Nonmaleficence is doing no

RABE 1 FUNDA 
harm, as stated in the historical
Hippocratic Oath. Harm can be
Ethics, simply defined, is a principle that intentional or unintentional.
describes what is expected in terms of
right and correct and wrong or incorrect  Accountability is accepting
in terms of behavior. For example, responsibility for one's own
nurses are held to ethical principles actions. Nurses are accountable
contained within the American Nurses for their nursing care and other
Association Code of Ethics. Ethics and actions. They must accept all of
ethical practice are integrated into all the professional and personal
aspects of nursing care. consequences that can occur as
the result of their actions.
The two major classifications of ethical
principles and ethical thought are  Fidelity is keeping one's promises.
utilitarianism and deontology. The nurse must be faithful and
Deontology is the ethical school of true to their professional
thought that requires that both the promises and responsibilities by
means and the end goal must be moral providing high quality, safe care
and ethical; and the utilitarian school of in a competent manner.
ethical thought states that the end goal
justifies the means even when the  Autonomy and patient self-
means are not moral. determination are upheld when
the nurse accepts the client as a
The ethical principles that nurses must unique person who has the
adhere to are the principles of justice, innate right to have their own
beneficence, nonmaleficence, opinions, perspectives, values and
accountability, fidelity, autonomy, and beliefs. Nurses encourage
veracity. patients to make their own
decision without any judgments
 Justice is fairness. Nurses must be or coercion from the nurse. The
fair when they distribute care, for patient has the right to reject or
example, among the patients in accept all treatments.
the group of patients that they
are taking care of. Care must be  Veracity is being completely
fairly, justly, and equitably truthful with patients; nurses
distributed among a group of must not withhold the whole
patients. truth from clients even when it
may lead to patient distress.
 Beneficence is doing good and
the right thing for the patient.
The most commonly occurring ethical are present in order to resolve ethical
issues and concerns in healthcare concerns and ethical dilemmas.
include the allocation of scarce
resources and end of life issues. In addition to utilizing these resources,
the nurse can take appropriate actions
Bioethics is a subcategory of ethics. when faced with an ethical dilemma by
Bioethics addresses ethical concerns like understanding and applying the ethical
those that occur as the result of guidelines provided in the American
advancing science and technological Nurses Association's Code of Ethics, the
advances. Some of the most common, American Medical Association's Code of
current bioethical issues revolve around Ethics, the World Medical Association's
stem cells, cloning, and genetic Code of Ethics, the American Nurses
engineering. Association's Standards of Care and
Standards of Practice, American Nurses
Association's position papers such as
Recognizing Ethical that which describes the ethical use of
narcotic analgesics at the end of life
Dilemmas and Taking even if this medication hastens death,
Appropriate Action state board of nursing declaratory
statements, and the International Nurses
Nurses have the responsibility to Association's Code of Ethics.
recognize and identify ethical issues that
The steps of the ethical decision making
affect staff and patients. For example,
process, like the problem solving
providing nursing care for clients
process, are:
undergoing an abortion may raise
ethical and moral concerns and issues
 Problem Definition. Problem
for some nurses; and some patients may
definition is the clear description
be affected with a liver transplant
of the ethical dilemma and the
rejection because donor livers are not
circumstances revolving around
abundant enough to meet the needs of
it.
all patients who request it.
 Data Collection. During this phase
Many hospitals, medical centers and
of the ethical decision making
other healthcare facilities have
process includes a review of
multidisciplinary ethics committees that
ethical codes, published evidence
meet as a group and resolve ethical
based practices, declaratory
dilemmas and conflicts. Nurses should
statements, professional position
avail themselves to ethicists and ethical
papers and the professional
committees within their facility when
literature.
such ethical resources and mechanisms
  Data Analysis. The collected data can and do affected client care. For
is then organized and analyzed. example, providing nursing care for
clients undergoing an abortion may
 The Identification, Exploration raise ethical and moral concerns and
and Generation of Possible issues for some nurses; and some
Solutions to the Problem and the patients may be affected with a liver
Implications of Each. All possible transplant rejection because donor livers
solutions and alternatives to are not abundant enough to meet the
resolve the ethical dilemma are needs of all patients who request it.
explored and evaluated.
Although a rare occasions, a patient
 Selecting the Best Possible may, at times, ask you to do something
Solution. All potential solutions that is not ethical. For example, a patient
and alternatives are considered may ask a nurse to assist in their suicide
and then the best and most at the end their life or they may inquire
ethical action is taken. about another patient in terms of their
diagnosis. When something like this
 Performing the Selected Desired occurs, the nurse must inform the client
Course of Action to Resolve the that they cannot do it for ethical and
Ethical Dilemma legal reasons.

 Evaluating the Results of the Clients may also need information about
Action. Like the evaluation phase ethics can affect the care that they
of the Nursing Process, actions to choose or reject. For example, a client
resolve ethical issues are may ask the nurse about whether or not
evaluated and measured in terms it is permissible ethically and legally to
of their effectiveness to resolve reject CPR at the end of life or to take
the ethical dilemma. pain medications even if it hastens their
death.

Informing the Client and

Staff Members of Ethical Practicing In a Manner
Issues Affecting Client Care Consistent with The
American Nurses
Nurses have the responsibility to identify
ethical issues that affect staff members Association's Code of
and patients; and they also have the Ethics and Other Ethical
responsibility to inform staff members
and affected clients of ethical issues that Codes
As previously discussed, nurses are – Branch of Philosophy w/c
expected to apply the ethical guidelines determines right and wrong
provided in the American Nurses Moral – personal/private
Association's Code of Ethics, interpretation from what is good and
the American Medical Association's bad.
Code of Ethics, the World Medical Ethical Principles:
Association's Code of Ethics, 1. Autonomy – the right/freedom to
the American Nurses Association's decide (the patient has the right
Standards of Care and Standards of to refuse despite the
Practice, American Nurses Association's explanation of the
position papers such as that which nurse) Example:  surgery, or any
describes the ethical use of narcotic procedure
analgesics at the end of life even if this 2. Nonmaleficence – the duty not
medication hastens death, state board to harm/cause harm or inflict
of nursing declaratory statements, and harm to others (harm maybe
the International Nurses Association's
physical, financial or social)
Code of Ethics.
3. Beneficence- for the goodness
and welfare of the clients
The American Nurses Association's Code 4. Justice – equality/fairness in
of Ethics, for example, contains elements terms of resources/personnel
that emphasize and speak to advocacy,
5. Veracity – the act of truthfulness
collaboration with others, the
6. Fidelity – faithfulness/loyalty to
clients
maintenance of client safety, the dignity
Moral Principles:
and worth of all human beings, the
1. Golden Rule
prohibition of any discrimination,
2. The principle of Totality – The
accountability, the preservation of
whole is greater than its parts
patient rights, such as dignity, autonomy
3. Epikia – There is always an
and confidentiality, and the provision of
exemption to the rule
competent, safe and high quality care of
4. One who acts through as agent
nursing care. is herself responsible –
(instrument to the crime)
ETHICO-MORAL 5. No one is obliged to betray
herself – You cannot betray
ASPECTS IN yourself
6. The end does not justify the
NURSING means
7. Defects of nature maybe
Ethos – comes from Greek work corrected
w/c means character/culture 8. If one is willing to cooperate in
the act, no justice is done to him
 9. A little more or a little less does search for properties.
not change the substance of an Private/Civil Law – body of law that
act. deals with relationships among
10. No one is held to impossible private individuals
Law – rule of conduct commanding Public law – body of law that deals
what is right and what is wrong. with relationship between
Derived from an Anglo-Saxon term individuals and the
that means “that which is laid down State/government and government
or fixed” agencies. Laws for the welfare of
Court -body/agency in government the general public.
wherein the administration of justice Private/Civil Law :
is delegated.
Plaintiff – complainant or person 1. Contract law – involves the
who files the case (accuser) enforcement of agreements
Defendant – accused/respondent or among private individuals or the
person who is the subject of payment of compensation for
complaint failure to fulfill the agreements
Witness – individual held upon to Ex. Nurse and client nurse
testify in reference to a case either and insurance
for the accused or against the Nurse and employer client
accused. and health agency
Written orders of court – an agreement between 2 or
1. Writ – legal notes from the court more competent person to
do or not to do some
A. Subpoena lawful act.
1. Subpoena Testificandum – a – it maybe written or oral=
writ/notice to an both equally binding
individual/ordering him to Types of Contract:
appear in court at a specific
time and date as witness. 1.  Expressed –when 2 parties
2. Subpoena Duces Tecum- notice discuss and agree orally or in
given to a witness to appear in writing the terms and conditions
court to testify including all during the creation of the contract.
important documents Example:
Summon – notice to a nurse will work at a hospital for only a
defendant/accused ordering him to stated length of time (6 months),under
appear in court to answer the stated conditions (as volunteer, straight
complaint against him AM shift, with food/transportation
Warrant of Arrest – court order to allowance)
arrest or detain a person
Search warrant – court order to
2. Implied – one that has not been incorrectly or ACT
explicitly agreed to by the parties, OF OMMISION –
but that the law considers to exist. something that
should have been
Example: done but was not.
Nurse newly employed in a hospital is
expected to be competent and to follow Classification of Tort
hospital policies and procedures even
though these expectations were not 1. Unintetional
written or discussed.
a. Negligence – misconduct or
Likewise: the hospital is expected to practice that is below the standard
provide the necessary supplies, expected of
equipment needed to provide ordinary, reasonable and prudent
competent, quality nursing care. person
– failure to do something due to
Feature/Characteristics/
lack of foresight or prudence
Elements of a lawful contract:
– failure of an individual
1. Promise or agreement between
to provide care that a
2 or more persons for the
reasonable person would
performance of an action or
ordinarily use in a
restraint from certain actions.
similar circumstance.
2. Mutual understanding of the
– An act of omission or
terms and meaning of the
commission wherein a nurse
contract by all.
fails to act in
3. A lawful purpose – activity must
accordance with the
be legal
standard of care.
4. Compensation in the form of
Doctrines of Negligence:
something of value-monetary
Persons who may not enter into a 1. Res ipsa loquitor – the thing
contract: minor, insane, deaf, mute speaks for itself – the injury is
and ignorant enough proof of negligence
2. Respondeat Superior – let the
1. Tort law – is a civil wrong master answer command
committed against a person or a responsibility
person’s property. 3. Force majuere – unforeseen
– person/person’s event, irresistible force
responsible for the tort are
b. malpractice – stepping
sued for DAMAGES
beyond one’s authority
– Is based on : ACT OF
COMMISSION – 6 elements of nursing malpractice:
something that was done
 1. duty – the nurse must have the client
a relationship with the client Example: physical
that involves providing care injury, medical
and following an acceotable cost/expenses, loss of wages,
standard of care. pain and

2. breach of duty – the suffering

standard of care expected in
a situation was not observed 6. damages – amount of
by the nurse money in payment of
damage/harm/injury
-is the failure to act as a
reasonable, prudent nurse under II. Intentional Tort
the
Unintentional tort – do not require
circumstances
intent bur do require the element of
-something was HARM
done that should not Intentional tort – the act was done
have been done or on PURPOSE or with INTENT
nothing – No
harm/injury/damage is
was done when it needed to be liable
should have been done
– No expert
3. foreseeability – a link must witnesses are needed
exist between the nurse’s act and
the injury suffered 1. Assault – an attempt or threat to
touch another person
4. causation – it must be unjustifiably
proved that the harm occurred as a Ex.: A person who threatens
direct result of the someone with a club or closed
fist.
nurse’s failure to follow
the standard of care and the Nurse threatens a client
nurse should or with an injection after
could have known that refusing to take the meds
the failure to follow the orally.
standard of care 1. Battery – willful touching of a
could result in such person, person’s clothes or
harm. something the person is
5. harm/injury –physical, carrying that may or may not
financial, emotional as a result of cause harm but the touching
the breach of duty to was done without permission,
 without consent, is whatever purpose without
embarrassing or causes injury. client’s consent.
Example: c. Public disclosure of private
a nurse threatens the patient with facts – private information
injection if the patient refuses his is given to others who
medsorally.  If the nurse gave the
have no legitimate need
injection without client’s consent, the
nurse would be committing battery even for that.
if the client benefits from the nurse’s d. Putting a person in a
action. false/bad light – publishing
information that is normally
1. False Imprisonment – considered offensive but
unjustifiable detention of a which is not true.
person without legal warrant to 1. Defamation – communication
confine the person that is false or made with a
– occurs when clients are careless disregard for the truth
made to wrongful believe and results in injury to the
that they cannot leave the reputation of a person
place Types:
Example:
Telling a client no to leave the hospital 1. Libel – defamation by means
until bill is paid of print, writing or picture
Use of physical or chemical restraints
False Imprisonment Forceful
Example: writing in the
Restraint=Battery chart/nurse’s notes that doctor A
is incompetent because he didn’t
1. Invasion Of Privacy – intrusion respond immediately to a call
into the client’s private domain
-right to be 1. Slander – defamation by the
left alone spoken word stating
Types of Invasion the client unprivileged (not legally
must be protected from: protected) or false word by
which a reputation is
a. use of client’s name for damaged
profit without consent – Example: Nurse A telling a client
using one’s name, that nurse B is incompetent
photograph for
advertisements of HC – person defamed may bring
agency or provider without the lawsuit
client’s permission – the material (nurse’s notes)
b. Unreasonable intrusion – must be communicated to
observation or taking of a 3  party in order that the
rd

photograph of the client for person’s reputation maybe

harmed
Public Law: standard of care that a reasonable
person would use in a particular set of
1. Criminal Law – deals with circumstances.”  Malpractice is a more
[1]

actions or offenses against the specific term that looks at a standard of

safety and welfare of the public. care, as well as the professional status
of the caregiver.”  [2]

1. homicide – self-defense
2. arson- burning or property To prove negligence or malpractice, the
3. theft – stealing following elements must be established
4. sexual harassment in a court of law:
5. active euthanasia
6. illegal possession of controlled  Duty owed the patient
 Breach of duty owed the patient
drugs  Foreseeability
Homicide – killing of any person  Causation
without criminal intent may be done  Injury
as self-defense  Damages [3]

Arson – willful burning of property

Theft – act of stealing To avoid being sued for negligence or
malpractice, it is essential for nurses
and nursing students to follow the scope
1.6 LEGAL CONSIDERATIONS & and standards of practice care set forth
ETHICS by their state’s Nurse Practice Act; the
American Nurses Association; and
OPEN RESOURCES FOR employer policies, procedures, and
NURSING (OPEN RN) protocols to avoid the risk of losing their
nursing license. Examples of nurses
Legal Considerations breach of duty that can be viewed as
negligence include: [4]

