pain threshold and at the same time

reduces associated fear and anxiety, thereby reducing pain
perception.
• 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.
4.0 CONCLUSION
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 SUMMARY
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
164
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.
• Drug abusers and alcoholics overreact to discomfort.

• Patients/Clients with minor illnesses have less pain than those
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.
• Health care personnel are the best authorities on the nature of the
patient’s/client’ pain.
• Psychogenic pain is not real.
Family and social support, Neurological status, Attention and

distraction, Fatigue, Previous Experiences, Anxiety, Culture,
Sex/Gender and Age.
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?
165
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

Psychophysiologic 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

Gil, K. (1990). Psychological Aspects of Acute Pain. Anesthesiol Report

2(2): 246.

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/Acupunture/ 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.
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.
166
MODULE 3
Unit 1 Infection Control

Unit 2 Ethical Issues in Nursing
Unit 3 Legal Aspects of Professional Nursing I
Unit 4 Legal Aspects of Professional Nursing II
Unit 5 Sexuality and Gender Issues
UNIT 1 INFECTION CONTROL
CONTENTS
1.0 Introduction
2.0 Objectives
3.0 Main Content
3.1 Infection Phases
3.2 Types and Chain of Infections
3.3 Predisposing Factors to Infection
3.4 Infection Control
3.5 Nursing Management of Person with Infection
4.0 Conclusion
5.0 Summary
1.0 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 hosts resistance. The outcome is determined by the
ability of the micro-organism to adhere, invade and damage the host
versus the hosts defence mechanism. It may be severe or mild.
There are various groups of micro organism 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 micro organism which lives on the skin or mucus
membrane. The micro organisms 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.
167
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.
2.0 OBJECTIVES
• describe the course of infection

• enumerate the chain of events which link the reservoir of
infectious agents with the susceptible host
• discuss the factors that predispose one to infection
• analyze the measures for infection control.
3.0 MAIN CONTENT
3.1 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 micro organism to the body and
the initial clinical manifestation of the infection. At this stage, the micro
organism 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 micro organism. The duration of the acute
illness varies from few hours to weeks and the disease.
168
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.
1. Mention 5 groups of micro organisms that causes infection

2. Who is a carrier?
3.2 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).
Chain of Infection
Infection results from chain of events which link the reservoir of

infection agents with the susceptible host. These are:
• Mode of escape from the reservoir.

• Means or route of transmission.
• Models of entry into the susceptible host.
169
The chain of event is hereby represented diagrammatically:
Causative agent
Bacteria, viruses, fungi, protozoa,
Parasitic worms
Reservior
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
Formites or inanimate objects.
*Chain of infection
3.3 Predisposing Factors to Infection
The manifestation of infection in any host is dependent on the following

factors:
i. 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.
ii. Occupation
Certain occupation provides increased exposure to infection than others

e.g. industrial, sea and hospital workers
170
iii. 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.
iv. Nutritional Imbalance
Protein and caloric undernutirtion is a prevalent cause of impaired cell

media led immunity. Without the required nutrients and energy the
production of antbodies, 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.
v. Stress
Naturally occurring persistent stress accompanied by poor coping alters

the body’s immunocompetence. (See unit 8 on stress and adaptation).
vi. Drug and Other Therapeutic Intervention
Some commonly used antibiotics may impair immune functions. All

drugs are capable of initiating a hypersensitivity reaction.
vii. Life Style
Life behaviors/style such as smoking, drinking and indolence can

precipitate infection.
Activity 2
• Considering the aforementioned factors, did any of the factors

applied to you when last you had an infection?
• What precautionary measures did you take?
3.4 Infection Control
Infection control is the effort made to maintain a micro organism 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
micro organism which may cause infection. The secreted mucus like
171
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 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) co-agulates protein within the cell. Sterilization
becomes effective when the heat is sufficient to destroy the micro-
organism.
172
Radiation: Non-iodizing and ionizing radiation are used for physical

sterilization and disinfection. They cause the death of microorganism by
altering their essential metabolic processes. The most common type of
non-ionizing radiation is the ultra violent 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.
1. Give 3 examples each of physical and chemical method of

sterilization.
2. What is the major difference between barrier nursing and
isolation?
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.
3.2 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:
(vii) physical and social isolation

(viii) altered nutrition
(ix) alteration in comfort
(x) Maintaining functioning of others body systems.
(xi) Alteration in self management.
Reading Assignment: Read this further in the recommended textbook

and discuss within your study group.
4.0 CONCLUSION
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
173
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.
5.0 SUMMARY
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.
A carrier is one who has no symptom of a disease but harbours the
infectious agent.
1. Dry heat, Radiation and Steam. (Physical).

