Ambo Universty College of Medicine and Health Science Department of Nursing Fundamental of Nursing I

AMBO UNIVERSTY
College of medicine and health science

Department of nursing
fundamental of nursing I
BY; Mergitu Eliyas(Bsc, Msc in AHN)
5/5/2021 By, Mergitu E. (BSC, MSc) 1

UNIT ONE
Definitions of Nursing
Learning Objectives:
 After completing this unit, the learners will be able to:
❖State the modern definition of nursing
❖Outline the historical background of nursing

worldwide and in Ethiopia
❖Identify the contribution of significant individuals

in nursing
❖Describe the nursing

5/5/2021 By, Mergituprocess
E. (BSC, MSc) 2
Definitions Nursing
Florence Nightingale “The act of utilizing the environment of the

patient to assist him in his recovery" (Nightingale, 1860).
Nightingale considered a clean, well-ventilated, and quite
environment essential for recovery.
Verginia Henderson (1960)"The unique function of the

nurse is to assist the individual, sick or well, in the
performance of those activities contributing to health or
its recovery (or to peaceful death)".
Canadian Nurses Association (CNA)
Described nursing practice as caring and helping relationship in
which the nurse assists the client to achieve and obtain optimal
health.
• Nursing is holistic: means it is the whole care that given for the
patient or individual physiologically, spiritually, socially,
psychologically and economically
• Nursing is concerned with health promotion, health maintenance,

and health restoration.
" goal oriented, and adaptable to the needs of the individual, the family,
and the community during health and illness" (ANA, 1973).
 In 1980, the (ANA) changed the definition of nursing to
"Nursing is the diagnosis and treatment of human
responses to actual or potential health problems".
 Nursing encompasses autonomous and collaborative care

of individuals of all ages, families, groups and
communities, sick or well and in all settings(WHO).
 It includes the promotion of health, the prevention of

illness, and the care of ill, disabled and dying people.
Cont’d
Definitions of nursing: it is an art and sciences
 Nursing is as an art the fully providing nursing
care(service)or it is relies on the knowledge that gain
from experiences
 Nursing is as sciences it is based on the body of

knowledge which is occurred as the result of
discovery or investigation of research
 The consideration of these both sciences and art help

to provide excellent health care.

Definitions of nurse…
❖ The nurse is a person who has completed a program of basic,
generalized nursing education and is authorized by the
appropriate regulatory authority to practice nursing in his/her
country
The Recipients of Nursing are sometimes called consumers,

sometimes patients, and sometimes clients.
• A consumer is an individual, a group of people, or a community

that uses a service

• People who use health care products or services are consumers
of health care
• A patient is a person who is waiting for or undergoing medical

treatment and care.
• The word patient comes from a Latin word meaning "to suffer"
• A client is a person who engages the advice or services of

another who is qualified to provide this service.
Nurses provide care for three types of clients: individuals,
families, and communities.
Nursing practice involves four areas: promoting health and

wellness, preventing illness, restoring health, and care
of the dying.
• Wellness is a state of well-being

• Nurses promote wellness in clients who are both
healthy and ill.
• This may involve individual and community activities

to enhance healthy lifestyles, such as
– improving nutrition and physical fitness
– preventing drug and alcohol misuse
– restricting smoking, and
– preventing accidents and injury in the home and

workplace.
Preventing Illness
The goal of illness preventing programs is to maintain optimal
health by preventing disease.
Nursing activities that prevent illness include;
• immunizations
• prenatal and infant care, and
• prevention of sexually transmitted disease.
Restoring Health :focuses on the ill client and it extends from early
detection of disease through helping the client during the recovery
period .
Settings for Nursing
In the past, the acute care hospital was the main

practice setting open to most nurses.
Today many nurses work in hospitals, they work

in clients homes, community agencies, long-
term care and health maintenance organization
(HMOs)

• Nurses have different degree of nursing
autonomy and nursing responsibility in the
various settings.
• They may provide direct care, teach clients
and support persons, serve as nursing
advocates and help determine health policies
affecting consumers in the community and in
hospitals.
READING ASSGIMENT
• Religious and civilization influence on nursing
• The history of Nursing in Ethiopia
• Over review of nursing theory
• Definition of terms related to theory
• Relationship of theory to practice and research
• Major nursing theories used for nursing practice

Why is Theory Important?
• Nursing is strengthened when knowledge is
built on sound theory
• Criteria to be a profession: distinct body of

knowledge as the basis for practice
• Ultimate goal is to support excellence in

practice

In nursing…
• Organizing and analyzing patient data
• Understanding connections between pieces of
data
• Discriminating between important and less
pertinent data
• Making sound clinical judgments based on
evidence
• Planning effective nursing interventions
• Predicting and evaluating outcomes of
interventions
Role of nurse
Caregiver encompasses the physical, psychosocial,

developmental, cultural, and spiritual levels.
• The nursing process provides nurses with a framework

for providing care.

Communicator
Communication is integral to all nursing roles.
• Nurses communicate with the client, support persons,
other health professionals, and people in the community
Teacher
As a teacher, the nurse helps clients learn about their health and
the health care procedures they need to perform to restore or
maintain their health

Client advocate
• A client advocate acts to protect the client.
• In this role the nurse may represent the client's needs and
wishes to other health professionals
• They also assist clients in exercising their rights and help

them speak up for themselves.

Counselor
• Counseling is the process of helping a client to
recognize and cope with stressful psychological or
social problems and to promote personal growth.
• It involves providing emotional and psychological

support.

Manager
• The nurse manages the nursing care of
individuals, families, and communities.
• The nurse manager also delegates nursing

activities to other nurses, and supervises and
evaluates their performance.

Nursing Process:
Definition:
WHAT IS A PROCESS?
❖A process is a series of steps or acts that lead to
accomplishment of some goal or purpose.
❖The nursing process is the framework for providing

professional, quality nursing care.
❖The steps of the nursing process build upon each

other,

 The nursing process is a step-by-step method of
providing care to client
 it is also defined as an organized, systematic method

of planning and providing individualized care to
clients
The purpose of the nursing process is to provide care

for clients that is individualized, holistic, effective,
and efficient
Cont’d….
Evolution of the Nursing Process
• Before the nursing process evolved, the nurse provide
care based on medical orders written by physicians.
• There were no clearly identifiable boundaries defined

for nursing practice.
• The term nursing process was coined by Lydia

Hall(1955).
Cont…
Purpose of Nursing Process:
➢ To identify clients health care needs
➢ To establish nursing care plan so as to meet those needs
➢ To complete the nursing intervention designed to meet

the needs it is systematic, scientific problem solving
action
➢ To provide individualized care Linda Hall first

introduces the term nursing process in 1965

Cont….
• There are five steps, or phases in the nursing process:

assessment, diagnosis, planning, implementation, and
evaluation
• These steps are not discrete steps, but rather, they

overlap and build on each other.

Cont’d....

Assessment
• Assessment is the first step in the nursing process and includes

❖ Collecting data from a variety of sources
❖ Validating the data
❖ Organizing data
❖ Categorizing or identifying patterns in the data
❖ Making initial inferences or impressions
❖ Recording or reporting data
❖ The completeness and correctness of the information obtained

during assessment are directly related to the accuracy of the
steps that follow.
Cont….
Data sources
• The patient is the primary data source.
• Other sources include;

– patient’s family or significant other’s,
– the patient’s admission sheet form
– the physician’s history
– laboratory and x-ray results
– information from other care givers

cont’d
The types of data includes:
❖ Subjective data are the facts presented by the patient
that show his or her perception
▪ An example of subjective data is the patent’s statement.
❖ Objective data are those facts that are observable and

measurable by the nurse.
▪ An example of objective data is the measurement and
recording of vital signs. Objective data are also gathered
through diagnostic procedures.
Cont…
Nurses obtain data by five methods:
• Interview.
• Physical examination.
• Observation.
• Review of records and diagnostic reports.