As discussed earlier in this chapter,  Failure to Assess: Nurses should assess for
nurses can be reprimanded or have all potential nursing problems/diagnoses,
their licenses revoked for not not just those directly affected by the
appropriately following the Nurse medical disease. For example, all patients
Practice Act in the state they are should be assessed for fall risk and
practicing. Nurses can also be held appropriate fall precautions implemented.
legally liable for negligence, malpractice,  Insufficient monitoring: Some conditions
or breach of patient confidentiality when require frequent monitoring by the nurse,
providing patient care. such as risk for falls, suicide risk, confusion,
and self-injury.
 Failure to Communicate:
Negligence and o Lack of documentation: A basic rule of
Malpractice thumb in a court of law is that if an
assessment or action was not documented,
it is considered not done. Nurses must
Negligence is a “general term that document all assessments and
denotes conduct lacking in due care, interventions, in addition to the specific type
carelessness, and a deviation from the
 of patient documentation called a nursing shared with others. Therefore, all types
care plan. of patient information should only be
o Lack of provider notification: Changes in shared with health care team members
patient condition should be urgently who are actively providing care to them.
communicated to the health care provider
based on patient status. Documentation of How do HIPAA regulations affect you as
provider notification should include the date, a student nurse? You are required to
time, and person notified and follow-up
adhere to HIPAA guidelines from the
actions taken by the nurse.
moment you begin to provide patient
 Failure to Follow Protocols: Agencies and care. Nursing students may be
states have rules for reporting certain disciplined or expelled by their nursing
behaviors or concerns. For example, a program for violating HIPAA. Nurses
nurse is required to report suspicion of who violate HIPAA rules may be fired
patient, child, or elder abuse based on data from their jobs or face lawsuits. See the
gathered during an assessment. following box for common types of
HIPAA violations and ways to avoid
Patient Confidentiality them.
Common HIPAA Violations and
Ways to Avoid Them [5]

In addition to negligence and

malpractice, patient confidentiality is a 1. Gossiping in the hallways or
major legal consideration for nurses and otherwise talking about patients
nursing students. Patient where other people can hear
confidentiality is the right of an you. It is understandable that you
individual to have personal, identifiable will be excited about what is
medical information, referred to as happening when you begin
protected health information (PHI), kept working with patients and your
desire to discuss interesting things
private. This right is protected by federal
that occur. As a student, you will
regulations called the Health Insurance be able to discuss patient care in a
Portability and Accountability Act confidential manner behind closed
(HIPAA). HIPAA was enacted in 1996 doors with your instructor.
and was prompted by the need to However, as a health care
ensure privacy and protection of professional, do not talk about
personal health records and data in an patients in the hallways, elevator,
environment of electronic medical breakroom, or with others who are
records and third-party insurance not directly involved with that
payers. There are two main sections of patient’s care because it is too
HIPAA law, the Privacy Rule and the easy for others to overhear what
you are saying.
Security Rule. The Privacy Rule
2. Mishandling medical records or
addresses the use and disclosure of leaving medical records
individuals’ health information. The unsecured. You can breach
Security Rule sets national standards for HIPAA rules by leaving your
protecting the confidentiality, integrity, computer unlocked for anyone to
and availability of electronically access or by leaving written
protected health information. HIPAA patient charts in unsecured
regulations extend beyond medical locations. You should never share
records and apply to patient information your password with anyone else.
 Make sure that computers are be shared with the parent unless
always locked with a password written permission is provided,
when you step away from them even if the minor is living at home
and paper charts are closed and and/or the parents are paying for
secured in an area where their insurance or health care. As a
unauthorized people don’t have general rule, any time you are
easy access to them. NEVER take asked for patient information,
records from a facility or include a check first to see if the patient has
patient’s name on paperwork that granted permission.
leaves the facility. 6. Texting or e-mailing patient
3. Illegally or unauthorized information on an unencrypted
accessing of patient files. If device. Only use properly
someone you know, like a encrypted devices that have been
neighbor, coworker, or family approved by your health care
member is admitted to the unit you facility for e-mailing or faxing
are working on, do not access their protected patient information. Also,
medical record unless you are ensure that the information is
directly caring for them. Facilities being sent to the correct person,
have the capability of tracing address, or phone number.
everything you access within the 7. Sharing information on social
electronic medical record and media. Never post anything on
holding you accountable. This rule social media that has anything to
holds true for employees who do with your patients, the facility
previously cared for a patient as a where you are working or have
student; once your shift is over as clinical, or even how your day went
a student, you should no longer at the agency. Nurses and other
access that patient’s medical professionals have been fired for
records. violating HIPAA rules on social
4. Sharing information with media. , ,
[6] [7] [8]

unauthorized people. Anytime
you share medical information with
anyone but the patient themselves, Social Media Guidelines
you must have written permission
to do so. For instance, if a Nursing students, nurses, and other
husband comes to you and wants health care team members must use
to know his spouse’s lab results, extreme caution when posting to
you must have permission from his
Facebook, Instagram, Twitter,
spouse before you can share that
information with him. Just Snapchat, and other social media sites.
confirming or denying that a Information related to patients, patient
patient has been admitted to a unit care, and/or health care agencies
or agency can be considered a should never be posted on social media;
breach of confidentiality. health care team members who violate
5. Information can generally be this guideline can lose their jobs and
shared with the parents of may face legal action and students can
children until they turn 18, be disciplined or expelled from their
although there are exceptions to nursing program. Be aware that even if
this rule if the minor child seeks you think you are posting in a private
birth control, an abortion, or
group, the information can become
becomes pregnant. After a child
turns 18, information can no longer public.
 The American Nurses Association In addition to legal considerations, there
(ANA) has established the following are also several ethical guidelines for
principles for nurses using social media: nursing care.
[9]

There is a difference between morality,

 Nurses must not transmit or place online ethical principles, and a code of
individually identifiable patient information. ethics. Morality refers to “personal
 Nurses must observe ethically prescribed
values, character, or conduct of
professional patient-nurse boundaries.
 Nurses should understand that patients, individuals within communities and
colleagues, organizations, and employers societies.”  An ethical principle is a
[11]

may view postings. general guide, basic truth, or

 Nurses should take advantage of privacy assumption that can be used with
settings and seek to separate personal and clinical judgment to determine a course
professional information online. of action. Four common ethical
 Nurses should bring content that could harm principles are beneficence (do good),
a patient’s privacy, rights, or welfare to the nonmaleficence (do no harm), autonomy
attention of appropriate authorities. (control by the individual), and justice
 Nurses should participate in developing (fairness). A code of ethics is set for a
organizational policies governing online
profession and makes their primary
conduct.
obligations, values, and ideals explicit.

In addition to these principles, the ANA The American Nursing Association

has also provided these tips for nurses (ANA) guides nursing practice with
and nursing students using social the Code of Ethics for Nurses.  This
[12]

media: [10]
code provides a framework for ethical
nursing care and a guide for decision-
 Remember that standards of making. The Code of Ethics for Nurses
professionalism are the same online as in serves the following purposes:
any other circumstance.
 Do not share or post information or photos
 It is a succinct statement of the ethical
gained through the nurse-patient
relationship. values, obligations, duties, and
 Maintain professional boundaries in the use professional ideals of nurses individually
of electronic media. Online contact with and collectively.
patients blurs this boundary.  It is the profession’s nonnegotiable
 Do not make disparaging remarks about ethical standard.
patients, employers, or coworkers, even if  It is an expression of nursing’s own
they are not identified. understanding of its commitment to
 Do not take photos or videos of patients on society.[13]

personal devices, including cell phones.

 Promptly report a breach of confidentiality or
privacy. The ANA Code of Ethics contains nine
provisions. See a brief description of
each provision in the following box.
Code of Ethics Provisions of the ANA Code of
Ethics [14]