Liquid solution/gases e.g. Ethylene Oxide, Chlorine Compounds,
Hibitane Lotion and Metylated Spirits. (Chemical).
2. Nursing a patient in an open ward while every item being used
for him or her is strictly kept and use exclusively for him/her.

What are nosocomial infections? Identify eight (8) ways of controlling
nosocomial infections?

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.
174
UNIT 2 ETHICAL ISSUES IN NURSING
CONTENTS
1.0 Introduction
2.0 Objectives
3.0 Main content
3.1 History of Nursing Ethics
3.2 Development of Nursing Codes of Conduct
3.3 Ethical Concepts Applied to Nursing
3.4 Patients Bill of Rights
3.5 Interrelationship of Ethics and Law
4.0 Conclusion
5.0 Summary
6.0 Tutor Marked Assignment
1.0 INTRODUCTION
In the last unit, we examined sexuality and gender in relation to nursing

practice. Two major factor that influences sexual attitudes a re 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 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.
2.0 OBJECTIVES
• enumerate the elements in Patients’ Bill of Rights that has ethical

concerns
175
• identify the differences between ethical and legal concerns of

nursing practice
• describe clients’ expectation which has implications in the face of
professional negligence.
3.0 MAIN CONTENT
3.1 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 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 patients 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.
Clearly differentiate between ethics and etiquette.
176
3.2 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 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
• 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.
• The nurse safeguards the client’s right to privacy by judiciously
protecting information of a confidential nature.
• 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.
• The nurse assumes responsibility and accountability for
individual nursing judgments and actions.
• The nurse maintains competence in nursing.
• The nurse exercises informed judgments and uses individual
competence and qualifications as criteria in seeking consultation,
accepting responsibilities and delegating nursing activities to
others.
• The nurse participates in activities that contribute to the ongoing
development of the professions’ body of knowledge.
• The nurse participates in the professions efforts to implement and
improve standards of nursing.
• The nurse participates in the profession’s efforts to establish and
maintain conditions of employment conducive to high – quality
nursing care.
• The nurse participates in the professions’ efforts to protect the
public from misinformation and misrepresentation and to
maintain the integrity of nursing.
177
• 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.
a. 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?
b. Discuss your opinion with others and check it in line with the
code of conduct for nurse number 2.
3.3 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.
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.
178
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.
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.
3.5 Patients Bill of Rights
2 Bill of Rights developed include:
• A patient’s bill of right developed by the American Hospital

Association in 1973.
• A Consumer Rights in health care published in Canada by the
National Consumers Association.
Patient’s Bill of Rights states the following:
• The patient has the right to considerate and respectful care. He

has the right to an explanation to what is happening.
• 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).
• 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.
• 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.
179
• Patient has the right to every consideration of his privacy

concerning his own medical programes.
• Patient has the right to expect that all communications and
records pertaining to his care should be treated as confidential.
• Patient has the right to expect that within its capacity a hospital
must take reasonable response to the request of a patient for
service.
• The patient has the right to be advised if the hospital propose to
engage in or perform human experimentation affecting his care or
treatment.
• Patient has the right to expect reasonable continuity of care.
• Patient has the right to examine and receive an explanation of his
bill regardless of source of payment.
• Patient has right to be informed of hospital rules and regulations
applied to his conduct as a patient.
• A disabled person has the right to treatments.
• A disabled person has the right to economic and social security
and to a decent level of living.
• A disabled person has the right to live with their families and
participate in all activities.
• A disabled person shall be protected against all exploitations.
• 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.
• The pregnant patient has the right to be accompanied during the
stress of labour for and who cares for her.
• 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:
1. Who gives what information?