I. The assessment process
 To perform an accurate assessment, the nurse must be
able to:
A. communicate effectively
❖All nurse – client interactions are based on

communication.
❖It incorporates verbal and non- verbal skills
❖Barriers to active listening include;

Cont….
Internal
❖The client in pain or anxious.
❖The nurse is thinking of something else.
❖The nurse is anxious
❖The nurse is in a hurry.
External
• Noise.
• Privacy lacking.
• Physical hindrances(interruption)

Cont…
B. Observing systematically
• The ability to observe systematically depends on the nurses’
knowledge base.
• Knowing what contributes to or causes a particular problem

enables the nurse to explore these areas with the client.
C. Interpreting data accurately

• The nurse must order the data or group cues in to patterns.
• A cue(hint) is information acquired through one or more of the
five senses.
• An inference is the nurse’s judgment or interpretation of cues.
Cont…
D. Validating data
• Validating the data with the client helps the nurse avoid
making incorrect inferences.
• For example, the nurse observes a client crying in her

room, the nurse familiar with the client’s recent medical
diagnosis of breast cancer may quite logically connect the
crying with the diagnosis.
• To validate the nurse should say some thing like, “I see

that you’re crying. Would you like to talk about your
feelings?
NURSING DIAGNOSIS
• Nursing diagnosis is clinical judgment about

individual, family, or community responses to actual
or potential health problems.
• Nursing diagnosis provides the basis for selection of

nursing interventions to achieve out comes for which
the nurse is accountable.

Cont…
Types and components of nursing diagnoses:
A. Actual nursing diagnoses
• An actual nursing diagnosis represents a problem that

has been validated by the presence of major defining
characteristics.
• This type of nursing diagnosis has three structural

components of nursing diagnostic statement
1.The problem (diagnostic label): describes the patient’s
response.
2.Related factors: Related factors are contributing factors that
influence the change in health status.
Such factors can be grouped in to four categories:
✓Pathophysiologic Examples include compromised
immune system and inadequate circulation.
✓Treatment – Examples include medications, diagnostic

studies, and surgery
✓Situational. include environmental, home, personal,

and life experiences
✓ Maturational. Examples include age -related influences.
3. Defining characteristic
• Defining characteristic are signs and symptoms that
seen together, represent the nursing diagnosis.
• Example;
A. Pain related to surgical incision as evidenced

by verbal comments
B. Impaired skin integrity related to prolonged
immobility secondary to fractured pelvis, as

evidenced by a 2 cm lesion on back
Cont…
B. Risk nursing diagnoses
A. clinical judgment that an individual, family, or
community is more vulnerable to develop the problem than
others
o Risk factors for risk diagnoses represent those situations

that increase the vulnerability of the client or group.
o Risk nursing diagnoses are two- part statements.

Example:
 Risk for impaired skin integrity related to immobility secondary to
pain.
C. Possible nursing diagnoses
o Are statements that describe a suspected problem

requiring additional data.
o Possible nursing diagnoses are two-part statements
consisting of:
 The possible nursing diagnoses.
 The “related to” data that lead the nurse to suspect the diagnosis.
 Example – possible disturbed body image related to post surgery.

Cont…
Difference of nursing and medical diagnoses
– You assess your patient to obtain data for making a

nursing diagnosis, just as the physician examines a
patient to establish a medical diagnosis.
– If you plan your care of patient around only the

medical aspects of his illness, you will probably
over look significant problems.
Cont’d....

PLANNING
Planning is the process of deciding in detail how to do
something before you actually start to do it.
The nursing plan of care refers to a written plan of action
designed to help you deliver quality patient care.
✓ This planning phase of the nursing process has the

following components:
A. Establishing a priority set of diagnosis
By identifying a priority set –a group of nursing diagnoses
that take precedence over others
Several methods of assigning priorities are available:
 Some nurses assign priorities based on the life threat
posed by a problem.
 Some nurses base their prioritization on Maslow’s

Hierarchy of needs. In this instance, Physiologic needs
would require attention before social needs.
 One way to establish priorities is to simply ask the patient

which problem he or she would like to pay attention to
first.

Cont…
B. Expected out comes
• Out comes or goals wants to achieve and objective
are terms that are frequently used interchangeably
because all indicate the end point we will use to
measure the effectiveness of our plan of care.
Guide line for expected out come writing
• Expected out comes are clearly stated in terms of

patient behavior or observable assessment factors.
• Example - Will increase oral fluid intake to 1500ml

per 24 hours
Cont…
• Expected out comes are realistic, achievable, safe,
and acceptable from the patient’s view point.
• Expected out comes are directly observable by use of

at least one of the five senses.
• Example – Accurately demonstrates self

administration of insulin.
• Expected out comes are patient centered rather than

nurse centered.
Cont…
IMPLEMENTATION
– Involves applying skills that nurses need to implement the

nursing interventions.
• Performing the activity for or assisting the client.
• Teaching clients to gain new knowledge concerning their own

health or the management of a disorder.
• Assisting clients to make decisions about their own health

care.
 Consulting with and referring to other health care professionals to
obtain appropriate direction.
 Providing specific treatment actions to remove, reduce, or resolve

health problems.
 Assisting clients to perform activities by them selves.
 Assisting clients to identify risks or problems and to explore options

available.

EVALUATION
 Evaluation involves three different considerations:
 Evaluation of the client’s status.
 Evaluation of the client’s progress toward goal

achievement.
 Evaluation of the care plan’s

UNIT TWO
• INFECTION PREVENTION AND
PATIENT SAFETY
❑At the end of this chapter students will be able to:-

❖Describe factors affecting environmental safety.
❖Describe the chain of infection.
❖Explain the principles of medical and surgical

asepsis.

➢Discuss factors that influence a client’s personal
hygiene practices.
➢Describe the nursing interventions that promote a

client’s personal hygiene.

Safe care is a basic need of all clients regardless of the
setting.
• safety: free from danger or protection from not
exposed to the risk
• Nurses are responsible for providing the client with a

safe environment through the delivery of quality
nursing care that incorporates
❑ safety precautions
❑ infection control practices, and
❑ hygiene assistance.

FACTORS AFFECTING SAFETY
➢ Client safety is influenced by several factors such as :
– age
– lifestyle
– sensory and perceptual alterations
– Mobility
– Emotional state→ depression, anxiety
➢ Infection is an invasion and multiplication of microorganisms in

body tissue
This microorganisms results in cellular injury.

Infection Control…
• Infectious agents that have capable of transmitting to a

client by direct or indirect contact are called
communicable agents.
• Diseases produced by these agents are referred to as

communicable diseases

INFECTION CONTROL PRINCIPLES
• Client safety in the health care environment requires the

reduction of microorganism transmission.
• Infection control practices are directed at eliminating

sources of infection in the health care agency or home.
• Nurses are responsible for protecting clients and

themselves by using infection control practices.