The nine provisions of the ANA

Code of Ethics are briefly described scholarly inquiry, professional
below. The full code is available to standards development, and the
read for free at Nursingworld.org. generation of both nursing and
health policy.
Provision 1: The nurse practices
with compassion and respect for the Provision 8: The nurse
inherent dignity, worth, and unique collaborates with other health
attributes of every person. professionals and the public to
protect human rights, promote
Provision 2: The nurse’s primary health diplomacy, and reduce health
commitment is to the patient, disparities.
whether an individual, family, group,
community, or population. Provision 9: The profession of
nursing, collectively through its
Provision 3: The nurse promotes, professional organizations, must
advocates for, and protects the articulate nursing values, maintain
rights, health, and safety of the the integrity of the profession, and
patient. integrate principles of social justice
into nursing and health policy.
Provision 4: The nurse has
authority, accountability, and
responsibility for nursing practice;
Code of Medical Ethics
makes decisions; and takes action Opinion 1.1.1
consistent with the obligation to
promote health and to provide The practice of medicine, and its
optimal care. embodiment in the clinical
Provision 5: The nurse owes the encounter between a patient
same duties to self as to others, and a physician, is
including the responsibility to fundamentally a moral activity
promote health and safety, preserve that arises from the imperative
wholeness of character and
integrity, maintain competence, and to care for patients and to
continue personal and professional alleviate suffering. The
growth. relationship between a patient
Provision 6: The nurse, through
and a physician is based on
individual and collective effort, trust, which gives rise to
establishes, maintains, and physicians’ ethical responsibility
improves the ethical environment of to place patients’ welfare above
the work setting and conditions of
employment that are conducive to
the physician’s own self-interest
safe, quality health care. or obligations to others, to use
sound medical judgment on
Provision 7: The nurse, in all roles patients’ behalf, and to advocate
and settings, advances the
profession through research and for their patients’ welfare.
 A patient-physician relationship
exists when a physician serves
a patient’s medical needs.
Generally, the relationship is Professional–Patient Relationship:
entered into by mutual consent III. Ethical Issues
between physician and patient III. ETHICAL ISSUES
(or surrogate).
However, in certain Until recently in the history of
circumstances a limited patient- healthcare, writing about and
physician relationship may be reflection on ethical issues in
created without the patient’s (or the health professional–
surrogate’s) explicit agreement. patient relationship have
Such circumstances include: focused primarily on the
1. When a physician provides interactions and expectations
emergency care or provides of two individuals: a
care at the request of the professional (traditionally, a
patient’s treating physician. In physician) and a patient. The
these circumstances, the relationship usually is
patient’s (or surrogate’s)
between a patient and a wide
agreement to the relationship
is implicit. range of health
2. When a physician provides professionals. Today, several
medically appropriate care for basic ethical values, moral
a prisoner under court order, in duties and rights, and virtues
keeping with ethics guidance continue to be relevant to
on court-initiated treatment. their interaction. The
3. When a physician examines a emphasis in this section of
patient in the context of an the entry is on concrete
independent medical questions related to morality.
examination, in keeping with
Thus, enduring normative
ethics guidance. In such
situations, a limited patient- ethical foundations of the
physician relationship exists. relationship as well as issues
that have become relevant
because of changes in the
character of the relationship
and the institutional settings CONDUCT-RELATED
in which it takes place will be ISSUES. Issues related to
discussed. In normative morally right conduct in a
ethics, basic questions relationship are understood
include, "What types of acts through an examination of
are morally right (or wrong)?" moral obligations and rights
and "What are the morally in the relationship. Today
praiseworthy (or some of the most
blameworthy) virtues of the fundamental have been
individuals or groups developed into general
involved?" categories
called principles. Several key
Conduct, Virtue, and Context
principles that ought to be
in the Professional–Patient
present in the professional–
Relationship
patient relationship are
Normative ethical judgments described later in this
about a relationship can be section.
made on the basis of
VIRTUE-RELATED
whether right conduct is
ISSUES. A second area of
exhibited by the parties
ethical issues is understood
toward each other, and
through an examination of
whether praiseworthy
the good or praiseworthy
character traits and
habits and dispositions of the
dispositions (virtues) that
parties in the relationship.
ought to manifest themselves
Here the focus is less on the
within the relationship are
things people do and more
present. The context in which
on the types of people
the relationship takes place
they are. Just as we can
also has moral relevance.
engage in reflection about
Ethical issues can arise from
ethical principles that help to
any of the three.
elucidate right from wrong
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reasoned judgments about
the character traits and expectations of the parties,
attitudes that people ought to the utility and function of the
exhibit in a relationship. For relationship, and the role of
example, we expect a person society's expectations.
with virtue to be more
disposed to honor another's A consideration of several
values and to try to create a dominant models that have
better community than would been proposed to
a person who lacks it. On this characterize this relationship
basis alone it is justifiable to will aid in the reader's
place expectations of virtue understanding of the ethical
on certain relationships. issues discussed in this
Some of the most basic article.
virtues that have bearing on Moral Models of the
the professional–patient Relationship
relationship also are
discussed later in this Robert Veatch was one of
section. the first contemporary
bioethicists to seriously
CONTEXTUAL consider that various moral
CONSIDERATIONS. Issues models exist. He offered four
involving judgments about models of the physician–
the conduct and virtues that patient relationship:
are morally appropriate may the priestly model, an
vary according to the larger explicitly paternalistic and
social and institutional value-laden approach in
context in which the which the physician assumes
relationship takes place. One competence not only for
needs to assess, for medical facts but also for
example, the special naming and interpreting
peculiarities of the way in value dimensions of
which the relationship was healthcare decisions on the
formed, the genesis of patient's behalf;
explicit or implicit the engineering model, in
which the physician acts as a technical expert only; in
scientist dealing with facts the interpretive model, the
divorced from questions of patient's life is viewed as a
value; the collegial model, in specific story
which physician and patient or narrative from which a
become pals assuming mutual understanding of
equality through mutual trust appropriate goals and
and loyalty; and interventions are derived;
the contractual model, which and in the deliberative
entails a mutual model, the physician, who
understanding of benefits provides the relevant
and responsibilities information to the patient,
incumbent on each person also acts as a combined
involved (Veatch, 1972). teacher-friend to empower
the patient in ways that are
In 1992, Ezekial Emanuel consistent with the patient's
and Linda Emanuel, two health-related values.
physician bioethicists, also
presented four models with Sheri Smith was among the
some parallels, but set the first to distinguish models of
context as one in which each the nurse–patient
model demonstrates the relationship, though others
tension between patients's have followed. In
autonomy and their health as the surrogate mother model,
well as among various the nurse is morally obliged
physician and patient values: to assume ultimate
In the paternalistic model, the responsibility for the well-
physician independently acts being and care of an
on behalf of the patient's essentially passive patient;
well-being; at the opposite the technician model
pole, in the informative characterizes the nurse's
model, the patient receives responsibility as limited to
all information and the competently applying
physician serves as a technical knowledge and
skills to meet the patient's patient (Bandman and
needs; and the contracted Bandman).
clinician model defines the
nurse's responsibility by the U.S. law places the
values and rights of the professional–patient
patient and assumes that the relationship in the class of
patient is capable of fiduciary relationships. In
determining her or his own fiduciary relationships "each
best interests (Smith). [person] must repose trust
and confidence in the other
In spite of important and must exercise a
differences, the similarities corresponding degree of
among all three models are fairness and good faith,"
more important. They point to because the two persons
a progression over time from cannot expect to have all of
traditional paternalism to the usual facts that would
more mutuality and shared allow them to contract as
decision making. Several equals (Garner, p. 640). This
models support the idea of law is used by the legal
the professional as a patient profession to help hold
(or client) advocate. The physicians (and, to varying
advocacy idea suggests that degrees, other health
a patient's health-related professionals) accountable
rights must be protected and for the fact that they have the
the health professional is in a greater measure of power
unique—or at least within the relationship and
opportune—position to may not be able to equalize
protect these rights. Lively that power merely by
debate continues for and disclosing relevant
against adopting the information to patients or
advocacy idea as the central their families. Trust is the
moral role of the health bridge to the success of the
professional in relation to the relationship, and the burden
is on the professional not
only to engender the patient's healthcare organizations,
trust but also to build a solid and patients's rights
foundation of trustworthiness documents, as well as many
upon which the patient can other ethics writings. The
depend. principle assumes that
persons have inherent or
The following discussion essential worth simply
provides the reader with because they are human
some basic components of beings. Diverse
ethical thought common to all philosophical, religious, and
of the models. scientific understandings of
Ethical Principles in the the nature of persons provide
Professional–Patient a wide base upon which the
Relationship health professions can
ground this ideal (Lammers
Several ethical principles are and Verhey). But the
relevant in an analysis of the principle also presents
professional–patient challenges to health
relationship and provide professionals: One is to
insight into its ethical discern categories of beings
foundations. Among the most that are persons; another is
important are respect for to discern practical direction
persons, nonmaleficence, from such a general ideal.
beneficence, veracity, For example, two health
autonomy, and justice. professionals may agree on
RESPECT FOR a Judeo-Christian-Islamic
PERSONS. Respect for interpretation that all persons
persons, highlighting the have worth or dignity
dignity of the patient as a because they are equally
person, is found in the children of God. They may
preambles of most follow the influential notion of
professional codes of ethics, the philosopher Immanuel
mission statements of Kant (1724–1804) that
persons must be treated as
ends and not as means to to live in any other type of
ends, yet the two may differ society would make each of
in their positions regarding us too vulnerable. This duty,
the moral status of the fetus he adds, is not covered by
and come to different the duty to prevent or remove
conclusions about whether a existing harm, or to do good
life-saving liver transplant (Ross).
should be given to a person
who has an acute alcohol The duty of nonmaleficence
addiction. In spite of its places the professional on
difficulties, however, this alert that society reasonably
principle makes a signal expects him or her not to be
contribution to the an agent of harm. Debate
understanding of the about physician-assisted
professional–patient dying, euthanasia, and
relationship by counseling abortion often focuses on the
professionals against making interpretation of harm and
hasty or arbitrary distinctions. the physician's, pharmacist's,
nurse's or other health
NONMALEFICENCE. The professional's role in
maxim to do no participating in activities that
harm, primum non cause harm. Discussion of
nocere, often is cited as the maleficence must take into
first ethical principle of account that some types of
medical practice. Its meaning harm are necessary in the
and usefulness can be name of a patient's greater
gleaned from the serious good: For example, the
thought given to the concept patient undergoes the harm
in deontological (duty- of the surgical knife in order
oriented) approaches to to have the pathology
moral philosophy. W. D. removed.
Ross argues that it is our
stringent duty to inflict no BENEFICENCE. The
harm intentionally, because principle of beneficence
delineates conduct directed to treat the patient's type of
to the welfare of others and condition. Therefore, the
is pivotal in the principle is put to the test
understanding of the when the professional is
professional–patient prejudiced against persons of
relationship. Since its a certain ethnicity, age,
inception, the relationship gender, religious conviction,
has had its grounding in the sexual orientation, or any
idea that the professional's other characteristic, and
ethical priority is to further therefore finds it difficult to
the welfare of a patient. give a full measure of
Other worthy goals, such as attention to members of such
furthering the knowledge groups. A health professional
about disease and its cure, also may judge an individual
or earning a just wage, or patient undesirable on the
maintaining the efficiency or basis of poor personal
financial solvency of the hygiene, irritating personality
institution, must take a lesser traits, or lifestyle choices. In
position on the scale of each case, the health
priorities. professional must regard the
patient in the relationship as
Taken in combination with worthy of treatment however
the principle of respect for great a gulf exists between
persons, the principle of their respective values. If
beneficence highlights that their differences create so
health professionals have a great a barrier on the part of
moral obligation to provide the professional that it
optimum care to all kinds of prevents good care, he or
patients with whom they are she must attempt to assure
in a professional relationship, that the patient receives it
assuming that the patient's from someone else. In short,
problem lends itself to the health professional must
healthcare intervention and focus on the person's needs
the professional is competent whether the patient be model
citizen or thief, old or young, necessary, in a benevolent
man or woman, likable or lie and bearing responsibility
not. for having breached the
patient's moral expectation
VERACITY. Philosophers that veracity would be
may treat the principle of honored.
truth telling as a separate
principle. More often today, Today this belief has shifted,
however, it is conceived as at least in some major
derived from respect for subcultures of North
persons (Veatch, 2003). America and Europe where
However, treating it as a the belief is that hope is
derived principle in this case enhanced by the patient's
only strengthens it since it is ability to take control of
derived from such a important life events. In other
fundamental moral premise words, the fostering of hope
of healthcare. is not dependent solely on
whether the truth is shared
Given the moral stringency of directly with the patient. More
truth telling, an interesting determinative is the role of
ethical quandary arises when veracity in maintaining a
it falls to the professional to patient's exercise of
convey bad news to patients autonomy and capability to
and families. Health actively participate in
professionals long have decisions. This interpretation,
believed that patients want however, does not
professionals to help them necessarily lead to
maintain hope in the face of professional conduct
catastrophe. In 1932, Nicolai consistent with it. For
Hartman noted that for example, Nicholas Christakis
centuries this was interpreted observed that physicians
as requiring the professional tend to convey information
to protect patients from the about a poor prognosis in a
truth at times, engaging, if way that avoids giving the
worst aspects and conforms historical roots of
to what the physician libertarianism in the United
believes the patient's States, first introduced as a
expectations are. political theory under the
influence of such British
AUTONOMY AND SELF- thinkers as John
DETERMINATION. In the Locke (1632–1704) and John
tradition of medical ethics, Stuart Mill (1806–1873), had
discussion regarding begun to seriously influence
autonomy did not focus on the character of the
patient autonomy but on the professional–patient
professional's autonomy, the relationship in the direction of
assumption being that honoring the patient's agency
freedom from impingement in healthcare decisions.
by others on his or her Although related to the idea
clinical judgment and that the patient should have
practice was a key means to access to the truth in
acting beneficently on behalf accordance with the principle
of the patient's best interests. of veracity, autonomy goes
However, there are beyond that aspect.
numerous government
regulations and other The principle of autonomy
controls within healthcare provided a social groundwork
today that restrict for the introduction of the
professional autonomy, idea of patients' rights within
causing thoughtful health the relationship. Applied to
professionals to worry the patient's situation the
whether they will be able to principle evolved from being
honor basic professional viewed as the patient's
tenets of the professional– prerogative to refuse
patient relationship. treatment to the negative
right to refuse it, and finally to
By the beginning of the the positive right to play a
twentieth century the central role in determining
the course of treatment. For effective when the patient is
example, the increased unable to express his or her
emphasis on informed wishes on the spot.
consent as the brokering chip
in the relationship places a In spite of the central role of
major focus on the patient's patient autonomy in bioethics
role as an active agent in discourse and the medical-
treatment decisions. legal aspects of health
Today informed professions' practice, lively
consent modes range from discussion about its
explicit or presumed consent appropriate moral limits is
in special situations to the growing (Schneierman).
more commonly discussed For example, new attention is
explicit consent. Moreover, in being devoted to tensions
1990 the U.S. Congress that develop when there is a
passed the Patient Self- serious disjuncture between
Determination Act, which the patient's expressed
took the idea of patient wishes and the professional's
autonomy as a right more judgment of how best to
deeply into the legal and life- carry out the professional
span arenas. The law was a obligations of beneficence
legislative mandate that and nonmaleficence. In other
patients have an opportunity words, under what conditions
to express their wishes about is it morally permissible for
potential treatments in critical the physician or other
situations. This form of professional to go against the
advance consent was patient's informed
buttressed through numerous preferences (hard
cases and laws affirming use paternalism) or not seek the
of living wills, durable power patient's input (soft
of attorney and other paternalism)?
surrogate/proxy or
substituted judgment The weight of moral opinion
mechanisms that are today supports at least four
areas of paternalistic professional engage in a
conduct. In the first instance clinically indicated and legally
the conduct is justified when sanctioned option that is
the professional knows for a morally repugnant to the
certainty that the intervention professional may cause
will harm the patient. moral distress for the
(How harm is defined professional and can be
becomes extremely denied. In this case, although
important. For instance, if he or she is not morally
death is judged an obligated to personally
unacceptable harm the participate in the intervention,
professional may engage in a the patient must be placed in
kind of vitalism that imposes the hands of another
additional suffering on a competent professional who
dying patient). A second can more sympathetically
situation exists when the assess the patient's informed
intervention being sought wishes.
goes beyond or against the
public moral mandate of Two critical concerns are
medicine and the other being raised regarding the
health professions. Third, centrality of patient autonomy
professionals need not be in the professional–patient
held hostage to patient relationship. The first
wishes that will be of no addresses an increased
benefit whatsoever to the awareness of the importance
patient even if it does no of diversity by professionals
harm. The idea of futility, In order to meet the moral
though imperfectly developed mandates of cultural
to date, is an attempt to sensitivity and cultural
provide criteria for setting competence, the professional
boundaries that will prevent must have a deep
these potential misuses of understanding of how various
healthcare. And fourth, a cultures conceptualize
request by a patient that the individual, family and clan
roles in regards to decision the professional–patient
making (Hyun). In some relationship, this has several
groups the professional's implications. First, its
insistence on the patient's relationship to beneficence is
individual informed consent apparent: The patient can
is morally and socially expect to be treated fairly.
antithetical to healing or Persons seeking treatment
other appropriate reasons for should not be given
seeking out professional advantage on the basis of
attention. A second concern arbitrary favoritism or be left
arises in instances of high out on the basis of arbitrary
medical/clinical uncertainty. dislike. The rules will be
The professional's disposition applied consistently, taking
to shared decision making into account legitimate
often falters, likely due to a departures from the norm.
fear that an admission of For instance, a procedural
uncertainty will undermine rule of first come, first served
the patient's or family's will be applied except in
confidence or create cases where greater need
additional stress for them morally requires that the rule
(Parascandola, Hawkins, and be flexible enough to allow
Danis). Both of these for valid exceptions.
concerns warrant careful
attention and research. The principle of justice raises
important ethical issues
JUSTICE. The principle of related to the allocation of
justice, stated simply, is that scarce resources. Health
each should get his or her professionals abide by a duty
due. What is due must be of beneficence, but that duty
derived from the high moral does not entail the
standards of healthcare and prerogative of automatically
the information available providing a disproportionate
about what will create the amount of a scarce resource
most benefit. At the level of to any one person, even if
that person's need could distribution of U.S.
warrant receiving all of it. The healthcare benefits and
resulting allocation may have burdens in spite of legislation
a relatively deleterious effect designed to prevent them
on one or more other (Garner). Other barriers are
patients because their imposed by today's
optimum benefits are bureaucratic context of
compromised. For example, healthcare: institutional
a nursing shortage on a unit mechanisms and societal
may require the nurses to arrangements designed to
make difficult (though not foster efficiency, profit, or
arbitrary) decisions about other goals, but not the
patient-care priorities. patient's well-being (Stein).
The relationship does not
Compensation for harm also stand in isolation from these
derives from our influences, all of which have
understanding of what justice profound effects on it.
requires. A patient who is
harmed in the relationship The health professional who
through, say, professional is committed to upholding the
error, has a right to know that profession's moral ideals
the harm has occurred and must work not only to
may wish to seek preserve justice within the
compensation for the harm. relationship directly but also
to remove barriers to it on a
Serious barriers to justice broader scale so that the
often arise outside of the appropriate ends of
relationship. Societal healthcare can be realized.
discrimination against
patients on the basis of race, Conflicts among Principles
ethnicity, religion, sex, and
age are well documented, As illustrated by the issue of
and continue to contribute to paternalism in truth-telling
serious disparities in the situations and the
compromise of beneficence
in situations of scarce right frame of mind and
resources, conflicts among heart. A life of moral virtue is
this set of general principles characterized by dispositions
inevitably arise in everyday and attitudes that can be
professional–patient cultivated into habits of
relationship situations. In preparedness that enable a
actual situations, person to act in ways that
professionals usually can use further the good of a
the basic moral ideas relationship or community.
imbedded in the principles as Aristotle also underscored
guides to set priorities the importance of the
consistent with the values of person's desire to become a
healthcare, the professions's good person, which in turn
moral codes and standards, requires knowledge of
and patients's informed ultimate goods and ends.
preferences. At the same Aristotle did not divorce
time, not all conflicts can be virtue from the realm of
resolved and sometimes feelings and emotions,
principles seem to remove us suggesting instead that acts
a step further from the arising out of various
immediacy of the situation. dispositions will give
pleasure and that, at the
Virtue in the Professional–
same time, ethical action
Patient relationship
resulting from a virtuous
Cognizant of the limitations in disposition requires the
an ethics based entirely on exercise of reason.
conduct, Aristotle
Since the late twentieth
in Nichomachean
century, several leading
Ethics suggested the
ethicists have led a lively re-
alternative of a focus
examination of the virtues
on virtues by those who are
that should be expressed by
decisionmakers so that they
health professionals. Notable
approach moral conflict in the
among them are Edmund
Pellegrino and David are understood differently
Thomasma who propose that today than in the past, and
the contemporary reappraisal our understanding of human
is not an attempt to demean relationships in general
the emphasis on rights-and- continues to undergo new
duty-based ethics, "but a evaluation. It is not surprising
recognition that rights and that our understanding of the
duties notwithstanding, their virtues also continues to
moral effectiveness still turns evolve. The following two
on dispositions and character illustrations of this evolution
traits of our fellow men and by no means exhaust the
women" (Pellegrino and important work that is being
Thomasma, p. 113). conducted in this area.
A challenge throughout the BENEVOLENCE AND
ages has been to identify CONSIDERATIONS OF
dispositions that the TRUST. The traditional
professional should cultivate professional virtue of
so as to further the good and benevolence or kindness has
proper ends of healthcare. enjoyed a long history in the
Many virtues have been writings on the professional–
proposed, among them patient relationship. This
benevolence and kindliness, character trait evokes
compassion, integrity, pictures of a physician,
honesty, fairness, midwife, or nurse sitting
conscientiousness, fidelity quietly at the bedside,
beyond duty, and humility. reassuring a patient, an
image consistent with a
These virtues are as period in which the
appropriate in today's professional was viewed as a
professional–patient kindly person who used the
relationship as they have limited technologies available
always been. However, some to minister to the clinical and
things about the relationship emotional needs of a
trusting, mostly passive commitment to respecting
patient. Today the notion of the patient's rights and
benevolence must be refined dignity assures the patient
to adapt to a relationship in that he or she is in the hands
which patients are active of a benevolent professional.
participants in the interaction,
suggesting that kindness met Benevolence as traditionally
by blind trust taken alone are understood is challenged
not adequate ingredients for further by a revitalized
the tasks of this relationship emphasis on professionalism
to be accomplished. At the in the medical profession. In
very least an adequate this broader
notion of professional conceptualization
benevolence today must benevolence commitments
include an examination of explicitly include
how the professional's competence, honesty,
trustworthiness figures in the confidentiality, maintenance
professional–patient of appropriate boundaries,
relationship. improvement of the quality of
and access to care, and
For example, traditionally management of conflicts of
confidentiality focused on the interest, to name some.
physician's duty. To the Moreover, a rise in the
extent that the physician had literature on such dimensions
cultivated a benevolent of the physician's moral role
disposition toward the as that of dealing positively
patient, the duty would come with professionals' errors
more naturally. Today the (Kohn et al.) and fatigue
moral focus has shifted to the (Gaba and Howard) are
patient, particularly to his or expanding the scope of what
her right to expect benevolence entails today.
confidentiality. Only
trustworthiness based on the COMPASSION AND
professional's authentic CONSIDERATIONS OF
CARING. Compassion also itself in the everyday work of
has long been viewed as a professionals. Among
virtue that should contemporary bioethicists
characterize the Warren Reich makes an
professional–patient important contribution to the
relationship. Compassion understanding of compassion
often has been interpreted by relating different modes of
according to its etymological compassion to different
root, "to suffer with." phases of a patient's
Theories vary about what, suffering. Care in the
exactly, this means in the relationship between health
healthcare context, but one professional and patient also
central theme is that healing has been seen as an activity
is enhanced when that reflects an attitude of
professionals exhibit a sensitivity to the patient's
disposition and ability to deepest values and
sympathize deeply with the concerns.
patient's plight. The
cultivation of this disposition Anne Bishop and John
leads the professional to Scudder propose that "Being
recognize that the key issue compassionate is not
is not only "Have I done my something that human
duty?" (e.g., truth telling) but beings can achieve by an act
also "Have I been sensitive of will. It is possible,
to the effect my approach will however, to be open to
have?" (e.g., how, when, by compassion, to be situated
whom, and where this so that compassion is likely
information should be to be evoked…" (p. 81). They
disclosed). The central notion conclude that professionals
of caring in the professional– who do not feel compassion
patient relationship sheds but have a deep desire to
light on important ways in show caring(i.e., feel called
which the virtue of to care) can actually express
compassion might manifest care by a focus on fostering
the patient's well-being as associated with women,
well as a commitment to full social devaluation of
participation in being an professions that promote
excellent practitioner. In care as a centerpiece of their
some current approaches to identity could follow to the
professional care, patient's detriment (Nelson).
compassion or other virtues Therefore, when a health
are not invoked at all; rather professional expresses care
the emphasis turns to a patient he or she may
exclusively to conduct and also appear to condone
behaviors that various injustices that derive from
professions describe being in a society that
as caring behaviors with the devalues women in a care-
goal of incorporating them giving role (Condon). At the
into an assessment of same time, recipients of care
measurable outcomes in may be forced into
patient management (Galt). stereotyped roles
This latter approach diverges of dependency. Eva Feder
dramatically from the Kittay calls for a
traditional and most reassessment of the
contemporary research on dichotomy often viewed as
the role of care and its existing between caregiver
relationship to compassion in and care receiver. Clearly,
the larger ethical context of the role of care and its
the professional–patient relationship to compassion
relationship. There have also warrants continued attention.
been serious caveats raised
Existential Dimensions of
about a professional ethic
the Patient's Experience:
based primarily on the
Implications for the
concept of care. Professional–Patient
Aware of problems created Relationship
by sexism, and that caring The existential dimensions of
and the care-giving role are the patient's experience also
deserve consideration in the helping the patient recognize
relationship. Existential, as aspects of him- or herself
used here, refers to the that the person may not even
human quest for meaning in be conscious of is the
the face of our limitations, professional's act of pattern
among them illness and recognition. The
death. Especially significant professional, acting as
are new insights regarding facilitator, can show how the
the health professional's role pieces fit. Once identified,
in exploring the existential professional and patient can
meaning of illness for a work together toward
patient. mutually agreed upon health
goals. Bishop and Scudder
One aspect of the exploration capture the essence of the
has focused on the professional's position in this
professional's desire and task as being a caring
ability to individualize the presence, a "personal
patient's situation and story: presence that assures others
Respect in the relationship of another's concern for their
rests on a premise that well-being" (Bishop and
health professionals are Scudder, p. 41).
called into a particular
relationship with patients Narratives, the patient's and
because of the importance of the professional's, are the
the illness experience to the professional's means of
patient, and the medium of gaining insight into the
that relationship is the existential complexities of the
patient's story (Purtilo and professional–patient
Haddad). The notion of relationship (Greenhalgh and
patients's patterns is the term Horwitz). Sociologist Arthur
used by Margaret Newman W. Frank, drawing partially
to describe what has value— on his own illness
is meaningful—in a patient's experiences
life. The professional's skill in (from patienthood to survivor
ship roles), powerfully respect the patient's story.
illustrates how the moral Even those who are so
responsibility of survivorship disposed may meet barriers
is to reconstruct, put back because both professional
together, a life that had been and patient believe that the
altered by interventions and professional holds the key to
professional interactions. knowing the real
Through that process the problem (i.e., the medical
wounded also becomes problem). The power
healer, but the process differential built into the
requires the mutual effort of structure of the relationship
professional and patient. means that the professional
When the professional, is believed to be empowered
through narrative, shows to to impute the real meaning of
the patient a personality with the patient's story. A
emotions, likes and dislikes, concentrated effort must be
fears and dreams, hopes and made to overcome such a
faults, the patient has a barrier (Brody). Merging from
greater opportunity to such thinking and reflection
understand that there is on the existential aspects of
a person in the professional the relationship and its key
role, not just a bundle of members are new materials
competencies and technical for refining their encounter,
skills. The patient becomes new ethical dimensions to
more trusting that his or her build on the traditional
own personality has a foundations of moral
chance of being taken obligations, rights, and
seriously (Purtilo). virtues. The healing quest
will be for the discovery of
Howard Brody, a physician the patient's lost or changed
bioethicist, notes that the self, not just for removal of a
challenge does not lie only in disease that resides in that
the professional's desire and person, and the recognition
willingness to hear and that in the deepest sense
each party is affected by the when dissatisfaction or
relationship. questions arise. This
advocate may learn that a
Mechanisms for Resolving
patient or family believes that
Ethical Conflict in the
the patient is being harmed
Professional–Patient
Relationship by receiving substandard
treatment. While not all such
Ethical issues in the situations involve ethical
professional–patient issues, many do. The
relationship are receiving advocate may act as a direct
more attention in the liaison between the parties or
everyday environments of may refer the issue to one of
healthcare. Inevitably, the other mechanisms
differences in judgment, even designed to provide
deeply held differences, arise assistance.
between professional and
patient (or the patient's Second, ethics consultants
family). Conflict does not are being hired by many
always denote a feeling of major hospitals. Their charge
animosity. Often it signals a is to deal with ethical issues
frustration shared by all regarding patient-care
involved in not knowing the decisions. Depending on the
best way to proceed. institution, the ethics
consultation service may be
There are several accessed by the physician,
mechanisms designed to nurse or other professional,
assist patients in such patient, or patient's family.
situations. First, the patient Usually the consultant meets
representative or patient with all the relevant parties to
ombudsperson is an help them identify the ethical
employee of the provider issues involved, reason
institution who is charged about the issues, and make
with being available to recommendations for how to
patients and their families weigh conflicting priorities.
The consultant does not resolution of conflict when it
make the final decision, does occur in the
which is correctly left to be professional–patient
decided within the relationship.
professional–patient
relationship. Legal Responsibilities of Nurses