2. To whom is the information given?
3. When is it appropriate to give it?
Activity 1
Quickly recap eight (8) of the Bill of Rights off hand. Of what use is
information to the nurse and patient?
180
3.7 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.
1. Mention 2 congruent situations:………………………………….

2. Mention 2 conflict situations:…………………………………...
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:
• 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.
• 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.
• 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.
• A reasonable compromise or acquiescence to a majority decision
by the nurse and lawyer may be in the overall best interest of all.
181
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.
4.0 CONCLUSION
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 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.
5.0 SUMMARY
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.
Ethics are virtues and rules governing practice. Etiquettes deals with
respect to constituted authority.
Alley her fears, be sympathetic and empathetic, Use your observed signs
to counsel her and provide full participation through answering of
questions.
Congruent situations are 1 and 4. While Conflict situations are 2 and 3.
182
List the fourfold fundamental responsibility of ethical concepts for

nurses. Briefly state the International Council of nurses’ code of ethics.
Davis, A.J. et al (1996). Ethical Dilemmas Nursing Practice: Appleton

and Lange, Stamford, (4th ed.).
Davis, A.J. Krueger J.C. (1980). Patients, Nurses, Ethics. New York:
American Journal of Nursing Co.
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 Rights, Washington, DC: ANA 1994.
183
UNIT 3 LEGAL ASPECTS OF PROFESSIONAL

NURSING I
CONTENTS
1.0 Introduction
2.0 Objectives
3.0 Main Content
3.1 Nature of Law
3.2 Sources and Types of Nigerian Law
3.3 Functions of Law in Nursing and the Legal
Responsibilities of Professional Nurses
Regulation of Nursing Practice in Nigeria
Contractual Arrangements in Nursing
4.0 Conclusion
5.0 Summary
1.0 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.
2.0 OBJECTIVES
• describe the legal framework and how laws are adapted

• discuss the impact of law on nursing practice
• enumerate legal responsibilities of nurses in delivering client care
• explain legal concepts that apply to nurses.
3.0 MAIN CONTENT
3.1 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
184
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. Bernzweig (1996) defined it as ‘those
rules made by human, which regulate social conduct in a formally
prescribed and legally binding manner’.
3.2 The Sources of Nigerian Law
Nigeria laws has its origin primarily from two sources namely:
a) Nigerian Legislation, which consist of:
• 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.
• The Constitution – This is an embodiment of principles upon

which any state (i.e. nation) is governed. A document written or
unwritten containing a 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.
• 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.
• 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.
• 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.
185
(b) Received English Law, which encompasses:
• 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.
• 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.
• Statutes of General Application in force in England on January

1, 1960.
• 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:
(a) Constitutional Law – The laws of the federal republic of Nigeria

is set forth in the Nigerian constitution.
(b) 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.
(c) 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 institute a criminal action in the
186
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).
(c) 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 unlike the criminal case, civil suit
can be withdrawn from the court by the parties and be settled out-of-
court.
(d) 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.
187
3.3 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:
(e) It provides a framework for establishing which nursing actions in

the care of clients are legal.
(f) It differentiates the nurse’s responsibilities from those of other
health professionals.
(g) It helps establish the boundaries of independent nursing action.
(h) It assists in maintaining a standard of nursing practice by making
nurses accountable under the law.
(i) It serves as a professional update of client’s/patient’s legal right.
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:
• 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.
• Discuss with the client the associated risks and outcomes inherent
in the plan of care as well as alternate treatment modalities.
• Maintain clinical competence and refuse to carry out orders that
would be injurious to client.
• 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),
188
this type of legal relationship creates the ancient legal doctrine known as
respondeat 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).
3.4 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 professional
standard, training and discipline.
3.5 Contractual Arrangements in Nursing
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
189
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:
• A gentle man’s agreement.