Chain of infection
 Describes the phenomenon of developing an
infectious process.
 There must be an interactive process that involves
the
❖agent,
❖ host and
❖environment.
 This interactive process must involve several
essential elements, or “links in the chain,” for
transmission of microorganisms to occur
Chain of infection …
Agent
An agent is an entity that is capable of causing
disease.
Agents that cause disease may be

– Biological agents: such as bacteria, viruses, fungi,
protozoa
In the chain of infection the main concern is the

biological agent and their effect on health.

Chemical agents: Substances that can interact with the body, such
as pesticides, medications and industrial chemicals
Physical agents: Factors in the environment that are capable of

causing disease, such as, noise, radiation, and machine
Host:- is an organism that can be affected by an agent.
• Generally, a human being is considered a host.
Susceptible host:- person who lacks resistance to an agent and

is thus vulnerable to disease

Environment:-consists of everything including the
agent and host.
• Environmental factors that affect the chain of infection
are
➢Water, food
➢Plants, animals
➢Housing conditions
➢Meteorological conditions and

Chain of infection…
• There are six essential links (elements) in the chain of

infection.
• Knowledge about the chain of infection for an

infectious process permits control or elimination of the
microorganism by breaking the links in the chain of
infection.

Chain of diseases transmition

Chain of Infection….
1. Infectious agent:- pathogen (disease causing micro organism )

that cause infection.
Common pathogenic mechanisms includes
❑ production of toxin
❑ direct tissue invasion
❑ persistent or latent infection
❑ immune suppression
❑ allergic reaction
5/5/2021 By, Mergitu E. (BSC, MSc)

2. Reservoir:-
A living (human being, animal or plant) or non-living
thing (soil etc.,) in which an infectious agent normally
lives ,transforms, develop and multiplies
3. Portal of exit:-
The site /way in which infectious agent leaves/ escapes
from the host
Possible portal of exist includes –all body secretion and
discharge (mucus, saliva, feces, urine)

4. Mode of transmission:-
• The mechanism by which an infectious agent is
transferred from a reservoir of infection to a new host.
• is the process that connectes the gap between the portal

of exit of the biological agent and the portal of entry of
the susceptible “new” host.
• Mode of transmission includes

➢Contact transmission
➢Air born transmission
➢Vehicle transmission
5/5/2021
➢Vector borne transmission
By, Mergitu E. (BSC, MSc) 65
There are two main modes of transmission
A. Direct transmission: the immediate transfer of

infectious agents from an infected host or reservoir to
an appropriate portal of entry on the susceptible host.

Con..
Examples of direct transmission includes:-
• 1. Direct contact: the contact of the skin, mucosa, or
It can occur through: Touching, breaks in skin,
kissing, Passage through the birth canal
• 2. Direct projection: of droplets of saliva created by
expiratory activities of coughing, sneezing, talking,
• 3. Transplacental: The direct transmission of an

infectious agent from mother to her fetus in utero
through the placenta.(eg. Syphilis, HIV)

B) Indirect Transmission:
➢ Airborne transmission:-dissemination through a

suitable portal of entry, usually the respiratory tract as
particles, dust, and droplet nuclei.
▪ Droplet nuclei- usually small residues that result from

evaporation of fluid from droplets emitted by an
infected host.
▪ Usually remain suspended in air for long period of

time.
Con..
➢ A vehicle is any non-living substance or object by which an
infectious agent can be transported Ex. Food, water, milk,
blood
➢ Vector is indirect mode of transmission whereby the infectious

agent is carried from the reservoir of infection to the
susceptible host by a vector.
• A vector is an organism, which transports an infectious agent to

a susceptible host or to a suitable vehicle
eg.fly, mosquitoes

5. PORTAL OF ENTRY:-
The site through which the infectious agent enters to the

susceptible host
Ex. GIT, RT, GUT, skin, eye…
6. SUSCEPTIBLE HOST:-
Person or animal not possessing sufficient resistance
against a particular infectious agent to prevent contracting
infection or disease when exposed to it
➢ Level of susceptibility depends on-age of individual
nutritional status, stress, pre-existing disease, Immunity
status

Conditions Predisposing to Infection
➢ Invasive techniques(surgical wounds)
➢ Changes in immune system
• Nosocomial Infection:-are infections that are acquired

while the client is in the hospital or
– Infections that were not present at the time of

admission.
– (when the patient acquire new disease from the hospital

area after 48hrs of his/her admission to the hospital).
Breaking the Chain of Infection
• Nurses focus on breaking the chain of infection by
applying proper infection control practices
❖The chain of infection can be broke
✓By interrupting or blocking the agent, portal of exit,

or portal of entry
✓By destroying the agent or
✓By decreasing the host’s susceptibility.

Breaking the Chain of Infection
Infectious agent
▼Cleaning, Disinfection, Sterilization
Reservoir
▼Hygiene, Dressing change, Disposal
of fluid in the container, Change soiled linen
Portal of exit
▼Cover mouth and nose when
coughing or sneezing
mode of transmission
▼
Chain of Infection---
mode of transmission
▼Wear gloves, masks, gowns,
goggles, Handwashing
Portal of entry
▼Sterile technique, Proper disposal
of needles or sharps
Susceptible host

Breaking the Chain of Infection…
 Aseptic technique is the infection control practice used

to prevent the transmission of pathogens.
 Two types of asepsis are

1. Medical asepsis and
2. Surgical asepsis.

Medical asepsis:- used to reduce the number, growth and spread of
microorganisms
▪ Medical asepsis is also referred to as “clean technique”
▪ Clean objects are considered to have some microorganisms that are

usually not pathogenic
▪ Common medical aseptic measures used for clean or dirty objects are;
✓Hand washing
✓Gloves
✓Changing linens daily
✓Cleaning floors and By,
5/5/2021
Hospital furniture
Mergitu E. (BSC, MSc) 76
Hand washing:- is the rubbing together of all surfaces
hands using a soap or chemical and water
➢ It is a component of all types of isolation
precautions
➢ It is the most basic and effective infection control

measure
➢ It prevents and controls the transmission of infectious

agents
Hand washing….
Purpose
• To prevent the spread of infection
• To increase psychological comfort
Equipment
• Soap for routine hand washing
• Orange wood stick for cleaning nails, if available
• Running warm water, paper towel

• Strongly scrubbing with warm, soapy water for at least

15sec is recommended.
❖The three essential elements of hand washing are

✓Soap containing antimicrobial agents
✓Water(warm water), and
✓Friction→(physically removes soil and transient)

• Hand washing should be performed;
➢After arriving at work
➢Before leaving work
➢Between client contacts
➢After nurseries
• Usually require about a 2min hand wash.
• Soiled hands usually require more time

Procedure
• Stand in front of but away from sink to avoid touching of
uniform to a sink.
• Ensure that paper towel is hanging down from dispenser.
• Turn on water using foot pedal or faucet (using elbow of hand)

so that flow is adequate, but not splashing.
• Adjust temperature to warm. Rationale: cold does not

facilitate cleaning; hot is damaging to skin.
• Wet hands under running water, wet hands facilitate

distribution of soap over entire skin surface.
• Place a small amount, one to two teaspoons (5-10mL) of liquid

 Thoroughly distribute overhands. Soap should come from a
dispenser, possible; this prevents spread of microorganism.
 Rub vigorously, using a firm, circular motion, while keeping

your fingers pointed down, lower than wrists. Start with each
finger, then between fingers, then palm and back of hand to
create friction on all surfaces.
 Wash your hands for at least 10-15 seconds. Duration of

washing is important to produce mechanical action and allow
antimicrobial products time to achieve desired effect