Third, clinical ethics

committees are present in Nurses have to abide by laws
many healthcare and regulations when practicing
environments. Usually nursing. All of the regulations and
multidisciplinary, they legal aspects of nursing are
function in a manner similar
to the ethics consultant. taught and explained to nurses
Sometimes an ethics throughout nursing school. Not
consultant will be called first, abiding by the code of ethics
and if he or she thinks that
could cost the nurse his or her
the issue merits further
deliberation by several nursing license and result in a
different disciplines and malpractice suit.
personalities, may call the
ethics committee together. Nurse Practice Act
Everyone would agree that Every state has a Nurse Practice
whenever possible,
prevention is the best Act, which states all the
approach to moral conflict in guidelines and laws for the
a professional or institutional nurses who are licensed to
setting. The professional's practice in the state. The act
diligence in communication,
technical competence, and includes the limitations and
caring are keys to conflict training specifications of each
prevention, as well as nurse. This means that each
powerful instruments for
nurse has been trained in a
specific area of nursing; patient and watch for any
therefore, the nurse must abnormalities or complications
practice in that area only. If a that may occur. If any occur, the
nurse is not trained to administer nurse must access a physician to
medication or treatment to a provide immediate care for the
patient, the nurse is not permitted patient.
to do so. The nurse must consult
Administering Medication
with a physician or other nursing
authority when a situation arises Any nurse who is certified to
that the nurse is not certified to administer medication to a
handle. Any wrongdoing is a patient must do so accurately
violation of this act, and the and timely. The nurse has the
nurse may lose his or her nursing legal responsibility to interpret
license, as well as having a suit the charts and files of a patient
filed against him or her or the and to understand what allergic
health care agency or hospital. reactions patients may or may
not have to a certain medication.
Patient Advocate
If a nurse does not administer the
A nurse has the legal correct dosage or medication to a
responsibility to be the advocate patient, the patient could suffer
for the patient in all health care major health risks or even death.
instances, including This is grounds for a malpractice
emergencies. The nurse will be suit against the nurse and health
the liaison between the physician care facility.
and the patient. The nurse has
Patient Neglect
the legal duty to monitor the
The nurse will provide care for family members of patients.
the patient he or she is Before a patient may undergo
monitoring at all times. If the surgery, he or she will need to
patient needs assistance with sign a consent form. If the nurse
any issues, such as hygiene, the is administering the treatment,
nurse has the legal responsibility such as anesthesia, it is the
to assist the patient. If a nurse nurse’s legal obligation to explain
does not monitor and provide the negatives and positives of the
care to the patient, this can be anesthesia. The patient or family
considered patient neglect, which member must then sign a
is unethical and illegal. The consent form acknowledging that
patient may try to move and use the patient understands the
the restroom on his or her own procedure. If this form is not
and may be physically injured in signed and complications occur,
the process. Some patients may the nurse may face legal
harm themselves while under the consequences.
influence of medication, which
Legal Liability in Nursing:
should not happen if the nurse is
Areas of Liability
paying proper attention to his or
Nurses can be held legally liable for a variety
her patient. of reasons. This lesson explains legal liability,
negligence and malpractice. It also explores
specific areas of nursing liability.
Consent Forms
https://study.com/academy/lesson/legal-
liability-in-nursing-areas-of-liability.html
Nurses have the legal
responsibility to explain all
treatment, medications and lab 3.3 PATIENT’S BILL OF RIGHTS
results to patients or authorized OPEN RESOURCES FOR
NURSING (OPEN RN)
Th Patient’s Bill of Rights is an evolving students, residents, or other
document related to providing culturally trainees.
competent care. In 1973 the American 5. The patient has the right to know
Hospital Association (AHA) adopted the the immediate and long-term
financial implications of treatment
Patient’s Bill of Rights.  See the
[1]

choices, insofar as they are

following box to review the original known.
Patient’s Bill of Rights. The bill has since 6. The patient has the right to make
been updated, revised, and adapted for decisions about the plan of care
use throughout the world in all health prior to and during the course of
care settings. There are different treatment and to refuse a
versions of the bill, but, in general, it recommended treatment or plan of
safeguards a patient’s right to accurate care to the extent permitted by law
and complete information, fair treatment, and hospital policy and to be
and self-determination when making informed of the medical
health care decisions. Patients should consequences of this action. In
case of such refusal, the patient is
expect to be treated with sensitivity and
entitled to other appropriate care
dignity and with respect for their cultural and services that the hospital
values. While the Patient’s Bill of Rights provides or transfer to another
extends beyond the scope of cultural hospital. The hospital should notify
considerations, its basic principles patients of any policy that might
underscore the importance of cultural affect patient choice within the
competency when caring for people. institution.
Patient’s Bill of Rights [2] 7. The patient has the right to have
an advance directive (such as a
1. The patient has the right to living will, health care proxy, or
considerate and respectful care. durable power of attorney for
2. The patient has the right to and is health care) concerning treatment
encouraged to obtain from or designating a surrogate
physicians and other direct decision-maker with the
caregivers relevant, current, and expectation that the hospital will
understandable information honor the intent of that directive to
concerning diagnosis, treatment, the extent permitted by law and
and prognosis. hospital policy. Health care
3. Except in emergencies when the institutions must advise patients of
patient lacks decision-making their rights under state law and
capacity and the need for hospital policy to make informed
treatment is urgent, the patient is medical choices, ask if the patient
entitled to the opportunity to has an advance directive, and
discuss and request information include that information in patient
related to the specific procedures records. The patient has the right
and/or treatments, the risks to timely information about hospital
involved, the possible length of policy that may limit its ability to
recuperation, and the medically implement fully a legally valid
reasonable alternatives and their advance directive.
accompanying risks and benefits. 8. The patient has the right to every
4. Patients have the right to know the consideration of privacy. Case
identity of physicians, nurses, and discussion, consultation,
others involved in their care, as examination, and treatment should
well as when those involved are
 be conducted so as to protect influence the patient’s treatment
each patient’s privacy. and care.
9. The patient has the right to expect 13. The patient has the right to
that all communications and consent to or decline to participate
records pertaining to his/her care in proposed research studies or
will be treated as confidential by human experimentation affecting
the hospital, except in cases such care and treatment or requiring
as suspected abuse and public direct patient involvement and to
health hazards when reporting is have those studies fully explained
permitted or required by law. The prior to consent. A patient who
patient has the right to expect that declines to participate in research
the hospital will emphasize the or experimentation is entitled to
confidentiality of this information the most effective care that the
when it releases it to any other hospital can otherwise provide.
parties entitled to review 14. The patient has the right to expect
information in these records. reasonable continuity of care when
10. The patient has the right to review appropriate and to be informed by
the records pertaining to his/her physicians and other caregivers of
medical care and to have the available and realistic patient care
information explained or options when hospital care is no
interpreted as necessary, except longer appropriate.
when restricted by law. 15. The patient has the right to be
11. The patient has the right to expect informed of hospital policies and
that, within its capacity and practices that relate to patient
policies, a hospital will make a care, treatment, and
reasonable response to the responsibilities. The patient has
request of a patient for appropriate the right to be informed of
and medically indicated care and available resources for resolving
services. The hospital must disputes, grievances, and conflicts,
provide evaluation, service, and/or such as ethics committees, patient
referral as indicated by the representatives, or other
urgency of the case. When mechanisms available in the
medically appropriate and legally institution. The patient has the
permissible, or when a patient has right to be informed of the
so requested, a patient may be hospital’s charges for services and
transferred to another facility. The available payment methods.
institution to which the patient is to
be transferred must first have
accepted the patient for transfer. Why Is Communication
The patient must also have the Important in Nursing?
benefit of complete information
and explanation concerning the
need for, risks, benefits, and Having good communication skills is
alternatives to such a transfer. essential to collaborating on teams with
12. The patient has the right to ask your fellow nurses and colleagues from
and be informed of the existence
other disciplines. It’s also important to
of business relationships among
the hospital, educational patient-centered care.
institutions, other health care
providers, or payers that may
Nurses who take the time to listen and For nurses, good communication in
understand the concerns of each of their healthcare means approaching every
patients are better prepared to address patient interaction with the intention to
issues as they arise, resulting in better understand the patient’s concerns,
patient outcomes. experiences, and opinions. This
includes using verbal and nonverbal
communication skills, along with active
On the other hand, poor communication, listening and patient teach-back
or lack of communication in healthcare, techniques. Below, we explore 10
can lead to patients misunderstanding communication skills that are important
directions and failing to follow treatment for nurses.
protocols. It can also lead to workflow
breakdowns on the team, resulting
in a medical error. A report by the Joint 1. Verbal Communication
Commission found that
poor communication in
healthcare during patient transfers Excellent verbal communication is key.
contributed to 80% of serious medical Aim to always speak with clarity,
errors. accuracy, and honesty. It’s also
important to know your audience and
speak appropriately according to the
Additionally, patients who have person’s age, culture, and level of health
established an open and secure literacy. If you are feeling stressed out
dialogue with a nurse or healthcare or frustrated, be aware of your tone of
provider are more likely to disclose the voice and don’t let these emotions leak
true extent of their symptoms. According into your patient interaction. You can:
to the book Interpersonal Relationships:
Professional Communication for Nurses
by Arnold and  Encourage patients to communicate
by asking open questions like, “Can
Boggs, healthcare communication comp
you tell me a bit more about that?”
etency offers a primary means for  Avoid condescending pet names like
establishing a trusting, collaborative “honey” or “sweetie” and instead use
relationship with patients and families. the patient’s first name or name of
Interpersonal communication skills choice.
influence the quality of decisions made,  Speak in clear, complete sentences
as well as the level of patient motivation and avoid technical jargon.
to follow treatment protocols and
achieve desired clinical outcomes. 2. Nonverbal Communication