• Agreement between family and friends relating to purely social or
domestic matters.
• An agreement to marry commonly known as engagement.
• Agreement made under duress.
Essentials of a Contract: A valid contract requires the following five

elements
• Offer
• Acceptance – the assent of the parties/persons involved.
• There must be a valid consideration or something of value, in
most cases financial compensation for fulfilling the terms of the
contract.
• 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.
• Intention to enter into a legal relationship which in most cases are
presumed by the parties’ conducts, must be manifestly seen.
4.0 CONCLUSION
5.0 SUMMARY
The unit opens with a succinct background to the need for nurses to
become conversant with legal concepatients 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.
190
Outline the need for Law in professional practice today and the legal
responsibilities of a professional nurse. Discuss the concept of
contractual agreement in Nursing.
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
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: Concepatients
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.
191
UNIT 4 LEGAL ASPECTS OF PROFESSIONAL

NURSING II
CONTENTS
1.0 Introduction
2.0 Objectives
3.0 Main Content
3.1 Selected Legal Aspects of Nursing Practice
3.2 Liability in Nursing Practice
3.3 The Nurse and the Criminal Law
3.4 Legal Safeguards for Nursing Practice
4.0 Conclusion
5.0 Summary
1.0 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 concepatients as they affect the practice of
her profession.
2.0 OBJECTIVES
• explain legal concepatients that apply to nursing

• identify areas of potential liability in nursing practice and actions
nurses can implement to avoid these problems
• differentiate between unprofessional conduct and negligence
• distinguish between tort and crime
• explain the role of the nurse in the informed consent process.
• discuss how privileged communication applies to the nurse-client
relationship
• discuss advance directives and differentiate between living will,
directive to physicians, and durable power of attorney.
192
3.0 MAIN CONTENT
3.1 Selected Legal Aspects of Nursing Practice
(a) 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 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
- Notifiable diseases
- Vital statistics such as births and deaths
(ii) With the consent of the patient.

(iii) 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.
(iv) Where the interest of the health personnel requires it, for instance
patients refusal to pay bill.
(b) 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
193
him after complete 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:
• Tubal ligation in a grand multiparous woman whose attitude

suggest acceptance of procedure.
• During surgery when additional procedures are needed that are
consistent with the procedure already consented to.
• 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:
• Witnessing the exchange between the client and the physician

• Establishing that the client really understands i.e. was really
informed.
• 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.
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?
194
• The consent must be given voluntarily, not coerced.

• The client must be of age of maturity and must be mentally
competent.
• 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:
• The purposes of treatment

• What the client can expect to feel or experience
• The intended benefits of treatment
• Possible risks or negative outcomes of the treatment
• 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:
• Prisoners – No legal right in court

• On a court order – If the court orders that certain procedures be
carried out on a client.
• Immigrants – Screening procedure to ensure safety of citizens.
• Milk and Food Handlers- Screen procedures for the health of the
generality of people.
(c) 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?
(d) 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
195
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:
• A living Will – This a written and legally witnessed document

prepared by a competent adult instructing health workers to
withhold or withdraw life-sustaining procedures in a person in
event of the person’s incapacitation or becoming unable to make
decisions personally.
• 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.
• 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?
• Understand the different types of advanced directives.

• Know the laws relating to the patient Self-Determination Act.
• Obtain assistance if the patient wishes to change an advanced
directive, as the person’s health or desires change.
• Teach patient so informed decisions can be made.
• 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).
3.2 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 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
196
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 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:
• Owe a duty of care (contractual engagement)

• Breach of the duty of care
• The client suffers an injury or loss
• 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
197
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.
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:
• Where the nurse commit clear cut professional mistakes.