Con..
• Clean under your fingernails with an orangewood
stick. (This should be done at least at start of day and
if hands are heavily contaminated).
• Rinse your hands under running water, keeping

fingers pointed down ward in order to prevent
contamination of arms.
• Resoap your hands, rewash, and re rinse if heavily

contaminated.
Con …
• Dry hands thoroughly with a paper towel, while keeping hands
positioned with fingers pointing up. Moist hands tend to gather
more microorganisms from the environment.
• Turn off water faucet with dry paper towel, if not using foot
pedal to avoid contaminating the hands.
• Restart procedure at step 5 if your hands touch the sink any

time between steps 5 and 13.
• Donning and Removing Gloves

• Equipment
– Gloves (both clean and sterile)
– Trash receptacle
• There are two methods for applying sterile gloves:
– Open:- Is used most frequently when performing
procedures that require the sterile technique such as
dressing changes
– Closed:- Is used when the nurse wears a sterile
gown

Procedure for clean glove
• Wash your hands to remove microorganism and avoid
contamination.
• Remove glove from glove receptacles Hold glove at

wrist edge and slip finger into opening. Pull glove up
to wrist.
• Place gloved hand under wrist edge of second glove

and slip fingers in to opening.

Cont…
• Remove glove by pulling off, touching only outside of glove at
cuff, so that glove turns inside out.
• Place rolled-up glove in palm of second hand.
• Remove second glove by slipping one finger under glove edge

and pulling down and off so that glove turns inside out.
• Both gloves are removed as a unit.
• Dispose of gloves in proper container, not at bedside.
• Wash your hands.

Procedures for putting on sterile gloves:
1. Wash the hands to limit the spread of

microorganisms
2. Open the outer glove package, on a clean, dry, flat

surface at waist level or higher
3. If there is an inner package, open it in the same way,

keeping the sterile gloves on the inside surface with
cuffs towards you.
4. Use one hand to grasp the inside upper surface of the

glove’s cuff for the opposite hand
Procedures for putting on sterile gloves:
5. Insert the opposite hand in to the glove, placing the

thumb and finger in to the proper penning.
• Pull the gloves in to place, touching only the inside of

the glove at cuff. Leave the cuff in place.
6. Slip the fingers of the sterile gloved hand under

(inside) the cuff of the remaining glove while keeping
the thumb pointed outward.

7.
a. Insert the ungloved hand in to the glove
b. Pull the second glove on; touching only then outside

of the sterile glove with the other sterile gloved hand
and keeping the fingers inside the cuff.
c. Adjust gloves and snap cuffs in to place. Avoid

touching the inside glove and wrist area
8. Keep the sterile gloved hands above waist level.

Make sure not to touch the cloths. Keep hands folded
when not performing
5/5/2021 a procedure.
By, Mergitu E. (BSC, MSc) Both actions help 90
• Surgical Asepsis (sterile technique)
✓Is a practices, which will maintain area free from

microorganisms.
✓Surgical asepsis is used to maintain sterility.
✓Use of effective sterile technique means that no

organisms are carried to the client.

• Sterile technique is used when
➢Changing dressings
➢Administering parentral medications, IM,IV,…
➢Performing surgical procedures and
➢Other procedures such as urinary catheterization.

➢Cleansing
➢Disinfecting and
➢Sterilizing can break link in the chain of

infection by:
❖Reducing or Destroying microorganisms on

objects

Disinfection and sterilization
• Disinfection:- is a process that results in the

destruction of most pathogens, but not
necessarily their spores(reproductive structure).
• Common methods of disinfection include the

use of
❖Alcohol wipes
❖A chlorohexidineor gluconate soap scrub or

Disinfection and sterilization…
➢ Stronger disinfectants include phenol and mercury bichloride
➢ Boiling can be used to disinfect in animate objects.
➢ However, it does not destroy all microorganisms or spores
• Sterilization: is the process of exposing articles to steam heat

under pressure or the chemical disinfectants long enough to kill all
microorganisms and spores.
• Exposure to steam at 18 pounds of pressure at a temperature of

125-oc for 15 minutes will kill even the hardest organisms.
Disinfection and sterilization…
 A pressure steam sterilizer is called an autoclave.
 Other methods of sterilization include radiation and gas
sterilization with ethylene oxide
 Items to be used to maintain sterility technique:-
✓Hair covering
✓Surgical mask
✓Sterile gown
✓Sterile glove
✓ Isolation

Maintaining sterility technique
• Isolation:- is defined as separation from others,
• Separation of people with infectious disease or

susceptible to acquire disease from others.
• There are two types of isolation

Maintaining sterility technique…
• Category-specific isolation, specific categories of

isolation
– (eg. Respiratory, contact, enteric, strict or wound).
• This form of isolation is based on the client’s
diagnosis.
• The colored cards are posted outside the client’s room

and
• State that visitors must check with nurses before

entering.
Maintaining sterility technique …
• Disease–specific isolation, uses a single all-purpose
sign.
• Nurse selects the items on the card that are appropriate

for the specific disease that is causing isolation.

Preparing for Isolation
Purpose
 To prevent spread of microorganisms
 To control infectious diseases
Equipment
 Specific equipment depends on isolation precaution system
used.
 Soap and running water.
 Isolation cart containing masks, gowns, gloves, plastic bags
isolation tape.
 Linen hamper and trash can, when needed.
 - Paper towel
 - Door card indicating precautions

Procedure
1. Check orders for isolation
2. Obtain isolation cart from central supply, if needed.
3. Check that all necessary equipment to carry out the isolation
order is available.
4. Place isolation card on the client’s door.
5. Ensure that linen hamper and trash cans are available, if needed.
6. Explain purpose of isolation to client and family.
7. Instruct family in procedures required.
8. Wash hands with antimicrobial soap* before and after entering

isolation room.
* Types of antimicrobial soap or agent depend on infectious agent

and client condition

Donning and Removing Isolation Clothing
Equipment
- Gown
- Clean gloves
Procedure
 For donning attire
1. Wash and dry hands
2. Take gown from isolation cart or cupboard. Put on a new gown each time
you enter an isolation room.
3. Hold gown so that opening is in back when you are wearing the gown.
4. Put gown on by placing one arm at a time through sleeves, put gown-up
and over your shoulder
5 Wrap gown around your back, tying strings at your neck

Con…
6. Wrap gown around your waist, making sure your back is
completely covered. Tie string around your waist.
7. Done eye shield and/or mask, if indicated. Mask is required if there

is a risk of splashing fluids.
8. Don clean gloves and pull gloves over gown wristlets.
 For Removing Attire
1. Unite gown waist strings
2. Remove gloves and dispose of then in garbage bag.
3. Next, untie neck strings, bringing them around your shoulders, so

that gown is partially off your shoulders.
Con..
4. Using your dominant hand and grasping clean part of wristlet,
put sleeve wristlet over your non-dominant hand. Use your
non-dominant hand to up pull sleeve wristlet over your
dominant hand.
5. Grasp outside of gown through sleeves at shoulders. Pull gown

down over your arms.
6. Hold both gown shoulders in one hand, carefully draw your

other hand out of gown, turning arm of gown inside out.
Repeat this procedure with your other arm.
7. Hold gown away from your body. Fold gown
up inside out.
8. Discard gown in appropriate place
9. Remove eye shield and/or mask and place in

receptacle.
10. Wash your hands.