10 Effective Using elements of nonverbal

communication—such as facial
Communication Skills for expressions, eye contact, body
Nurses language, gestures, posture, and tone of
voice—is also essential in creating
rapport. Simply smiling can go a long
way. You can also:
  Show interest in what the patient is  Make notes immediately following
saying by maintaining eye contact patient care so you do not forget
and nodding your head. anything.
 Smile, but don’t stare.  Write legibly and clearly, using simple
 Sit down when you can, and lean language.
forward to show you’re engaged.  Be sure to note accurate dates and
 Use nonthreatening body language times.
that conveys openness.
5. Presentation Skills
3. Active Listening

Effective presentation skills are most

“Active listening” means listening in applicable during “handover”—when you
order to understand the other person’s are transferring patient care to another
experience. The highest and most nurse or other healthcare providers.
effective form of listening requires These skills will also help you
complete attention and engagement. demonstrate your knowledge and
This skill is important not only for clinical expertise clearly in a variety of
nurses but also for nurse executives and workplace settings, such as presenting
other healthcare providers as a tool for at conferences, participating in job
building trust and commitment with their interviews, giving case reports to
staff. Active listening includes both physicians, and more. It’s a good idea
verbal and nonverbal communication to:
skills. For example:
 Plan out your presentation and
 Nod your head, but never interrupt. practice.
 Lean forward and maintain eye  Pay attention to both your verbal
contact to let the person know you’re communication and body language.
engaged.  Add visuals to your presentation for a
 Include minimal verbal better explanation.
encouragement, such as “I  Understand your audience and know
understand,” and “go on.” what they want and need from the
presentation.
4. Written Communication
6. Patient Education (Patient Teach-Back)

Written communication skills are also

essential for effective nurse-to-nurse Nurses are in charge of most of the
communication. As a nurse, you will be communication between the healthcare
responsible for creating and team and patients. This includes
updating the patient’s medical record. It informing patients and family members
is critical of health conditions, diagnoses,
that the medical record is accurate and treatment plans, and medication
current so your patients can receive the protocols. This skill is especially
best care possible. Also, remember to important for family nurse
protect patient confidentiality. Some tips: practitioners who work with patients and
families to provide health and education
counseling.
Patient teach-back is an effective settings are scary for some patients. It’s
communication strategy where providers important to make them feel as
ask patients to repeat the information comfortable as possible.
back to them. This method improves
patient understanding and encourages
adherence to care instructions. Poor Trust is something that nurse
understanding of information can cause educators and leaders should also
patients and their family members to cultivate as they work to develop the
feel anxious or become defensive. For next generation of nurses. To inspire
example, you can say: trust, nurse leaders and educators
should:

 “We’ve gone over a lot of information.

Now I’d like you to repeat it back to  Always tell the truth.
me to make sure you remember  Share information openly.
everything.”  Be willing to admit mistakes.
 “Can you repeat the instructions for
taking this medicine back to me?” 9. Cultural Awareness
 “Let’s review what we just discussed.
Can you explain it to me in your own
words?” You will likely work with people every
day who come from a wide range of
7. Making Personal Connections social, cultural, and educational
backgrounds. Every patient and
coworker is unique, and it’s important to
It’s important to get to know the person be aware and sensitive. For example,
behind the patient. Patient-centered gauge the patient’s fluency with English
relationships are critical in helping and grade your vocabulary accordingly
patients feel safe and comfortable. or bring in a translator if necessary and
Creating meaningful connections with possible. With trans and gender
patients can improve outcomes and nonbinary patients, be sure to use their
trust. Some ideas: preferred name and pronoun.

 Spend a couple of extra minutes 10. Compassion

every day with each patient getting to
know them.
 Find out a fun fact about each patient. Conveying compassion is an essential
 Show interest in their lives and share communication skill in healthcare.
stories of your own. According to the Journal of
Compassionate Healthcare, “studies
8. Trust show that compassion can assist in
prompting fast recovery from acute
It’s important for healthcare illness, enhancing the management of
professionals to inspire trust in patients chronic illness, and relieving anxiety.”
by listening actively and taking every You can deliver compassionate nursing
complaint and concern seriously. care by putting yourself in the patient’s
Building trust takes time. Healthcare
shoes and understanding their needs the patient’s age, as well:
and expectations. A 12-year-old and a 70-year-old will
have very different ideas of what health
and healthcare mean to them.
How to Overcome
Communication Barriers in Psychological Barriers
Nursing
For many patients, a trip to the doctor is
anxiety-inducing. Anxiety and stress are
Sometimes the message sent is not
psychological barriers, as are dementia
always received the way it was desired.
and other cognitive conditions. To help
Communication barriers in nursing result
reduce their influence, it helps to take
in weak patient-nurse interactions and
extra time to listen, empathize, and be
relationships. To overcome these, we
supportive. Such psychosocial care has
must first understand the types of
been proven to improve patient health
communication barriers that nurses
outcomes and quality of life.
face. In the article “Communication and
Language Needs,” Dawn Weaver
identifies three common communication Nurses may also need to overcome their
barriers in nursing: physical, social, and own psychological barriers. Speaking to
psychological. patients and family members about
death, disease, and other sensitive
Physical Barriers topics can be distressing. A study in
the Journal of Advanced
Nursing explored the fact that many
The environment in which you nurses experience feelings of anxiety
communicate with a patient can make a when discussing patient medical needs
huge difference in effective and conditions.
communication. Busy, loud, and
distracting settings can increase patient
stress. To create a safe and comfortable
environment, try closing doors, opening
blinds, and mitigating outside noises
whenever you can.

Social Barriers

Social barriers include differences in

language, religion, culture, age, and
customs. Understanding each patient’s
cultural background can help nurses
avoid prejudice and communicate
clearly. It’s a good idea to tailor your
communication strategies depending on
 MICROBIOLOGY most important one is hand hygiene, which
includes hand washing and use of alcohol-based
AND hand sanitizer.

PARASITOLOGY
 Always wash your hands before meals, after
using the bathroom, and before and after any
RABE 1 contact with your clients. 
 Wash your hands after touching your own or
your client’s body fluids, such as urine, feces,
MEDICAL AND blood, saliva, vomitus, or genital discharge. 
 When coughing or sneezing, always cover your
SURGICAL ASEPSIS nose and mouth with a tissue or your elbow.
Teach your clients to do the same.
INTRODUCTION
Asepsis is defined as the absence of pathogens. Next up are personal items.
Now, there are two basic types of asepsis:
medical asepsis and surgical asepsis.
 Each client should have their own soap, cups,
toothbrushes, and towels. 
 Personal equipment should be regularly cleaned
 Medical asepsis (a.k.a. “clean technique”):
practices that kill some microorganisms to to prevent the growth of microorganisms. 
 When cleaning the room and objects, make sure
prevent them from spreading. 
 Surgical asepsis (a.k.a. “sterile technique”): to not stir up the dust (i.e., avoid shaking dirty
linens, and use a moistened cloth or mop to wipe
practices that completely kill and eliminate
microorganisms. dust). 
 When disposing of dirty linens to laundry bins,
keep them away from your uniform. This will
Figure 1: The differences between medical prevent the contamination of your uniform, and
and surgical asepsis.  subsequently, the spread of microorganisms. 
 Regularly empty the garbage because trash is a
MEDICAL ASEPSIS perfect environment for pathogen growth. 
 Finally, maintain good personal hygiene and
assist your clients to achieve the same!
Medical asepsis includes sanitization,
antisepsis, and disinfection. Figure 2: Sanitization includes hand
washing and cleaning of clients’ personal
Sanitization equipment, clothing, and linens.
Sanitization refers to cleaning practices and
techniques that physically remove Antisepsis
microorganisms. These include hand washing Antisepsis is the process of killing
and cleaning of clients’ personal equipment, microorganisms or limiting their growth on the
clothing, and linens. skin and non-living objects. Chemicals used in
antisepsis are called antiseptics, and the most
There are several things that you should know in common ones include rubbing alcohol and
order to maintain a sanitary environment. The iodine. Antiseptics can be used for hand
scrubbing; treating cuts, wounds, and burns; and used on people; instead, it is used on equipment
preoperative skin cleaning. and instruments that must be totally free of
microorganisms. For example, a commonly used
Figure 3: Antiseptics, like rubbing alcohol device to sterilize surgical instruments is
and iodine, kill microorganisms or limit the autoclave, which uses high pressure and
their growth on the skin and non-living temperature to kill microorganisms and their
objects.  spores (Fig. 5b).

Disinfection Finally, it’s important to note that before

Disinfection refers to the process of killing something can be disinfected or sterilized,
microorganisms on objects that are commonly in organic materials, such as blood, feces or urine,
contact with your clients, such as overbed tables, must be removed using sanitization practices
wheelchairs, stretchers, urinals, bedpans, and and techniques.
blood pressure cuffs. It’s important to note that
disinfection cannot destroy spores, which are
highly resistant forms of microorganisms that Figure 5: Surgical asepsis is ensured by
develop in conditions that are inconvenient for using A. sterile supplies and B. devices to
their growth. sterilize instruments, such as an autoclave.

Chemicals used in disinfection are WHAT IS THE CHAIN OF

called disinfectants. In contrast to antiseptics,
disinfectants are much stronger; therefore, they INFECTION AND HOW
are not used on the skin! Moreover, in order to TO BREAK IT
prevent skin irritation, you should always wear
nderstanding how the infection is spread is
household or utility gloves while handling essential to our efforts to prevent and contain its
disinfectants.  spread, especially when there is no definitive
treatment available.
Figure 4: Disinfectants kill microorganisms,
except spores, on objects and should be
handled with gloves.  Modes of
SURGICAL ASEPSIS Transmission
Examples of surgical asepsis include the use of
disposable sterile supplies, such as syringes, There are three modes of transmission: contact,
droplet, airborne.
needles, and surgical gloves; and the use of
reusable sterile equipment, such as surgical
instruments (Fig. 5a). Contact Transmission
Most commonly, surgical asepsis is acquired occurs when there is physical contact between an
through a process known as sterilization. You infected person/contaminated object and another
person.
can think of sterilization as the highest level of This can happen in two ways:
asepsis because it kills both microorganisms and
spores. Just like disinfection, sterilization is not 1. Through direct contact where the infection
travels to another person through touch.
2. Through indirect contact when an individual
touches an object contaminated by COVID-19.
When an infected person coughs, droplets can land
on objects and surfaces around them. When
another person touches these surfaces, their hands
can get contaminated with the virus. If they touch
their nose or mouth with contaminated hands, they
can get infected. It is therefore essential to make
hand hygiene a priority and wash your hands
regularly.

Droplet Transmission
happens when an infected person coughs, sneezes,
or talks, and tiny drops from the infected person
enter another person’s eyes, nose and mouth.
 Infectious Agent – microorganism (e.g. virus,
  bacteria, or fungi)
 Reservoir (source) – a host which allows the
Airborne Transmission microorganism to live, and possibly grow, and
multiply. Humans, animals and the
occurs when small particles in the air (<5um in environment can all be reservoirs for
size) containing the virus are inhaled into a microorganisms.
person’s respiratory system (Pan et al., 2019).  Portal of Exit – a path for the microorganism
Although one study has reported that the virus can to escape from the host. This can happen
remain viable in the air for up to 3 hours (van through the mouth, if a person coughs or
Doremalen et al., 2020), more research is needed sneezes, through a cut, if a person is bleeding,
to confirm if airborne transmission occurs with during diaper changes or toileting.
COVID-19.
 Mode of Transmission – how the infectious
  agent is transmitted from one person to
another. It can be in the form of droplets, direct
or indirect contact, or through airborne
Chain of Infection transmission.
 Portal of Entry – a place for the
microorganism to get into a new host, similar
Certain conditions must be met in order for a to the portal of exit.
microbe or infectious disease to be spread from
person to person. This process is known as the  Susceptible Host – it’s either a baby, an
chain of infection (CDC, 2016) which is shown in elderly person or someone with a weakened
Fig 1. There are six steps in the chain of infection immune system that is susceptible to the
and transmission will only take place if all six infectious agent.
links are intact. If any of the links are broken then the infection
will not occur. Infection Control principles are
aimed at breaking one or more links in this chain.

 
Prevention Washing Hands
Strategies with Soap and
To prevent and of viruses, WHO recommends
employing basic hygiene principles through
Water Regularly
standard and transmission-based precaution.
Hand washing thoroughly with soap and water is
Standard precautions include: one of the best ways to prevent you or someone
you know from getting infected. Washing your
 hand hygiene (5 Moments for Hand Hygiene); hands frequently helps to remove potentially
harmful microorganisms from your hands which
 use of personal protective equipment (PPE)
helps stop the spread of infection. The
 routine environment cleaning; recommendations for washing your hands by
following the 12 steps shown in the image below.
 cough etiquette
 aseptic technique
precautions include: use of appropriate
personal protective equipment (PPE), including
gloves, aprons or gowns, eyewear, face shields and
face masks.