• 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.
• In cases of visiting nurses who have been selected with due care
but are not servants of the hospital governor.
• 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 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
198
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 client’s/patient’s cultural values, beliefs, and practices
and ethnic orientation. In the U.S, as a 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
199
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 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.
3.4 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 deaths.
Manslaughter in the second degree involves culpable negligence of a
drunken doctor or nurse.
200
4.0 CONCLUSION
The significance of law in professional nursing practice cannot be

overemphasized. The fact that ignorance is not a defense in law has
therefore makes it mandatory for nurses to acquaint themselves with
legal concepatients and issues relating to their practice. In pursuance of
this lofty objective, this unit has provided a compendium of legal issues
emanating from nurse-patient and nurse-employer’s relationship. It is
believed that if attention is given to these seemingly trivial but delicate
issues, nurses will be able to wade off a lot of potential litigations.
5.0 SUMMARY
It contends that all nurses must know the law that applies to their area of
practice.
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.
2. It is no exaggeration that nurse is the closest set of health
practitioners to the patients and indeed the group that stay longest
with the patients. However, this in itself tends to open them to
liabilities. As a nurse clinician, give a succinct discussion of legal
safeguards in nursing.
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

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.
201
Kozier, B.; Erb, G.; Berman, A.U. & Burke, K. (eds.). (2000). Legal
Aspects of Nursing. Fundamental of Nursing: Concepatients
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.
202
UNIT 5 SEXUALITY AND GENDER ISSUES
CONTENTS
1.0 Introduction
2.0 Objectives
3.0 Main Content
3.1 Concept of Sexuality
3.2 Sexual Anatomy and Physiology
3.3 Attitudes towards Sexuality
3.4 Sexuality Counselling
3.5 Disorders of Sexuality
3.6 Sexuality and Nursing Process
4.0 Conclusion
5.0 Summary
1.0 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 well being. In the face of this recognition, there is
still lack of 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.
203
2.0 OBJECTIVES
• state the concept of sexuality and gender identity

• identify various attitudes towards sexuality
• discuss the nursing intervention in relation to sexuality and
gender issues.
3.0 MAIN CONTENT
3.1 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 with
female or male genitalia social roles is the main ingredient to the
emergence of sexuality.
The adult sexuality has four major divisions:
• Biological sex
• Sexual behaviour
• Core gender identity
• 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
204
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.
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.
1. Mention 3 examples of sex role imagery beliefs for male and

female alike.
Male Female
2. When does sex role imagery learning begins and ends?
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.
3. XY Chromosomes gives rise to ----------- foetus.

4. XX Chromosomes gives rise to ---------- foetus.
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
205
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 prostrate gland, seminal vesicles and cowpers
glands whose secretions become part oaf 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).
N.B: You will have an extensive lecture on male and female

reproductive system on Anatomy Course at 200 Level.
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 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
206
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.
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:
• 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.
• 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.
• Specific Suggestions: these may be a suggested course of action
through more in-depth education and sexual exercise.
• Intensive Therapy: highly individualized and provided by
professionals who have advanced experience and knowledge in
the sex therapy field.
Using levels 2 and 3 what will be your guiding principle in the sexuality
counseling of an Acquired Immune Deficiency Syndrome (AIDS)
patient / client.
Disorders of Sexuality
Disorders of sexuality can occur in each of the four areas of sexuality

can occur in each of the four area 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.
• Tran sexuality in which an individual appears to have a gender

identity at odds with his or her physical self.
• Ambiguous genitalia which presents a genitalia different from the
physical gender identity on the child.
207
• 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.
• Sexual dysfunction in the form of impotence, premature
ejaculation, frigidity, dyspareunia and vaginism. It can be as a
result of psychological or physical factors.
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.
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 clients 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.
208
4.0 CONCLUSION
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.
5.0 SUMMARY
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.
1 Male: Leadership, Benefactor, and Dominance.

Female: Service, Caretaker and Role model.
2 From 3years to death.
Closed monitoring, Provide privacy in management, provide education

to overcome the stigma and offer suitable treatment.
1. What are the key elements in the concept of sexuality?