Transporting Isolated Client outside the Room
Equipment
• Transport Vehicle
• Bath blanket
• Mask for client if needed
Procedure
• Explain procedure to patient
• If client is being transported from a respiratory
isolation room, instruct him or her to wear a mask for
the entire time out of isolation. This prevents the
spread of airborne microbes.

Con..
 Cover the transport vehicle with a bath blanket if
there is a chance of soiling when transporting a
client who has a draining wound or diarrhea.
 Help client to transport vehicle. Cover client with a

bath blanket.
 Tell receiving department what type of isolation

client needs and what type of precaution hospital
personnel should follow.
Remove bath blanket, and handle as
contaminated linen when client returns to
room.
Instruct all hospital personnel to wash their

hands before they leave the area.
Wipe down transportation vehicle with

antimicrobial solution if soiled.

Protocol for Leaving Isolation Room
• Untie gown at wrist
• Take off gloves
• Untie gown at neck
• Pull gown off and place in laundry hamper
• Take off goggles or face shield
• Take off mask

Guide lines for Disposing of Contaminated
Equipment
 Disposable gloves: place in isolation bag separate from
burnable trash and direct to appropriate hospital area for
disposal
 Glass equipment: Bag separately from metal equipment and
return to CSR (Central sterilization Room).
 Metal equipment: Bag all equipment together, label and return
to CSR
 Rubber and plastic items: Bag items separately and return to
CSR for gas sterilization.
 Dishes: Requires no special precautions unless contaminated
with infected material; then bag, label and return to Kitchen.
 Plastic or paper dishes: Dispose of these items in burnable
trash.

Con.
• Soiled linens: place in laundry bag, and send to separate area
of laundry room from special care. If possible place linens hot-
water-soluble bag. This method is safes for handling as bag
may be placed directly into washing machine. (Double-
bagging is usually required because these bags are easily
punctured or torn. They also dissolve when wet.)
• Food and liquids: Dispose of these items by putting them in

toilet – flush thoroughly.
• Needles and syringes: Do not recap needles; place in puncture

proof (resistant) container.
Con..
• Sphygmomanometer and stethoscope: Require no special
precaution unless they are contaminated. If contaminated,
disinfect using the appropriate cleaning protocol based on
the infective agent.
• Thermometers: Dispose of electronic probes cover with

burnable trash. If probe or machine is contaminated,
clean with appropriate disinfectant or infective agent. If
reasonable thermometers are used, disinfect with
appropriate solution
Universal/Standard Precaution Guidelines
• Wash hands thoroughly after removing gloves and

before and after all client contact
• Wear gloves when there is direct contact with blood,

body fluids, secretions, excretions, and contaminated
items.

Maintaining sterility technique…
• Protect clothing wear gowns or plastic aprons if there is a
possibility of being splashed or direct contact with
contaminated material.
• Wear masks, goggles, or face shield to avoid being splashed

including during suctioning, irrigations and deliveries.
• Do not break or recap needles, discard them intact in to

puncture resistant containers.

• Place all contaminated articles and trash in leak proof
bags.
• Clean spills quickly with a 1:10 solution of bleach or

according to facility policy.
• Place clients at risk of contaminating the environment

in a private room with separate bathroom facilities.
• Transport infected clients using appropriate barriers,
• Dispose waste using three baskets system

General Instructions for all Nursing Procedures
 Wash your hands before and after any procedure.
 Explain procedure to patient before you start.
 Assemble necessary equipment before starting the procedure.
 Close doors and windows before you start some procedures like bed
bath and back care.
 Do not expose the patient unnecessarily.
 Whenever possible give privacy to all patients according to, the
procedure keep in appropriate position.
 After completion of a procedure, observe the patient reaction to the
procedure, take care of all used equipment and return to their proper
place.
 Wash your hands and record the procedure at the end
Colour coding system of waste disposal methods
 Red pail (container )used for disposing used, dressing
material, mucus membrane, dead tissue etc..
 Black pail (container) used for food particles eg.banana,
 White colour container used for I.V bag, ampulse,vials
 Yellow colour container used for used glove
 Safety box used for needle and sharp material

THE PATIENT UNIT
Definition:
• Patient: A Latin word meaning to suffer or
• Is a person who is waiting for or undergoing medical/nursing

treatment and care.
• Patient Care Unit: is the space where the patient is

accommodated in hospital or patient home where to receive
care.
• The patient unit is the place in health institution where a

patient stays after admission . It is his /her immediate
environment.
The patient unit in the hospital is of three types
• Private room – is a room in which only one patient be
admitted
• Semi private room – is a patient unit which can

accommodate two patients
• Ward- is a room, which can receive three or more
patients. Consists of a hospital bed, bed side stand, over
bed table, chair, overhead light, suction and oxygen,
electrical outlets ,sphygmomanometer, a nurse’s call
light, waste container and bed side table and others as
needed and available.
Care of Hospital and Health Care Unite Equipments
1. General Instructions for Care of Hospital Equipment

• Use articles only for the purpose for which they are intended.
• Keep articles clean and in good condition. Use the proper cleaning
method.
• Protect mattresses with rubber sheets.
• Use protective pillowcases on pillows.
• Do not boil articles, especially rubber articles and instruments
longer than the correct time.
• Do not sterilize rubber goods and glass articles together - wrap glass
in gauze when sterilizing it by boiling.
• Protect table tops when using hot utensils or any solution that may
leave stain or destroy the table top.

2. Care of used Equipment in General
• Rinse used equipment in cold water. Sock materials in

recommended antiseptic solutions.
• Remove any sticky material. Hot water coagulates the protein

of organic material and tends to make it adhere.
• Wash well in hot soapy water. Use an abrasive, such as a stiff-

bristled brush, to clean equipment.
• Rinse well under running water.
• Dry the article.
Clean the gloves, brushBy,and

•5/5/2021 clean the
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CHAPTER THREE
ESSENTIAL ASSESSMENT
COMP ONENTS Vital Signs

Objectives-
• At the end of the chapter students will be able to –
1. Describe the normal range of the vital signs
2. Identify the techniques of vital sign taking
3. State the essentials of vital sign in nursing care

• VITAL SIGNS
➢ The “taking of vital signs” refers to measurement of
the client’s body temperature (T), pulse (P) and
respiratory (R) rates, and blood pressure (BP).
➢ Vital signs are fundamental to physical assessment

(the first step in the physical examination) to establish
baseline values of the client’s cardiorespiratory
integrity
Vital signs/ Cardinal Signs
• Vital signs reflect the body’s physiologic status and provide

information critical to evaluating homeostatic balance.
• The term “vital” is used because the information gathered is the

clearest indicator of overall health status.

Vital sign…
• Baseline values establish the norm against which
subsequent measurements can be compared
• to identify any abnormalities(devation) from normal

finding/values.
• To aid in diagnosing patient condition (diagnostic

purpose)
• For therapeutic purpose so that to intervene accordingly

Vital sign…
❖ When to take Vital signs
• Vital signs are taken whenever the client is admitted to a health
care facility or service.
• For example:-
– Home health care
– Clinic or other ambulatory setting
– On a routine basis in the hospital.
– On admission ,before, during &after some nursing care.