Hand Hygiene – 5
Moments of Hand
Hygiene

Using Hand
Sanitiser
When you don’t have access to soap and water,
using hand sanitiser containing at least 60%
alcohol, such as PrimeOn Hand Sanitiser is a great
way to ensure your hands are clean. Make sure to
check the bottle’s label for the kill log rate to see
how effective it is.

When using hand sanitiser, make sure to follow the

steps below:

 Cover your mouth and nose with a

tissue when coughing or sneezing and
dispose of the tissue immediately
 If you do not have a tissue, sneeze
into your elbow rather than your
  hands.
Only when you are sick should you
Cough and Sneeze 
wear a face mask when out in public
to prevent infecting others around
Etiquette you.
 Wash your hands with soap and
As droplets from coughs and sneezes travel up to 2 water immediately after coughing or
metres, these simple steps can help to reduce the
spread of COVID-19. Individuals with symptoms sneezing.
of acute respiratory infection should practise cough
etiquette by maintaining distance with others.
Where possible, close contact with people Routine
suffering from acute respiratory infections should
be avoided.
Environmental
Cleaning
To break the chain and prevent infection, it is
important to be more mindful about the surfaces
we touch and to keep those surfaces clean. It is
recommended to enhance the cleaning and
disinfecting of a patient’s environment. Healthcare
workers should wear gloves and PPE when in a
patient’s surrounding and clean high-risk areas to
prevent any potential spread of the infection.
 clean and disinfect frequently used mucous membranes, or areas of open skin,
you must use personal protective equipment
surfaces such as benchtops, desks and (PPE).
doorknobs Follow standard precautions with all patients,
based on the type of exposure expected.
 clean and disinfect frequently used
objects such as mobile phones, keys, Depending on the anticipated exposure, types
wallets and work passes of PPE that may be required include:

 to increase the amount of fresh air

 Gloves
available by opening windows or
 Masks and goggles
adjusting the conditioning.
 Aprons, gowns, and shoe covers

It is also important to properly clean up

afterward.
Transmission-based Precautions
Transmission-based precautions are extra
steps to follow for illnesses that are caused by
certain germs. Transmission-based
precautions are followed in addition to
standard precautions. Some infections require
more than one type of transmission-based
precaution.

Follow transmission-based precautions when

an illness is first suspected. Stop following
Isolation precautions these precautions only when that illness has
been treated or ruled out and the room has
been cleaned.
       

Isolation precautions create barriers between Patients should stay in their rooms as much
people and germs. These types of as possible while these precautions are in
precautions help prevent the spread of germs place. They may need to wear a mask when
in the hospital. they leave their rooms.

Anybody who visits a hospital patient who has Airborne precautions may be needed for
an isolation sign outside their door should germs that are so small they can float in the
stop at the nurses' station before entering the air and travel long distances.
patient's room. The number of visitors and  Airborne precautions help keep staff, visitors, and
staff who enter the patient's room may be
other people from breathing in these germs and
limited.
getting sick.
Different types of isolation precautions protect
 Germs that warrant airborne precautions
against different types of germs.
include chickenpox, measles, and tuberculosis
(TB) bacteria infecting the lungs or larynx
Standard Precautions (voicebox).
When you are close to patients or close to
handling blood, bodily fluid, bodily tissues,
 People who have these germs should be in special facilities are made of materials
rooms where the air is gently sucked out and not that are heat stable and
allowed to flow into the hallway. This is called a therefore undergo heat, primarily
negative pressure room.
steam, sterilization. However,
 Anyone who goes into the room should put on a since 1950, there has been an
well-fitted respirator mask before they enter. increase in medical devices and
Contact precautions may be needed for germs instruments made of materials
that are spread by touching. (e.g., plastics) that require low-
 Contact precautions help keep staff and visitors temperature sterilization.
from spreading the germs after touching a person Ethylene oxide gas has been
or an object the person has touched.
used since the 1950s for heat-
 Some of the germs that contact precautions protect and moisture-sensitive medical
from are C difficile, norovirus, and COVID-19. devices. Within the past 15 years,
These germs can cause serious infection in the a number of new, low-
intestines or lungs. temperature sterilization systems
 Anyone entering the room who may touch the (e.g., hydrogen peroxide gas
person or objects in the room should wear a gown
plasma, peracetic acid
and gloves.
immersion, ozone) have been
Droplet precautions are used to prevent developed and are being used to
contact with mucus and other secretions from
the nose and sinuses, throat, airways, and sterilize medical devices. This
lungs. section reviews sterilization
 When a person talks, sneezes, or coughs, droplets technologies used in healthcare
that contain germs can travel about 3 feet (90
and makes recommendations for
centimeters).
their optimum performance in
 Illnesses that require droplet precautions include the processing of medical
influenza (flu), pertussis (whooping cough), devices.1, 18, 811-820

mumps, and respiratory illnesses, such as those  Sterilization destroys all

caused by coronavirus infections including microorganisms on the surface
COVID-19.
of an article or in a fluid to
 Anyone who goes into the room should wear a
prevent disease transmission
surgical mask.
associated with the use of that
 Sterilization item. While the use of
 Guideline for Disinfection and inadequately sterilized critical
Sterilization in Healthcare items represents a high risk of
Facilities (2008)
transmitting pathogens,
 Most medical and surgical
documented transmission of
devices used in healthcare
pathogens associated with an
 inadequately sterilized critical sterile when used because any
item is exceedingly rare.  This
821, 822
microbial contamination could
is likely due to the wide margin result in disease transmission.
of safety associated with the Such items include surgical
sterilization processes used in instruments, biopsy forceps, and
healthcare facilities. The concept implanted medical devices. If
of what constitutes “sterile” is these items are heat resistant,
measured as a probability of the recommended sterilization
sterility for each item to be process is steam sterilization,
sterilized. This probability is because it has the largest margin
commonly referred to as the of safety due to its reliability,
sterility assurance level (SAL) of consistency, and lethality.
the product and is defined as the However, reprocessing heat- and
probability of a single viable moisture-sensitive items requires
microorganism occurring on a use of a low-temperature
product after sterilization. SAL is sterilization technology (e.g.,
normally expressed a 10 . For
−n
ethylene oxide, hydrogen
example, if the probability of a peroxide gas plasma, peracetic
spore surviving were one in one acid).  A summary of the
825

million, the SAL would be 10 . −6 823,

advantages and disadvantages
 In short, a SAL is an estimate of
824
for commonly used sterilization
lethality of the entire sterilization technologies is presented in
process and is a conservative Table 6.
calculation. Dual SALs (e.g.,  Lesson 1: Introduction to
10 SAL for blood culture tubes,
−3
Epidemiology
drainage bags; 10  SAL for
−6

scalpels, implants) have been

 Section 8: Concepts
used in the United States for
many years and the choice of a of Disease
10 SAL was strictly arbitrary and
−6
Occurrence
not associated with any adverse
outcomes (e.g., patient  A critical premise of
infections).823
epidemiology is that disease
 Medical devices that have and other health events do not
contact with sterile body tissues occur randomly in a
or fluids are considered critical population, but are more likely
items. These items should be to occur in some members of
 the population than others interactions of these three
because of risk factors that components. Development of
may not be distributed appropriate, practical, and
randomly in the population. As effective public health
noted earlier, one important measures to control or prevent
use of epidemiology is to disease usually requires
identify the factors that place assessment of all three
some members at greater risk components and their
than others. interactions.

 Causation  Figure 1.16 Epidemiologic

 A number of models of disease Triad
causation have been proposed. 
Among the simplest of these is
the epidemiologic triad or
triangle, the traditional model
for infectious disease. The triad
consists of an external agent, a
susceptible host, and
an environment that brings  Image Description
the host and agent together. In  Agent originally referred to an
this model, disease results infectious microorganism or
from the interaction between pathogen: a virus, bacterium,
the agent and the susceptible parasite, or other microbe.
host in an environment that Generally, the agent must be
supports transmission of the present for disease to occur;
agent from a source to that however, presence of that
host. Two ways of depicting agent alone is not always
this model are shown in Figure sufficient to cause disease. A
1.16. variety of factors influence
whether exposure to an
 Agent, host, and
organism will result in disease,
environmental factors
including the organism’s
interrelate in a variety of
pathogenicity (ability to cause
complex ways to produce
disease) and dose.
disease. Different diseases
require different balances and
 Over time, the concept of genetic composition,
agent has been broadened to nutritional and immunologic
include chemical and physical status, anatomic structure,
causes of disease or injury. presence of disease or
These include chemical medications, and psychological
contaminants (such as the L- makeup.
tryptophan contaminant
responsible for eosinophilia-  Environment refers to
myalgia syndrome), as well as extrinsic factors that affect the
physical forces (such as agent and the opportunity for
repetitive mechanical forces exposure. Environmental
associated with carpal tunnel factors include physical factors
syndrome). While the such as geology and climate,
epidemiologic triad serves as a biologic factors such as insects
useful model for many that transmit the agent, and
diseases, it has proven socioeconomic factors such as
inadequate for cardiovascular crowding, sanitation, and the
disease, cancer, and other availability of health services.
diseases that appear to have
 Component causes and causal pies
multiple contributing causes
 Because the agent-host-
without a single necessary one.
environment model did not
 Host refers to the human who work well for many non-
can get the disease. A variety infectious diseases, several
of factors intrinsic to the host, other models that attempt to
sometimes called risk factors, account for the multifactorial
can influence an individual’s nature of causation have been
exposure, susceptibility, or proposed. One such model
response to a causative agent. was proposed by Rothman in
Opportunities for exposure are 1976, and has come to be
often influenced by behaviors known as the Causal Pies.(42)
such as sexual practices, This model is illustrated in
hygiene, and other personal Figure 1.17. An individual
choices as well as by age and factor that contributes to cause
sex. Susceptibility and disease is shown as a piece of
response to an agent are a pie. After all the pieces of a
influenced by factors such as pie fall into place, the pie is
 complete — and disease itself. For example, even
occurs. The individual factors exposure to a highly infectious
are called component causes. agent such as measles virus
The complete pie, which might does not invariably result in
be considered a causal measles disease. Host
pathway, is called a sufficient susceptibility and other host
cause. A disease may have factors also may play a role.
more than one sufficient cause,
with each sufficient cause  At the other extreme, an agent
being composed of several that is usually harmless in
component causes that may or healthy persons may cause
may not overlap. A component devastating disease under
that appears in every pie or different
pathway is called a necessary conditions. Pneumocystis
cause, because without it, carinii is an organism that
disease does not occur. Note harmlessly colonizes the
in Figure 1.17 that component respiratory tract of some
cause A is a necessary cause healthy persons, but can cause
because it appears in every pie. potentially lethal pneumonia in
persons whose immune
 Figure 1.17 Rothman’s systems have been weakened
Causal Pies by human immunodeficiency
 virus (HIV). Presence
of Pneumocystis
carinii organisms is therefore a
necessary but not sufficient
cause of pneumocystis
pneumonia. In Figure 1.17, it
 Image Description would be represented by
 Source: Rothman KJ. Causes. Am J Epidemiol component cause A.
1976;104:587–592.