2. Briefly describe the interrelationship of the four (4) aspects of
sexuality.
209
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.
210
MODULE 4
Unit 1 Stress and Adaptation

Unit 2 Nursing and Society
Unit 3 Health Education
UNIT 1 STRESS AND ADAPTATION
CONTENTS
1.0 Introduction
2.0 Objectives
3.0 Content
3.1 Concept of Stress
3.2 Models of Stress and Stressor
3.3 Factors Influencing Response to Stressors
3.4 Sources of Stress
3.5 Adaptation Responses
3.6 Management of Stress
3.7 Nursing Intervention of Stress
4.0 Conclusion
5.0 Summary
1.0 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 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
211
response to stress, adaptation and stress management for improved

patients’ care.
2.0 OBJECTIVES
• explain the concept of stress and stressor

• discuss four (4) models of stress as they relate to nursing practice
• describe stress-management techniques required for clients care.
3.0 MAIN CONTENT
3.1 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 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 well being; threatens the way a person normally perceives
reality, solves problems or think; threatens relationship and sense of
belonging and a persons 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
• Have you ever been faced with stress? Yes or No

• If yes, what is/are the cause?
212
• How did you recognize that you were under stress?

• What did you do?
• What other sources of stress do you know?
Now that you have attempted Activity 1, discuss your

views with another colleagues/learner before you
continue.
3.3 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:
• Response Based Model (RBM)

• Adaptive Based Model (ABM)
• Stimulus – Based Model (SBM)
• Transaction- Based Model(TBM)
*Please follow as we discuss these models in relation to nurse client

therapeutic care.
i) 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).
ii) 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;
213
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.
iii) 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.
3) All people have a common threshold of stimulus, and illness
results at any point after the threshold.
iv) 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.
1. Identify 3 physiological changes in the body that goes for Local

Adaptation Syndrome (LAS)
2. Identify the physiological changes in the body that goes for
General Adaptation Syndrome.
3.4 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
214
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.
3.4.1 Sources of Stress
The common sources of stress are classified under the following

headings:
A) Stress problems at home: these includes
• Problem with co- tenants or neighbours

• Fear of attack by armed robbers
• Looking after dependants
• …………………………………
• ………………………………… (complete the last two)
B) Stress provoking situations in the society:
• Eratic supply of electricity water and fuel

• Reckless driving and traffic hold ups
• Insecurity
• ………………………………………….
• …………………………………………….(complete the rest)
C) Stress provoking situation at work:
• having too much to do

• too much pressure and repeated deadlines
• poor physical working conditions
• ……………………………………..……………………………
Activity 3
Now recap on the sources of stress above and compare with your write
up in Exercise 1.
3.5 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
persons family’s or community’s adaptation to stress because many
215
stressors cannot be avoided. It involves reflexes, 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.
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:
216
i) 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).
ii) 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.
3.6 Management of Stress
The management of stress is classified into 3 headings for easy

assimilation and understanding.
i) Reducing stressful situation through:
a) Habit formation
b) Change avoidance
c) Time blocking
d) Time management
e) Environment modification.
ii) Decreasing physiological response through:
a) Regular exercise
b) Humour
c) Nutrition
d) Rest
e) Relaxation
iii) 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.
What are the support system’s roles in alleviating stress in an expectant

mother who is due to put to bed in a week’s time?
217
3.7 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.
4.0 CONCLUSION
Each person reacts to stress differently according to perception of the

stressor, personality, prior expectations with stress and use of coping
mechanism.
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.
5.0 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.
1. Trauma, Illness and physiological change.

2. Alarm reaction, Resistance and Exhaustion stage.
218
Family (social, economic, emotional), Friends, Colleagues, Acquitances

and the Nurse.
What is your concept of stress? Identify and discuss the four (4) models
of stress as they relate to nursing practice.
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.
Selye (1986). Stress: Signs, Sources, Symptoms, Solution. Switzerland,

Editions, Roche Basel.
219
UNIT 2 NURSING AND SOCIETY
CONTENTS
1.0 Introduction
2.0 Objectives
3.0 Main Content
3.1 Demographic Changes
3.2 Technological Advances
3.3 Increasing Consumer Knowledge
3.4 Human Rights Movement
3.5 Women Liberation Movement
3.6 Professionalism in Nursing
4.0 Conclusion
5.0 Summary
1.0 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.
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.
2.0 OBJECTIVES
• to examine the societal changes and nursing practice

• to discuss the current societal trends and influence on nursing
practice
• to identify the place of Nursing in the society.
220
3.0 MAIN CONTENT
3.1 Demographic Changes
Demography is the statistical description of population using: birth,

death, migration, emigration, life expectancy, 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, etc.
Nurses therefore have to explore new methods for providing care and
establish practice standards in new areas.
Activity 1
a) What is the population of Nigeria today?