Vital sign…
 The frequency of V/S measurements for the hospitalized client is
determined by;
✓The client’s health status
✓Physician orders and
✓The established standards of care for the particular
clinical setting or service.
 The sequence for recording vital signs measurement in the nurses’
notes is T->P->R-> BP./TPR&BP
 Vital sign guides nursing and medical decision making and
interventions

Equipment
• Vital sign tray
• Stethoscope
• Sphygmomanometer
• Thermometer (glasses, electronic and tympanic)
• Second hand watch
• Red and blue pen
• Pencil;
• Vital sign sheet
• Cotton swab in bowel
• Disposable gloves if available
• Dirty receiver kidney dish

Body Temperature
 Body temperature is the measurement of heat inside a
person’s body (core temperature); it is the balance
between heat produced and heat lost
 Body temperature is measured during the routine
physical examination
 Accuracy of temperature measurement is essential
 Temperature is consistently measured and recorded
using either the centigrade or Fahrenheit scale.

There are Two Kinds of Body Temperature
1. Core Temperature
• Is the Temperature of the deep tissues of the body,
such as the cranium, thorax, abdominal cavity, and
pelvic cavity
• Remains relatively constant
• Is the Temperature that we measure with thermometer
2. Surface Temperature:
• The temperature of the skin, the subcutaneous tissue
and fat

Body temperature …
Alterations in Body Temperature
• Normal body temperature is 370 C or 98.6 0F (Average)
• the range is 36-38 0c (96.8 – 100 0F)
• Pyrexia: a body temperature above the normal ranges 38 0c –
410 c (100.4 – 105.8 F)
• Hyper pyrexia: a very high fever, such as >41 0c leads to death.

• Hypothermia: – body temperature between 34 0c – 35 0c &, <
34 0c is death
• A client who has fever is referred as febrile; the one who has not
is a febrile.

Common Types of Fevers
1. Intermittent fever: the body temperature alternates at regular

intervals between periods of fever and periods of normal or
subnormal temperature.
2. Remittent fever: a wide range of temperature fluctuation

(more than 2 0c) occurs over the 24 hr period, all of which are
above normal
3. Relapsing fever: short febrile periods of a few days are

interspersed with periods of 1 or 2 days of normal temperature.
4. Constant fever: the body temperature fluctuates minimally but

always remains above normal
Factors Affecting Body Temperature
1. Age
• Children’s temperature continue to be more labile than those of
adults until puberty
• Elderly people, particularly those > 75 are at risk of
hypothermia
• Normal body temperature of the newborn if taken orally is 37
0C.
2. Diurnal variations (circadian rhythms)
• Body temperature varies throughout the day
• The point of highest body temperature is usually reached
between 8:00 p.m. and midnight and lowest point is reached
during sleep between 4:00 and 6:00 a.m.
Sex : during ovulation due to hormonal secretion or
progesterone female tmp.increases 0.65oc
Body Temperature…
 Centigrade to Fahrenheit conversion: multiply the centigrade
reading by 9/5 and add 32: °F = (°C × 9/5) + 32
 Fahrenheit to centigrade conversion: deduct 32 from the

Fahrenheit reading and multiply by 5/9: °C = (°F – 32) × 5/9.
 Sites to Measure Temperature
 Most common are:
 Oral
 Rectal
 Axillary
 Tympanic
Types of thermometer
 Oral thermometer
Has long slender tips
 Rectal thermometer
Short, rounded tips
 Axillary

Body Temperature…
 Rectal Temperature:
◦ Readings are considered to be more accurate, most reliable

◦ It is > 0.65°C higher than the oral temperature
 Procedure
➢ Explain the procedure to the patient
➢ Wash hands and assemble necessary equipment to the patient
bedside .Position the person laterally
➢ Apply lubricant 2.5 cm above the bulb;
➢ Insert the thermometer 1.5–2.5cm for infants, 3.5cm for
children and 4cm for adults into the rectum.
Body Temperature…
• Procedure …
➢Measured for 2-3 minutes
➢Remove the thermometer and read the finding
➢Clean the thermometer with tissue paper
➢A rectal thermometer record does not respond to
changes in arterial temperature as quickly as an oral
thermometer.

Body Temperature…
• Contraindications
Rectal or Perineal surgery
Fecal impaction – the depth of the thermometer
insertion may be insufficient
Rectal infection
Neonates –can cause rectal perforation and
ulceration

Body Temperature…
▪ Taking Oral Body Temperature.
❖Explain the procedure to the patient
❖Wash hands and assemble necessary equipment to the
patient bedside.
❖Position the person comfortably and request the patient
to open the mouth
❖Hold the thermometer firmly with the thumb and fore
finger
❖Shake it with strong wrist movements until the mercury
line falls to at least 35 °C.
Body Temperature…
❖ Place the bulb of the thermometer well under the client’s tongue.
❖ Instruct the client to close the lips (not the teeth) around the bulb
❖ Ensure that the bulb rests well under the tongue, where it will be
in contact with blood vessels close to the surface.
❖ Remove the thermometer after 3-5 min.
❖ Remove the thermometer, wipe it using once a firm twisting
motion
❖ Hold the thermometer at eye level.
❖ Read to the nearest tenth
❖ Wash the thermometer in lukewarm, soapy water.
❖ Dry and replace the thermometer in a container at bedside.
Body temperature…
• Contraindication
➢Child below 7 yrs
➢If the patient is mentally ill & unconscious
➢Uncooperative or in severe pain
➢Surgery of the mouth
➢Nasal obstruction
➢If patient has nasal or gastric tubes in place

Body temperature…
• Axillary
• Procedure
➢Wash hands
➢Explain the procedure to the client
➢Make sure that the client’s axilla is dry
➢After placing the bulb of the thermometer in to the
axilla, bring the client’s arm down against the body
as tightly as possible, with the forearm resting across
Body temperature…
➢Hold the glass thermometer in place for 8 to 10
minutes.
➢Hold the electronic thermometer in place until the

reading registers directly,
➢Remove and read the thermometer,
➢Dispose of the equipment properly,
➢Wash hands,
➢Record the reading.

Body temperature…
• Tympanic Temperature
– The tympanic temperature is placed snugly in to the

client’s outer ear canal.
– It records temperature in 1 to 2 seconds.
– Many pediatric and intensive care units use this type

of thermometer because it records a temperature so
rapidly

Body temperature…
• Procedure
❖Wash the hands
❖Explain the procedure to the client to ensure
cooperation and understanding
❖Hold the probe in the dominant hand.
❖Use the client’s same ear as your hand

Body temperature…
❖Select the desired mode of temperature.
❖Use the rectal equivalent for children under 3 years

of age Wait for “ready” message to display.
❖With your non dominant hand, grasp the adult’s

external ear at the midpoint.
❖Pull the external ear up and back.

Body temperature…
❖For a child of 6 years or younger, use your non
dominant hand to pull the ear down and back.
❖Slowly advance the probe in to the client’s ear with a
back and forth motion until it seals the ear canal.
❖Point the probe’s tip in an imaginary line from the
client’s sideburns to his or her opposite eyebrow.