 The component causes may

 As the model indicates, a
include intrinsic host factors as
particular disease may result
well as the agent and the
from a variety of different
environmental factors of the
sufficient causes or pathways.
agent-host-environment triad.
For example, lung cancer may
A single component cause is
result from a sufficient cause
rarely a sufficient cause by
 that includes smoking as a example, elimination of
component cause. Smoking is smoking (component B) would
not a sufficient cause by itself, prevent lung cancer from
however, because not all sufficient causes I and II,
smokers develop lung cancer. although some lung cancer
Neither is smoking a necessary would still occur through
cause, because a small fraction sufficient cause III.
of lung cancer victims have
https://www.youtube.com/watch?
never smoked. Suppose v=_WGKt8ffFno
Component Cause B is
smoking and Component
Cause C is asbestos. Sufficient
Cause I includes both smoking
(B) and asbestos (C). Sufficient Antibiosis
Association in which one species of
Cause II includes smoking microorganism prevents growth or
without asbestos, and destroys another species
Sufficient Cause III includes Bacteriology
asbestos without smoking. But The study of bacteria
Chlorophyll
because lung cancer can The green substance in plants that
develop in persons who have manufactures carbohydrates to use for
never been exposed to either energy
smoking or asbestos, a proper Microbiology
The study of microorganisms
model for lung cancer would Microorganisms
have to show at least one more Tiny, living plants and animals of varying
Sufficient Cause Pie that does sizes and shapes that cannot be seen
not include either component without a microscope; microbes
Optimum
B or component C. The condition most favorable for growth
or activity
 Note that public health action Parasite
does not depend on the An organism that lives within, upon, or
identification of every at the expense of another living
organism called the host
component cause. Disease Pathogen
prevention can be A microorganism capable of causing a
accomplished by blocking any disease. Adjective form is pathogenic
single component of a Pathology
The study of the nature and cause of
sufficient cause, at least disease which involves changes in
through that pathway. For structure and function
Phagocytosis Cannot grow or reproduce until they
Engulfment of bacteria by white blood have taken over a living cell, smallest
cells know pathogen
Saprophyte Helminths (metazoa)
An organism that lives on dead or Multicelled animals, cells form tissues
decaying matter
Symbiosis
The ability of different microbe species
to live together
Toxin
Poisonous substance produced by
some bacteria
Ultraviolet rays
Light waves that cause tanning of the
skin, production of vitamin D, and The Concepts of
destruction of some organisms
Functions of microorganism Man and His Basic
Metabolism (physical processes, Needs
chemical processes), growth,
reproduction, irritability, motion, The concept of man for
protection ms the first foundation
Five factors that influence the growth of
microorganisms al component of Nursin
Light exposure (amount of light, type of g .   T o   p r o v i d e   a n individua
light), temperature, moisture, food lized, holistic, and quality
availability, oxygen supply nursing care, it is important to
Bacteria
One-celled microorganisms, usually do
understand man.
not contain chlorophyll, may take The 4 Major
various forms, may be pathogenic or Attributes of Human
non-pathogenic Being
Fungi (yeast are one celled; molds have 1.
more) mycotic Capacity to think or
Parasites or saprophytes, most common
diseases, plant-like organisms such as conceptualize on the abstract
molds or yeast, do not have chlorophyll level.2 . F a m i l y   F o r m a t i o
Protozoa n 3.Tendency to seek and
One celled animals, simplest form of maintain a
animal life, mY reproduce sexually or
asexually, capable of movement by
t e r r i t o r y 4.Ability to use
variety of means verbal symbols as
Rickettsiae language, a means of
Organisms smaller than bacteria but developing and maintaining
larger than virus, grow only within cells
culture.
of the living host(parasites)
Viruses
 https://www.scribd.com/document/ 4. Esteem
110225311/The-Concepts-of-Man- 5. Self-actualization
Physiological Needs
and-His-Basic-Needs Things that are vital for our survival;
includes:
https://www.scribd.com/document/ 1. Food
110225311/The-Concepts-of-Man- 2. Water
and-His-Basic-Needs 3. Breathing
4. Homeostasis
5. Shelter and clothing
SISTER CALLISTA ROY 6. Sexual Reproduction
Man is a biophysical and spiritual being Safety and Security Needs
who is in constant contact with the includes:
environment 1. Financial security
MARTHA ROGERS 2. Health and wellness
Man is composed of parts which are 3. safety against accidents and injuries
greater than and different from the sum 4. finding a job
of all his parts 5. moving to a safer neighborhood
FLORENCE NIGHTINGALE Social Needs
Man is an individual with vital reparative includes:
process to deal with disease and 1. Friendships
desirous of health but passive in terms 2. Family
of influencing the environment or nurse 3. Romantic attachments
VIRGINIA HENDERSON 4. Social Groups
Man is a whole, complete and 5. Community groups
independent being who has 14 6. Churches and religious organizations
Fundamental needs Emotional Needs
DOROTHEA OREM Need for appreciation and respect;
Man is a unity who can be viewed as getting recognition from others boosts
functioning biologically, symbolically, confidence in abilities and avoid
and socially and who initiates and inferiority
perform self-care activities on own Self-Actualization Needs
behalf in maintaining life, health, and Achieved the full potential as human
well-being beings
4 Major Attributes of Human Beings ...
1. Capacity to think/conceptualize (Under Safety and security Needs)
2. Family formation 9. Avoid dangers from environment so
3. Tendency to seek and maintain do harming others
territory 14 Components of Virginia Henderson's
4. Ability to use verbal symbols as Need Theory
language (Under Physiological Needs)
Maslow's Hierarchy of Needs 1. Breathe normally
(from the bottom) 2. Eat and drink adequately
1. Physiological Needs 3. Eliminate body wastes
2. Safety and Security Needs 4. Move and maintain desirable
3. Love and Belonging (Social Needs) postures
5. Sleep and rest *A dynamic state in which the
6. Select suitable clothes
individual adapts to changes in
7.Maintain body temperature within
normal range internal and external environment to
8. Keep body clean and well groomed maintain a state of well being
...
(Under Love and Belongingness)
10. Communicate with others Models of Health and
expressing emotions, fear, or opinions
11. Worship according to one's faith Illness
...
(Under Esteem Needs) 1. Health-Illness Continuum
12. Work with sense of accomplishment (Neuman) – Degree of client
13. Play or participate in various forms
of recreation wellness that exists at any point in
14. Learn, discover, satisfy curiosity time, ranging from an optimal
wellnesscondition, with available
energy at its maximum, to death
Health and which represents total energy
depletion.
Illness 2. High – Level Wellness Model
(Halbert Dunn) – It is oriented
Health toward maximizing the health
potential of an individual.This
 As defined by the World Health model requires the individual to
Organization (WHO): state of maintain a continuum of balance
complete physical, mental and and purposeful direction within the
social well-being, not merely the environment.
absence of disease or infirmity. 3. Agent – Host – environment Model
Characteristics (Leavell) – The level of health of an
individual or group depends on the
1. A concern for the individual as a dynamic relationship of the agent,
total system host and environment
2. A view of health that identifies  Agent – any internal or external
internal and external factor that disease or illness.
environment  Host – the person or persons
3. An acknowledgment of the who may be susceptible to a
importance of an individual’s particular illness or disease
role in life
 Environment – consists of all 6. Health Promotion Model – A
factors outside of the host “complimentary counterpart models
4. Health – Belief Model – Addresses of health protection”. Directed at
the relationship between a person’s increasing a client’s level of well
belief and behaviors. It provides a being. Explain the reason for client’s
way of understanding participation health-promotion
and predicting how clients will behaviors. The model focuses on
behave in relation to their health three functions:
and how they will comply with  It identifies factors
health care therapies. (demographic and socially)
Four Components enhance or decrease the
 The individual is perception of participation in health
susceptibility to an illness promotion
 The individual’s perception of  It organizes cues into pattern to
the seriousness of the illness explain likelihood of a client’s
 The perceived threat of a participation health-promotion
disease behaviors
 The perceived benefits of taking  It explains the reasons that
the necessary preventive individuals engage in health
measures activities
5. Evolutionary – Based Model –
Illness
Illness and death serves as a
evolutionary function. Evolutionary  State in which a person’s
viability reflects the extent to physical, emotional, intellectual,
which individual’s function to social developmental or
promote survival and well-being. spiritual functioning is
The model interrelates the following diminished or impaired. It is a
elements: condition characterized by a
 Life events deviation from a normal, healthy
 Life style determinants state.
 Evolutionary viability within the 3 Stages of Illness
social context
 Control perceptions 1. Stage of Denial – Refusal to
 Viability emotions acknowledge illness; anxiety,
 Health outcomes fear, irritability and
aggressiveness.
2. Stage of Acceptance – Turns to dressing/grooming, toileting
professional help for assistance and mobility
3. Stage of Recovery (Rehabilitation 3. Mobility
or Convalescence) – The patient 4. Integrity of skin
goes through of resolving loss 5. Control of bowel and bladder
or impairment of function function
Rehabilitation
1. A dynamic, health oriented What are vital signs?
process that assists individual
Vital signs are measurements of the
who is ill or disabled to achieve body's most basic functions. The four
his greatest possible level of main vital signs routinely monitored by
physical, mental, spiritual, social medical professionals and health care
providers include the following:
and economical functioning.
2. Abilities not disabilities are  Body temperature
emphasized.  Pulse rate
3. Begins during initial contact  Respiration rate (rate of
breathing)
with the patient  Blood pressure (Blood pressure
4. Emphasis is on restoring the is not considered a vital sign, but
patient to independence or is often measured along with the
vital signs.)
regain his
pre-illness/predisability level of Vital signs are useful in detecting or
function as short a time as monitoring medical problems. Vital signs
possible can be measured in a medical setting, at
home, at the site of a medical
5. Patient must be an active emergency, or elsewhere.
participant in the rehabilitation
goal setting an din rehabilitation What is body temperature?
process.
Focuses of Rehabilitation The normal body temperature of a
person varies depending on gender,
recent activity, food and fluid
1. Coping pattern consumption, time of day, and, in
2. Functional ability – focuses on women, the stage of the menstrual
self-care: activities of daily cycle. Normal body temperature can
range from 97.8 degrees F (or
living (ADL); feeding,
Fahrenheit, equivalent to 36.5
bathing/hygiene, degrees C, or Celsius) to 99 degrees F
(37.2 degrees C) for a healthy adult. A
person's body temperature can be taken
in any of the following ways:
About glass thermometers
containing mercury
 Orally. Temperature can be
taken by mouth using either the According to the Environmental
classic glass thermometer, or the Protection Agency, mercury is a toxic
more modern digital substance that poses a threat to the
thermometers that use an health of humans, as well as to the
electronic probe to measure body environment. Because of the risk of
temperature. breaking, glass thermometers
 Rectally. Temperatures taken containing mercury should be removed
rectally (using a glass or digital from use and disposed of properly in
thermometer) tend to be 0.5 to accordance with local, state, and federal
0.7 degrees F higher than when laws. Contact your local health
taken by mouth. department, waste disposal authority, or
 Axillary. Temperatures can be fire department for information on how
taken under the arm using to properly dispose of mercury
a glass or digital thermometer. thermometers.
Temperatures taken by this route
tend to be 0.3 to 0.4 degrees F What is the pulse rate?
lower than those temperatures
taken by mouth. The pulse rate is a measurement of the
 By ear. A special thermometer heart rate, or the number of times the
can quickly measure the heart beats per minute. As the heart
temperature of the ear drum, pushes blood through the arteries, the
which reflects the body's core arteries expand and contract with the
temperature (the temperature of flow of the blood. Taking a pulse not
the internal organs). only measures the heart rate, but also
 By skin. A special thermometer can indicate the following:
can quickly measure the
temperature of the skin on the  Heart rhythm
forehead.  Strength of the pulse

Body temperature may be abnormal due The normal pulse for healthy adults
to fever (high temperature) ranges from 60 to 100 beats per minute.
or hypothermia (low temperature). A The pulse rate may fluctuate and
fever is indicated when body increase with exercise, illness, injury,
temperature rises about one degree or and emotions. Females ages 12 and
more over the normal temperature of older, in general, tend to have faster
98.6 degrees Fahrenheit, according to heart rates than do males. Athletes,
the American Academy of Family such as runners, who do a lot of
Physicians. Hypothermia is defined as a cardiovascular conditioning, may have
drop in body temperature below 95 heart rates near 40 beats per minute
degrees Fahrenheit. and experience no problems.
 If your doctor has ordered you to check
your own pulse and you are having
difficulty finding it, consult your doctor or
nurse for additional instruction.

What is the respiration rate?

The respiration rate is the number of
breaths a person takes per minute. The
rate is usually measured when a person
is at rest and simply involves counting
the number of breaths for one minute by
How to check your pulse counting how many times the chest
rises. Respiration rates may increase
As the heart forces blood through the with fever, illness, and other medical
arteries, you feel the beats by firmly conditions. When checking respiration, it
pressing on the arteries, which are is important to also note whether a
located close to the surface of the skin person has any difficulty breathing.
at certain points of the body. The pulse
can be found on the side of the neck, on Normal respiration rates for an adult
the inside of the elbow, or at the wrist. person at rest range from 12 to 16
For most people, it is easiest to take the breaths per minute.
pulse at the wrist. If you use the lower
neck, be sure not to press too hard, and
never press on the pulses on both sides What is blood pressure?
of the lower neck at the same time to
prevent blocking blood flow to the brain. Blood pressure is the force of the blood
When taking your pulse: pushing against the artery walls during
contraction and relaxation of the heart.
 Using the first and second Each time the heart beats, it pumps
fingertips, press firmly but gently blood into the arteries, resulting in the
on the arteries until you feel a highest blood pressure as the heart
pulse. contracts. When the heart relaxes, the
 Begin counting the pulse when blood pressure falls.
the clock's second hand is on the
12. Two numbers are recorded when
 Count your pulse for 60 seconds measuring blood pressure. The higher
(or for 15 seconds and then number, or systolic pressure, refers to
multiply by four to calculate beats the pressure inside the artery when the
per minute). heart contracts and pumps blood
 When counting, do not watch the through the body. The lower number, or
clock continuously, but diastolic pressure, refers to the pressure
concentrate on the beats of the inside the artery when the heart is at
pulse. rest and is filling with blood. Both the
 If unsure about your results, ask systolic and diastolic pressures are
another person to count for you. recorded as "mm Hg" (millimeters of
mercury). This recording represents how if your blood pressure readings are not
high the mercury column in an old- within the normal range.
fashioned manual blood pressure device
(called a mercury manometer or Why should I monitor my
sphygmomanometer) is raised by the
pressure of the blood. Today, your blood pressure at home?
doctor's office is more likely to use a
simple dial for this measurement. For people with hypertension, home
monitoring allows your doctor to monitor
High blood pressure, or hypertension, how much your blood pressure changes
directly increases the risk of heart during the day, and from day to day.
attack, heart failure, and stroke. With This may also help your doctor
high blood pressure, the arteries may determine how effectively your blood
have an increased resistance against pressure medication is working.
the flow of blood, causing the heart to
pump harder to circulate the blood. What special equipment is
Blood pressure is categorized as needed to measure blood
normal, elevated, or stage 1 or stage 2 pressure?
high blood pressure:
Either an aneroid monitor, which has a
 Normal blood pressure is dial gauge and is read by looking at a
systolic of less than 120 and pointer, or a digital monitor, in which the
diastolic of less than 80 (120/80) blood pressure reading flashes on a
 Elevated blood pressure is small screen, can be used to measure
systolic of 120 to blood pressure.
129 and diastolic less than 80
 Stage 1 high blood pressure is
systolic is 130 to 139 or diastolic
About the aneroid monitor
between 80 to 89
The aneroid monitor is less expensive
 Stage 2 high blood pressure is
than the digital monitor. The cuff is
when systolic is 140 or
inflated by hand by squeezing a rubber
higher or the diastolic is 90 or
bulb. Some units even have a special
higher feature to make it easier to put the cuff
on with one hand. However, the unit can
These numbers should be used as a be easily damaged and become less
guide only. A single blood pressure accurate. Because the person using it
measurement that is higher than normal must listen for heartbeats with the
is not necessarily an indication of a stethoscope, it may not be appropriate
problem. Your doctor will want to see for the hearing-impaired.
multiple blood pressure measurements
over several days or weeks before
making a diagnosis of high blood About the digital monitor
pressure and starting treatment. Ask
your provider when to contact him or her The digital monitor is automatic, with the
measurements appearing on a small
screen. Because the recordings are the cuff directly above the bend
easy to read, this is the most popular of the elbow. Check the monitor's
blood pressure measuring device. It is instruction manual for an
also easier to use than the aneroid unit, illustration.
and since there is no need to listen to  Take multiple readings. When
heartbeats through the stethoscope, this you measure, take 2 to 3
is a good device for hearing-impaired readings one minute apart and
patients. One disadvantage is that body record all the results.
movement or an irregular heart rate can  Take your blood pressure at the
change the accuracy. These units are same time every day, or as your
also more expensive than the aneroid healthcare provider recommends.
monitors.  Record the date, time, and blood
pressure reading.
About finger and wrist blood  Take the record with you to your
next medical appointment. If your
pressure monitors blood pressure monitor has a
built-in memory, simply take the
Tests have shown that finger and/or monitor with you to your next
wrist blood pressure devices are not as appointment.
accurate in measuring blood pressure  Call your provider if you have
as other types of monitors. In addition, several high readings. Don't be
they are more expensive than other frightened by a single high blood
monitors. pressure reading, but if you get
several high readings, check in
with your healthcare provider.
Before you measure your  When blood pressure reaches a
blood pressure: systolic (top number) of 180 or
higher OR diastolic (bottom
The American Heart Association number) of 110 or higher, seek
recommends the following guidelines for emergency medical treatment.
home blood pressure monitoring:
Ask your doctor or another healthcare
 Don't smoke or drink coffee for 30 professional to teach you how to use
minutes before taking your blood your blood pressure monitor correctly.
pressure. Have the monitor routinely checked for
 Go to the bathroom before the accuracy by taking it with you to your
test. doctor's office. It is also important to
 Relax for 5 minutes before taking make sure the tubing is not twisted
the measurement. when you store it and keep it away from
 Sit with your back supported heat to prevent cracks and leaks.
(don't sit on a couch or soft
chair). Keep your feet on the floor Proper use of your blood pressure
uncrossed. Place your arm on a monitor will help you and your doctor in
solid flat surface (like a table) monitoring your blood pressure.
with the upper part of the arm at
heart level. Place the middle of
 Place the  Flex the
client in a knees slightly
horizontal and support
recumbent them with
position. knee rolls.
 Elevate the Flexion
head of the bed prevents hyper
to extension
approximately of the knees and
45 degrees prevents
angle. This is to slipping from
provide comfort the
and facilitates bed.
various  Drape as
procedures. in dorsal
recumbent. basal lung
Proper lobes.
draping  Assist the
provides client to
comfort and horizontal
privacy. recumbent
TRENDELEN position.
BURG (shock Trendelenburg
position) position is done
Promotes for
venous certain types
circulation in of shock,
certain clients. surgical
Provides procedures,
postural and postural
drainage of drainage.
 Elevate the Supports will
foot of the bed prevent the
so that the patient from
lower slipping out of
tuck is higher the bed.
than the head  Drape as
and shoulders. in horizontal
 Support the recumbent.
shoulders and Proper
knee. The draping
weight provides
of the body is comfort and
pulled privacy.
downwards by KNEE
gravity. CHEST
(genupectoral)
This position the knee
provides slightly
maximal separated.
exposure of  Bend
rectal forward so that
area. the chest is
 Place the resting on
client on a the bed and the
prone position. thighs are
This perpendicular to
preparatory for the legs. This
assuming the is for rectal
desired and vaginal
position. examination
 Assist to and as a
kneel with form of
exercise for
some and prevention
gynecological from
conditions. smothering.
 Turn the 5. Drape the
head to one side patient properly
and place the so that only the
arms area to
either above be examined is
head or flex at exposed. Proper
the elbow and draping
rest along the provides
side of the comfort and
head. This is https://www.studocu.com/ph/
document/mabini-colleges/