b) List three (3) problems of over population.
3.2 Technological Advances
The ongoing scientific research has continued to uncover new

knowledge at a faster pace. With the advert of computer and other
management information systems, societal values and quest for
services have been tailored towards this e.g. canned foods, drinks and
additives. Scientific advances closely associated with health illness,
organ transplants, 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.
Mention four (4) advancement in communication/technology that can

facilitate Nursing Care in a Hospital set up.
221
3.3 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.
3.4 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 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.
3.5 Women Liberation Movement
Women to day 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.
a) Who is the mother of modern Nursing?

b) When was she born?
c) What was her major role?
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.
222
3.6 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.
1) List the six – (6) societal changes identified already.
4.0 CONCLUSION
The scope and range of nursing responsibilities in meeting the needs of

society mean assuming increasing responsibility for patient care,
developing collaboration 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.
5.0 SUMMARY
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.
C.T. Scan, Ultra Sound Machines, and Electrocardiography.
223
A). Florence Nightingale B). 1820 C). A researcher, a caring nurse of

the sick and well. She gave birth to professionalism in nursing.
Demographic changes, Technological changes, Increasing consumer

knowledge, Human Rights movement, Women Liberation movement
and Professionalism in Nursing.
Discuss in details the societal changes that have come on Nursing and its
influence on the practice.
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.
Lippincolt Co.
Potter and Perry (1993). Fundamentals of Nursing: Concepts, Process

and Practice, (3rd ed.). St. Louis: J. B. Lippincolt Co.
Royle and Walsh (1980). Watsons Medical-Surgical Nursing and

Related Philosophy (4th ed.). Toronto , Philadelphia: J. B. Lippincolt 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.
224
UNIT 3 HEALTH EDUCATION
CONTENTS
1.0 Introduction
2.0 Objectives
3.0 Main Content
3.1 Definition of Health Education
3.2 Growth of Health Education
3.3 Purposes of Health Education
3.4 Process of Health Education.
3.5 Principles of Heath Education.
3.6 Health Education in Nursing.
4.0 Conclusion
5.0 Summary
1.0 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 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).
225
2.0 OBJECTIVES
• explain his/her own concept of health education

• list the objectives of health education
• describe how health education can be planned and methods of
delivery.
3.0 MAIN CONTENT
3.1 Definitions
Activity 1
• What do you understand by the word ‘health’?

• What is education?
(Write the answer somewhere and then read on)
Health: It is a state of complete physical, mental, social and spiritual

well being 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 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).
226
It is an all-round process which involves the whole life thereby helping

people to help themselves live a healthful life.
What is your concept of (idea) of health education?
3.2 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

pubic is dependent on the public conviction about health. Health
education initially was the 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.
3.3 Purposes of Health Education
Health education is a process that informs, motivates and helps people

to adapt and maintain healthy practises 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.
227
• 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.
Why do you need to health educate?
3.4 Process of Health Education
The process involved in health education as identified by Books (1980)

includes: assessment, objectives setting, readiness, implementation and
evaluation.
GOAL ACHIEVED STAGE I STAGE II STAGE III

Assessment Setting of Setting of
of Need Objectives Objectives
STAGE IV
Reassessment
Evaluation STAGE V
Implementation
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.
3.5 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,
228
learning and inculcation of habits concerned with healthful living. The

guiding principles are:
• Issues to be discussed must be interesting (or made interesting)

to the people.
• Personal involvement in form of group discussion, panel
discussion and workshops.
• Start health education from what the people knew before the
unknown.
• Study the people’s level of understanding, literacy and education
to ensure prompt comprehension.
• Reinforcement and repetition at intervals is useful.
• Motivation: incentives must be incorporated for good and bad
habits.
• 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.”
• Make the whole exercise attractive, palatable and acceptance
with necessary methods.
Health education involves the following?
3.6 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:
• Supply relevant, accurate information about general and specific