Body temperature…
❖ As soon as the instrument is in correct position, press the
button to activate the thermometer.
❖ Keep the probe in place until the thermometer makes a sound

or flashes a light.
❖ Read the temperature and discard the probe cover.
❖ Replace the thermometer and wash your hands.
❖ Record the temperature on the client’s record

Sites of Taking body Temperature`
Oral No hot or cold drinks or Leave in place 3 min
smoking 20 min prior to temp.
Posterior sublingual Must be awake & alert.
pocket – under tongue Not for small children (bite
(close to carotid artery) down)
Axillary Non invasive – good for Leave in place 5-10 min.
Bulb in center of axilla children. Less accurate (no Measures 0.5 C lower than oral
Lower arm position across major bld vessels nearby) temp.
chest
Rectal When unsafe or inaccurate by Leave in place 2-3 min.
Side lying with upper leg mouth (unconscious, Measures 0.5 C higher than oral
flexed, insert lubricated bulb (1- disoriented or irrational)
1 1/2 inch adult) (1/2 inch Side lying position – leg flexed
infant)
Ear Rapid measurement 2-3 seconds
Close to hypothalmus – Easy assessibility
sensitive to core temp. changes Cerumen impaction distorts
Adult - Pull pinna up & back reading
Child – pull pinna down & back Otitis media can distort reading
Pulse
• It is a wave of blood created by contraction of the left
ventricle of the heart.
– i.e. the pulse reflects the heart beat or is the same as

the rate of ventricular contractions of the heart – in a
healthy person.
• In some types of cardiovascular diseases heartbeat and

pulse rate differs.
– E.g. Client's heart produces very weak or small

5/5/2021
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Mergitu E. (BSC, MSc)
in a peripheral pulse 151
far
Pulse…
• Pulse: is commonly assessed by palpation (feeling) or
auscultation (hearing)
• The middle 3 fingertips are used with moderate pressure for

palpation of all pulses except apical; the most distal parts are
more sensitive,
• Peripheral Pulse: is a pulse located in the periphery of the body
e.g. in the foot, and or neck
• Apical Pulse (central pulse): it is located at the apex of the
heart. The PR is expressed in beats/ minute (BPM)
• Pulse Deficit- It is a difference that exists between the apical
and radial pulse

Factors Affecting Pulse Rates
1. Age: as age increase the PR gradually decreases. New born to

1 month – 130 BPM 80-180 (range) and Adult 80 BPM (beat
per minute) – 60 – 100 BPM (beat per minute range )
2. Sex: after puberty the average males PR is slightly lower than
female
3. Exercise: PR increase with exercise
4. Fever: increases PR in response to the lowered B/P that results
from peripheral vasodilatation – increased metabolic rate
5. Medications: digitalis preparation decreases PR, Epinephrine –
increases PR

Con..
6. Heat: increase PR as a compensatory mechanism
7. Stress: increases the sympathetic nerve stimulation –
increases the rate and force of heart beat
8. Position changes: when a patient assumes a sitting or
standing position blood usually pools in dependent
vessels of the venous system. Pooling results in a
transient decrease in
• the venous blood return to heart and subsequent
decrease in BP increases heart rate

Pulse …
• Assess the pulse for
1.Rate:-
– Normal 60-100 b/min (80/min)
– Tachycardia – excessively fast heart rate (>100b/min)
– Bradycardia < 60b/min
2.Rhythm:-
– The pattern and interval between the beats expressed
as
• Random
• Irregular beats or
• Dysrythymia

Pulse …
3.Pulse Volume:- the force of blood with each beat
• A normal pulse can be felt with moderate pressure of the fingers

and can be obliterated with greater pressure.
• Full or bounding pulse forceful or full blood volume obliterated

with difficulty
• Weak, feeble or thready readily obliterate with pressure from the

finger tips

Pulse …
4.Elasticity of arterial wall
A healthy, normal artery feels, straight, smooth, soft
and pliable, easily bent after breaking
If the pulse is regular, count for 30 seconds and
multiply by 2
 If it is irregular count for 1 full minute

Pulse…
• Pulse Sites
➢Carotid:- at the side of the neck below tube of the ear
(where the carotid artery runs between the trachea
and the sternoclidiomastoid muscle)
➢Used routinely for infants and during shock or
cardiac arrest or to assess cranial circulation
➢Temporal:- the pulse is taken at temporal bone area.
➢Used routinely for infants and when radial is not
accessible

Pulse…
➢Apical: at the apex of the heart: is used to assess apical-
radial deficit
—Routinely used for infant and children<3 yrs
 In adults–Left midclavicular line under the 4th, 5th,
6th intercostals space
 Children < 4 yrs of the left midclavicular line

Pulse …
• Brachial: at the inner aspect of the biceps muscle of the

arm or medially in the antecubital space (elbow crease)
• Used in cardiac arrest for infants, to assess lower arm

circulation, and to auscultate blood pressure

Pulse…
➢ Radial: on the thumb side of the inner aspect of the
wrist – readily available and routinely used
✓Used routinely in adults to assess character of
peripheral pulse
➢ Femoral: along the inguinal ligament.
✓Used for infants and children
➢ Popiliteal: behind the knee.
✓By flexing the knee slightly

Pulse…
➢ Posterior tibial: on the medial surface of the ankle
➢ Pedal (Dorslais Pedis): palpated by feeling the dorsum

(upper surface) of the foot on an imaginary line drawn
from the middle of the ankle to the surface between the
big and 2nd toes

Normal Heart Rate
Age Heart Rate (Beats/min)
Infants 120-160
Toddlers 90-140
Preschoolers 80-110
School agers 75-100
Adolescent 60-90
Adult 60-100

Procedure for measuring radial pulse (the most common
 Wash hands
 Explain the procedure to the client
 Position the client’s fore arm comfortably with the wrist extended and the
palm down
 Place the tips of your first, second, and third fingers over the client’s radial
artery on the inside of the wrist on the thumb side.
 Press gently against the client’s radial artery to the point where pulsation
can be felt distinctly
 Using a watch, count the pulse beats for 30 seconds and multiply by two to
get the rate per minute
 Count the pulse for full minute if it is abnormal in any way or take an
apical pulse
 Record the rate (BPM) on paper or the flow sheet. Report any irregular
findings to appropriate person
 Wash your hands

Respiration
✓Respiratory assessment is the measurement of the breathing
pattern
✓Respiration is the act of breathing (includes intake of O2 and

removal of CO2)
✓Ventilation is another word, which refer to the movement of

air in and out of the lungs
✓Hyperventilation: very deep, rapid respiration
✓Hypoventilation: very shallow respiration

Respiration…
• Two Types of Breathing
1. Costal (thoracic)
– Involves the external muscles and other accessory
muscles (sternoclodio mastoid)
– Observed by the movement of the chest up ward and
down ward.
Commonly used for adults
2. Diaphragmatic (abdominal)
– Involves the contraction and relaxation of the
diaphragm, observed by the movement of abdomen.
– Commonly used for children
Respiration …
• Assessment
➢The client should be at rest,
➢Assessed by watching the movement of the chest or
abdomen
➢Rate, rhythm, depth and special characteristics of
respiration are assessed

Respiration …
1. Rate: is described in respiration per minute (RPM)
– Healthy adult RR = 12- 20/ min.
– Is measured for full minute, if regular for 30 seconds.
– As the age decreases the respiratory rate increases.
➢ Eupnea- normal breathing rate and depth
➢ Bradypnea- slow respiration rate
➢ Tachypnea - fast breathing
➢ Apnea – temporary cessation of breathing

Respiration …
2.Rhythm:- is the regularity of expiration and inspiration
• Normal breathing is automatic & effortless.
3.Depth:- described as normal, deep or shallow.
➢ Deep:- a large volume of air inhaled & exhaled, inflates
most of the lungs.
➢ Shallow:- exchange of a small volume of air minimal
use of lung tissue.