for fundamentals-of-nursing/
fundamentals-of-nursing-positioning-

support,
and-draping/23611989

convenience
POSITIONIN body is
G AND aligned,
DRAPING whether
POSITIONING standing, sitting
a client in good or lying, no
body alignment excessive strain
and is placed on
changing the these structures:
position DRAPING is
regularly are the manner of
essential arranging the
aspects covering in
of nursing order to expose
practice. the part being
When the examined,
treated or
cleaned
Chapter 4The Physical The Physician–Patient
Examination Interaction
Earl W. Campbell, JR and Christopher K. Lynn. Aside from the hospital room and office,
physical examination may occur in a variety
Go to:
of other settings where it is difficult to
establish privacy and quiet. The best
Definition resource available to the physician to set the
Physical examination is the process of stage for the physical examination is to
evaluating objective anatomic findings communicate respect and a genuine interest
through the use of observation, palpation, in the patient's welfare. The patient should
percussion, and auscultation. The be addressed politely and asked to perform
information obtained must be thoughtfully the required maneuvers of the examination,
integrated with the patient's history and a technique far preferable to imperative
pathophysiology. Moreover, it is a unique language such as, "I want you to. …"
situation in which both patient and physician Patients should be prepared for unpleasant
understand that the interaction is intended to portions of the examination.
be diagnostic and therapeutic. The physical Aside from explanations and reassurance, it
examination, thoughtfully performed, should is not necessary to maintain a continuous
yield 20% of the data necessary for patient conversation with the patient during the
diagnosis and management. examination. Avoid embarrassing the
Go to: patient. Be certain that draping material is
used appropriately and that personal areas
are not subjected to undue exposure. An
The Context
examination that ends abruptly may
Almost without exception, some medical diminish the value of the doctor–patient
history about the patient is available at the relationship and may destroy its therapeutic
time of the physical examination. Rarely, content. The patient may benefit from a brief
there may be no history, or at best brief summary of relevant findings and may
recordings of acute events. Information require reassurance about what has and has
pertinent to the physical examination can be not been found.
learned from observation of speech, Go to:
gestures, habits, gait, and manipulation of
features and extremities. Interactions with
relatives and staff are often revealing. The Materials
Pigmentary changes such as cyanosis, The single most useful device for optimal
jaundice, and pallor may be noted. performance of the physical examination is
Diaphoresis, blanching, and flushing may an inquisitive and sensitive mind. Next most
provide clues about vasomotor tone related useful is mastery of the techniques of
to mood or physiologic abnormalities. observation, palpation, percussion, and
Aspects of patient habits, interests, and auscultation. Less important are the tools
relationships can be ascertained from required for the examination (Table 4.1).
pictures, books, magazines, and personal
objects at the bedside.
Go to:
Table 4.1 Table 4.2
Equipment Required for the Physical Positions of Patient and Examiner during the
Examination. Physical Examination.
Go to:
The general physical examination can take
The Examination many forms depending upon circumstances.
Most often, the examiner evaluates body
As the environment affects the quality of the regions in a general way, looking for
physical examination, it is wise to arrange abnormalities. Clues derived from the
for quiet and privacy, darkening the room history signal the need for a more precise
for parts of the examination, and comfort for and detailed examination of a given system.
the patient and examiner. A thorough physical examination often
includes the sequence presented in Table
The complete examination should proceed
4.3.
in an orderly fashion with a minimum of
required position shifts by the patient (Table
4.2). On the other hand, the physician must
be able to ascertain the integrity of the
various organ systems from regional
examinations. For instance, from
examination of the head and neck, the
physician must identify the vascular,
neurologic, lymphatic, skeletal, and
integumentary components and must relate
Table 4.3
them to their complements in other body
regions. It would be tedious, by contrast, to Steps of the Physical Examination.
examine the vascular system in its entirety,
followed by a complete neurologic The clinically significant physical
examination and the other organ systems examination is a flexible entity that should
each in turn. When examining an anatomic vary with the needs of the patient. Periodic
region, the observer must be alert to the examinations for health assessment need to
appearance of any abnormality and question be comprehensive, as do most hospital
at the time the morphologic aspects of the admission examinations. In contrast, it will
abnormality and its clinical significance. not be cost effective to undertake a complete
physical examination in most patients
presenting with symptoms of an upper
respiratory tract infection or a urinary tract
infection.
Go to:
Conclusion than is the graded intensity of breath sounds.
The presence or absence of ascites in
The physical examination is a key part of a patients with known liver disease has been
continuum that extends from the history of shown to be difficult to determine when
the present illness to the therapeutic using physical exam techniques alone. The
outcome. If the history and physical bedside measurement of forced expiratory
examination are linked properly by the time by auscultation however, has been
physician's reasoning capabilities, laboratory shown to have a small interobserver
tests should in large measure be variability in trained observers and to have
confirmatory. The physical examination, clinical value in following the degree of
however, can be the weak link in this chain airway obstruction.
if it is performed in a perfunctory and
superficial manner. Understanding the Because of the large degree of variability in
pathophysiologic mechanism of a physical observing many physical signs, the
abnormality is essential for correct diagnosis following recommendations can be made
and management. For instance, the failure to when reporting and interpreting physical
discriminate between and know the origin of findings.
carotid bruits and transmitted sounds of 1. Emphasis should be placed on
valvular origin can have critical dichotomous variables (i.e., presence or
significance. absence of râles) rather than on graded
As knowledge of disease changes, the variables (i.e., intensity of breath
techniques of physical examination become sounds).
augmented. The astute physician constantly 2. Some physical signs (i.e., clubbing of the
reviews and adds to the repertoire of fingers) represent a continuum from
techniques for physical examination. obviously normal to obviously
abnormal. Emphasis should be placed
Evaluation of the physical examination in
on those findings which represent the
terms of sensitivity and specificity is
extremes rather than the "borderline"
difficult. Interpretation of isolated physical
cases.
findings is often influenced by the presence
or absence of historical information and 3. Recognition of those physical findings
coexisting physical findings. For instance, which have a high degree of
the assessment of whether clubbing of the interobserver variability is important.
fingers is present or absent has significant Good examples of this include detection
interobserver variability and has been of moderate or small amounts of ascitic
demonstrated to be influenced by the clinical fluid and detection of diaphragmatic
appearance of the patient. movement by percussion. These
findings should be deemphasized in
A number of studies have attempted to look favor of those with better
at the validity of the physical exam as a reproducibility.
diagnostic tool. The concept of interobserver
and intraobserver variability has been 4. It is beneficial to use the body's
introduced when looking at specific isolated "symmetry" to advantage. Differences
findings. For example, judging the presence auscultated in breath sounds between
or absence of râles is more likely to be similar area of the right and left lung
agreed upon by several observers and on are far more clinically important than
repeated exams by a single blinded observer, an overall decrease in breath sounds.
If these points are kept in mind, the physical external spermatic fascia, cremaster
exam will fill its proper role in the care of muscle and fascia, and internal
the patient. That is as an adjunct to a spermatic fascia
thorough history and as a way for the What accessory glands are located
physician to interact physically with the behind the bladder?
patient. prostate gland
Which gland forms a ring around the
urethra?
prostate
Which glands are located beneath the
prostate within the urogenital
What is the primary function of the male diaphragm?
reproductive system? bulbourethral
To produce, maintain, and transport In the penis, which structure surrounds
sperm and semen the urethra?
What is the primary function of the Corpus sponglosum
female reproductive system? Which fold of skin surrounds the glans
produce the female egg cells, called the penis?
ova or oocytes prepuce (foreskin)
In addition to sperm production, what Which structure are paired dorsal
hormone do the testes secrete? erectile tissues?
testosterone corpora cavernosa
What is the name of the pouch of skin Why is the female's reproductive system
and connective tissue that contains the more complex than the male's?
testes? because they produce gametes, it is
scrotum also developed to protect and give
Which two muscles help regulate the nutrients to the developing embryo
temperature of the testes? Which organs produce ova, estrogen,
cremaster muscle and dartos muscle and progesterone?
Where are sperm produced? ovarus
in the testes where are the ovaries located?
Which cells secrete testosterone? pelvic cavity
interstitial cells Which ligament attaches the ovary to
What is another name for the ductus the uterus?
deferens? ovarian ligament
vas deferens Which portion of the ovary does
Which structure is ligated during a oogenesis occur in: cortex or medulla?
vasectomy? cortex
vas deferens When does oogenesis begin in the
What carries structures (such as blood female?
vessels and nerves) to and from the before birth
testes? What structure (formerly the corpus
spermatic cord hemorrhagicum) produces progesterone
What are the three structures found in and estrogen?
the spermatic cord? corpus luteum
What structure carries the ovulated Which structure produces milk in
oocyte from the ovary to the uterus? lactating females?
uterine tube mammary glands
Where does fertilization usually occur? What do lactiferous ducts expand to
fallopian tube in the oviduct form?
Is there any direct contact between the nipple
infundibulum and the ovary?
no
Name the rounded region of the uterus
Mons pubis
above the opening to the uterine tubes:
Hair covered fat pad overlying
fundus
symphysis pubis
What is the largest portion of the
Labia majora
uterus?
Outer rounded folds of adipose tissue
cervix
Labia minora
Which narrowed uterine structure
Inner, thinner, pinkish folds which
projects into the vagina?
extend to form the prepuce and clitoris
Isthmus
Bartholins glands
What is the thick layer of smooth muscle
Located on each side of the vagina
that is important during childbirth?
opening, but aren't usually visible
myometrium
What is the function of the bartholins
What is the innermost layer that lines
glands?
the uterine cavity?
Keep internal labial surfaces
endometrium
continuously lubricated
Name the 10 cm muscular tube that
How do you palpate the bartholins
extends from the uterus.
glands?
vagina
Insert index finger into vagina & place
What are the recessed areas around the
thumb at the posterior labia - palpate
cervix called?
and feel for swelling and tenderness
vaginal fortix
What is the role of the ovaries?
What general term describes the
- production of ova (eggs)
female's external genitalia?
- secretion of hormones (estrogen and
valva (pudendum)
progesterone)
What structures are paired adipose-
Fallopian tubes
containing folds and are the
Where fertilization takes place
homologues of the male scrotum?
Where does the endometrial lining shed
Labia majora
every month is an egg?
Which area is enclosed by the labia
Uterus
minora?
What is the lower part of the uterus
vestibule
which protrudes into the vagina?
What two orifices are contained in the
Cervix
vestibule?
What is the name for the opening into
external urethra and vagina
the vagina?
name the circular pigmented area that
Introitus
surround the nipple.
What is a musculomembranous tube?
Areola
The vagina
Menarche
Menstrual period - feel for ovaries (left of uterus)
The onset of menses generally follows - test pelvic muscle strength
what? Rectovaginal examination
Breast budding - 2to3 years - insert index finger in vagina- and
Leukorrhea middle finger of same hand in anus
Vaginal discharge - normal - increased - assess for colorectal cancer
discharge jay come with ovulation or - pelvic pathology
sexual arousal - retroverted uterus, rectovaginal fistula,
Menopause rectocele
12 consecutive months without menses Rectal examination
Amenorrhea - index finger in anus
No period - palpate for hemorrhoids, masses
Primary amenorrhea - check for occult blood with hemoccult if
Failure for menses to be initiated needed
Secondary amenorrhea - always have client get dressed before
Cessation of menses after previous discussing findings
existance Examination tips
Dysmenorrhea - intercourse and periods does not affect
Painful menses the exam
Polymenorrhea - empty bladder fully
Frequent menstruation - lithotomy position "labor position"
Menorrhagia What could douching lead too?
Increased amount of bleeding or longer Infertility- if there is a vaginal infection
periods that gets pushed to the uterus
Metorrhagia Why is the no need to douche?
Bleeding that occurs between menses The uterus already has normal flora and
Acute vaginal assessment menses to clean it
- excessive vaginal bleeding Health promotion topics
- abdominal pain (chronic/acute) - birth control options/ family planning
- Bartholins gland infection - menopausal changes
- pelvic inflammatory disease - HPV immunizations
- ruptured tubal pregnancy - screening for cervical cancer
Internal pelvic exams include what? - STI prevention
- PAP smear - self care - wiping front to back
- sample of cultures - self examination
What should you note about the cervix Excessive vaginal bleeding
during a PAP? - unexpected vaginal bleeding is not
- any ulcers? Bleeding? Nodules? uncommon in childbearing years
Bimanual examination - always a possibility of concealed
- insert fingers excessive bleeding
- palpate cervix What can be associated with excessive
-NOTE: shape and consistency , vaginal bleeding?
mobility and tenderness Interstitial tumours and subendomentrial
- palpate uterus with OTHER hand (feel fibromyomata
over suprapubic area What if a women has excessive vaginal
bleeding after menopause?
- HIGHLY SIGNIFICANT - interfere with absorption of oral
- malignancy of the endometrium must contraceptives
be ruled out What is the current most common and
Bartholins gland infection frequently reported bacterial STI in
- inflammation usually results from Canada ?
infection Chlamydia trachomatis
- streptococci, staphylococci, chlamydia,
escherichia coli
Symptoms of bartholins gland infection
-Affected glands are typically inflamed
and painful
- pt. May be febrile
Ruptured tubal pregnancy
- spills blood into peritoneal cavity
- severe abdominal pain, shoulder pain
and tenderness
- bleeding
Gravida
Number of pregnancies a women has
had
Para
Number of births a women has has
AFTER 20 weeks even if fetus died at
birth
Term
Infant born after 37 weeks gestation
Preterm
Infant born after 20 weeks but before 37
weeks
Gravida 1
One pregnancy and having two children
- TWINS
How long is the usually menstrual
cycle?
28 to 32 days
What is a PAP smear?
Cytologic evaluation of the cells of the
cervix to screen for precancerous
cervical lesions - IT DOES NOT
SCREEN FOR STIs
What are antibiotics affects in the
female genetalia?
- can strip the vaginitis of its usual flora
- create an environment that promotes
yeast infections