health matters to patients and relatives.
• Teach patients and relatives on self-care, avoidance of
complication and reduction of consequences of ill health.
• Teach patient and relatives how to cope effectively with
disability both in hospital and after discharge.
• Communicate effectively, appropriately and sensitively with
patients and relatives.
Mention 4 problems in health education. (If in doubt study 3.5 again)
229
4.0 CONCLUSION
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 practises 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).
5.0 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.
The answer is to incorporate all round process/procedure which

contributes to healthy living.
To provide information that will bring about a desired change in

behaviour.
Teaching, Learning and inculcating habits that is concerned with

healthy living.
No clarity of purpose, inappropriate methods, Wrong audience and

Wrong evaluation
230
A health educator must possess certain qualities to be effective in

his/her assignment. Comment in not less that 2 pages on four (4) of the
qualities. Discuss the three (3) specific objectives of health education.
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) Indria Gandhi

National Open University, New Delhi: Berny Art Press.
UNICEF (1999). Publications on Health Communications.
231

NSC111 A PDF

Uploaded by

Copyright:

Available Formats

NSC111 A PDF

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

NSC111 A PDF

Uploaded by

Copyright:

Available Formats

NATIONAL OPEN UNIVERSITY OF NIGERIA

COURSE CODE : NSC111

Course Team Dr. Reuben Fajemilehin (Developer/Writer) - OAU

NATIONAL OPEN UNIVERSITY OF NIGERIA

National Open University of Nigeria

First Printed 2010

All Rights Reserved

NSC111: Foundations of Nursing course is a two (2) unit credit course

What You Will Learn in this Course

The course provides a broad base understanding of the facts that

The aim of the course is to give you an understanding on the

1. Verbal discussion and in writing the fundamental physiological,

This course is made up of the following units:

Unit 1 Health and Human Needs I

Unit 1 Assessing Health II (Vital Signs Contd).

Unit 1 Infection Control

Unit 1 Stress and Adaptation

Textbooks and References

Cox, C.L. (1995). Health and Human Needs. In H. B. M. Heath (ed.).

Coy, J. (1998). Comfort and Sleep. In S. C. Delaune & P.K. Ladner,

Furest, et al (1974). Fundamentals of Nursing, J.B. Lippincott Co.,

Tutor-Marked Assignment (TMA)

There are 20 tutor-marked assignments in the course. You are advised

Continuous self-assessment materials will be enclosed with the

How to Get the Most Out of the Course

Here is a list of practical strategy for working through the course:

• Read the course guide thoroughly.

Course Code NSC111

Course Team Dr. Reuben Fajemilehin (Developer/Writer) - OAU

NATIONAL OPEN UNIVERSITY OF NIGERIA

National Open University of Nigeria

First Printed 2010

All Rights Reserved

Unit 1 Health and Human Needs I …………….…………. 1

Unit 1 Assessing Health II (Vital Signs Contd).…………. 67

Module 3 …………………………………………………….. 167

Unit 1 Infection Control …………………………………. 167

Module 4 …………………………………………….……….. 211

Unit 1 Stress and Adaptation ……………………………… 211

Unit 1 Health and Human Needs I

UNIT 1 HEALTH AND HUMAN NEEDS

Health and human needs are inextricably interrelated. Humans need a

At the end of this unit, you should be able to:

• state the basic human needs

3.0 MAIN CONTENT

3.1 Overview of Individual Needs

Primary needs otherwise known as Basic needs, are survival needs.

Secondary needs or Meta needs (growth needs) as they are sometimes

any order, depending upon a person's wants or circumstances, as long as

3.2 The Basic Human Needs

3.3 Physiologic Needs

Undoubtedly the physiological needs are the most pre-potent of all

Perhaps it should be mentioned that any of the physiological needs and

Clients with compromised oxygenation status need careful assessment

Water and Fluids – It is no exaggeration that though a man can survive

allowing organic compounds to react in ways that ultimately allows

Dehydration and oedema indicate unmet fluid needs. Dehydration is the

Food and Nutrients – Food is any substance that can be consumed, be

Optimal nutrition (intake matches energy expenditure; proper amount of