Assessing Respiration
Rate # of breathing cycles/minute (inhale/exhale-1cycle)
N – 12-20 breaths/min – adult - Eupnea – normal rate & depth breathing
Abnormal increase – tachypnea
Abnormal decrease – bradypnea
Absence of breathing – apnea
Depth Amt. of air inhaled/exhaled

normal (deep & even movements of chest)
shallow (rise & fall of chest is minimal)
SOB or shortness of breath (shallow & rapid)
Rhythm Regularity of inhalation/exhalation

Normal (very little variation in length of pauses b/w I&E
Character Digressions from normal effortless breathing

Dyspnea – difficult or labored breathing

Blood Pressure
 Blood pressure is the pressure exerted by blood against the wall of blood
vessels. It includes arterial, venous and capillary pressures
 Arterial BP: it is a measure of a pressure exerted by the blood as it flows

through the arteries. Arterial blood pressure (BP) = cardiac output (CO)
x total peripheral resistance (TPR).
❖There are two types of blood pressure.
Systolic pressure: is the pressure of the blood as a result of contraction

of the ventricle
Diastolic blood pressure: is the pressure when the ventricles are at rest

Blood Pressure…
Pulse pressure: is the difference between the systolic and
diastolic pressure
• Blood pressure is measured in mm Hg and recorded as fraction.
• An increase in blood pressure is called hypertension
• A decrease in BP is called hypotension
• Sites for Measuring Blood Pressure
➢Upper arm- using brachial artery (commonest)
➢Thigh - around Popiliteal artery
➢Fore arm - using radial artery
➢Leg- using posterior tibial or dorsal Pedis

Blood Pressure…
✓ Blood pressure can be assessed directly or indirectly
1.Direct:- it is an invasive procedure
✓ Measurement involves the insertion of catheter in to the brachial, radial
or femoral artery.
✓ The clinician inserts the catheter and monitors the pressure reading.
✓ With use of correct placement, it is highly accurate.
2.Indirect (non invasive methods)
◦ The auscultator
◦ The palpatory
 The auscultatory method is the commonest method used in
health activities.
Blood Pressure…
• Purpose
– To obtain base line measure of arterial blood pressure
for subsequent evaluation
– To determine the clients homodynamic status
– To identify and monitor changes in blood pressure

resulting from a disease process and medical therapy

Blood Pressure…
• EQUEPMENT
– Stethoscope
– Blood pressure cuff of the appropriate size
– Sphygmomanometer

Blood Pressure…
 Procedure
1.Prepare and position the patient appropriately
✓Make sure that the client has not smoked or ingested

caffeine, with in 30 minutes prior to measurement.
✓Position the patient in sitting position
✓The arm should be slightly flexed with the palm of the

hand facing up and the fore arm supported at heart level
✓Expose the upper arm

Blood Pressure…
2. Wrap the deflated cuff evenly around the upper
arm.
✓Apply the center of the bladder directly over the
medial aspect of the arm.
✓The bladder inside the cuff must be directly
over the artery to be compressed if the reading
to be accurate.
✓For adult, place the lower border of the cuff
approximately 2 cm above antecubital space.
Blood Pressure…
3. For initial examination, perform preliminary palpatory
determination of systolic pressure
✓Palpate the brachial artery with the finger tips
✓Close the valve on the pump by turning the knob
clockwise.
✓Pump up the cuff until you no longer feel the brachial
pulse
✓Note the pressure on sphygmomanometer at which the
pulse is no longer felt
✓Release the pressure completely in the cuff, and wait 1 to 2
minutes before making further measurement
Blood Pressure…
4.Position the stethoscope appropriately
✓ Insert the ear attachments of the stethoscope in your ears so that

they tilt slightly fore ward.
✓ Place the diaphragm of the stethoscope over the brachial pulse;

hold the diaphragm with the thumb and index finger.
5. Auscultate the client's blood pressure
✓ Pump up the cuff until the sphygmomanometer registers about 30

mm Hg above the point where the brachial pulse disappeared.

Blood Pressure…
✓ Release the valve on the cuff carefully so that the
pressure decreases at the rate 2-3 mmHg per second.
✓ As the pressure falls, identify the manometer reading at
each of the five phases
✓ Deflate the cuff rapidly and completely

Blood pressure classification for adults
Blood pressure Systolic blood Diastolic blood
category pressure (mmHg) pressure (mm Hg)
Optimal < 120 < 80

and
Normal 120–129 and 80–84
High normal 130–139 or 85–89
Stage 1 hypertension 140–159 or 90–99
or
Stage 2 hypertension 160–179 100–109
or
Stage 3 hypertension ≥ 180 ≥ 110

Factors affecting BP
Age Medications
Stress Nutrition
 Elasticity of the blood
Gender vessels
Stroke volume  Arteriosclerosis
Obesity
Peripheral Hemorrhage
resistant

Study guide questions:-
1.Explain vital sings and list what it includes.
2.Identify important times to assess vital signs.
3.What does pulse deficit mean?
4.What is pulse pressure?
5.Define arterial blood pressure.
6.Explain the two methods of assessing blood pressure.
7.Mention some of the factors affecting body temperature.

8. Mention some of the factors affecting pulse rate.
9. Mention some of the factors affecting BP.
10. Mention some of the factors affecting RR.

Good luck
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AMBO UNIVERSTY

College of medicine and health science

5/5/2021 By, Mergitu E. (BSC, MSc) 1

❖Outline the historical background of nursing

❖Identify the contribution of significant individuals

❖Describe the nursing

Florence Nightingale “The act of utilizing the environment of the

Verginia Henderson (1960)"The unique function of the

• Nursing is concerned with health promotion, health maintenance,

 Nursing encompasses autonomous and collaborative care

 It includes the promotion of health, the prevention of

 Nursing is as sciences it is based on the body of

 The consideration of these both sciences and art help

5/5/2021 By, Mergitu E. (BSC, MSc) 6

The Recipients of Nursing are sometimes called consumers,

• A consumer is an individual, a group of people, or a community

5/5/2021 By, Mergitu E. (BSC, MSc) 7

• A patient is a person who is waiting for or undergoing medical

• A client is a person who engages the advice or services of

Nursing practice involves four areas: promoting health and

5/5/2021 By, Mergitu E. (BSC, MSc) 9

• This may involve individual and community activities

– preventing drug and alcohol misuse

– restricting smoking, and

– preventing accidents and injury in the home and

Nursing activities that prevent illness include;

• prenatal and infant care, and

• prevention of sexually transmitted disease.

In the past, the acute care hospital was the main

Today many nurses work in hospitals, they work

5/5/2021 By, Mergitu E. (BSC, MSc) 12

• The history of Nursing in Ethiopia

• Over review of nursing theory

• Definition of terms related to theory

• Relationship of theory to practice and research

• Major nursing theories used for nursing practice

5/5/2021 By, Mergitu E. (BSC, MSc) 14

• Criteria to be a profession: distinct body of

• Ultimate goal is to support excellence in

5/5/2021 By, Mergitu E. (BSC, MSc) 15

Caregiver encompasses the physical, psychosocial,

• The nursing process provides nurses with a framework

5/5/2021 By, Mergitu E. (BSC, MSc) 17

maintain their health

5/5/2021 By, Mergitu E. (BSC, MSc) 18

• A client advocate acts to protect the client.

• They also assist clients in exercising their rights and help

5/5/2021 By, Mergitu E. (BSC, MSc) 19

• It involves providing emotional and psychological

5/5/2021 By, Mergitu E. (BSC, MSc) 20

• The nurse manager also delegates nursing

5/5/2021 By, Mergitu E. (BSC, MSc) 21

❖The nursing process is the framework for providing

❖The steps of the nursing process build upon each

5/5/2021 By, Mergitu E. (BSC, MSc) 22

 it is also defined as an organized, systematic method

The purpose of the nursing process is to provide care