Fundamental nursing

1. UNIT ONE
Introduction to Nursing Profession
Definition of nursing
The word “nursing” is originated from the Latin
word “Nutrix” meaning “to nourish”.
Nurse is a person who nourishes, foster & protects
others. or ; a person prepared to take care of sick,
injured & aged person
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2. WHAT IS NURSING?
An acceptable version of the word nurse
N – Noble
U – unselfish
R – Responsible
S – Sincere
E – Efficient
There were different definitions given for nursing at
different times by different individuals. Some of
these are:
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3. • Nursing is an art and a science that deals with
prevention of disease, care and treatment of
the sick and rehabilitation of patients.
• Science- knowledge based for care given
• Art – means skilled application of knowledge to
help others
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4. F.Nightingale defination of nursing
• Nursing is the act of utilizing the environment
of clients to assist him/her in his/her recovery.
• It is to put the patient in a best condition for
nature to act up on him.
• American nursing association (ANA)
• It is the diagnosis and treatment of human
response to actual and potential health
problems.
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5. Cont…d
• Nursing is an art, and if it is to be made an art,
it requires as exclusive devotion, as hard a
preparation, as any painter’s or sculptor’s work,
for what is having to do with the living body -
the temple of God’s spirit? It is one of the fine
Arts; I had almost said the finest of the fine
Arts". Florence Nightingale
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6. Virginia Henderson definition of nursing
“ Nursing is assisting the individuals sick or well in
the performance of those activities (contributing
to health or its recovery or to a peaceful death)
that he will perform unaided, if he had the
necessary strength, will or knowledge and to do
this in such a way as to help him gain
independence as rapidly as possible.”
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7. Nursing is profession (more than job or
occupation)
Criteria to be a profession
• has well defined body of knowledge
• presence of strong service orientation
• presence of recognized authority by professional
group
• governed by code of ethics
• has professional organization that sets standards
• conduct ongoing research & has autonomy
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8. Definitions of important term
• Care-involves activities from carrying out complicated
technical procedures to something seeming simple.
• Health-is a state of optimal functions.
• Lay-point of view- doing ones activity& doesn’t
outwardly show any symptom of any disease.
• Mahler- the ability to lead socially acceptable &
economically productive life.
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9. Cont..d
• WHO – is a state of complete mental, physical&
social well-being not merely absence of disease or
infirmity.
• Physical health- anatomical integrity& physiological
functioning of the body.
• To be physically healthy
• All body parts must be present
• All body parts in natural place& position
• None of them has any pathology
• All doing their physiological function properly
• They work each other harmoniously
• Mental health- the ability to learn& think clearly.
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10. Cont…d
• Social health- ability to make& maintain
acceptable interaction with others.
• Illness- the subjective state of a person who feels
aware of not being well.
• Disease- denotes the condition of the human body
in which something has gone wrong & has upset
the normal functions of the body or mind.
• Disability- any restriction or lack of ability to
perform an activity in a manner or range
considered normal for human beings.
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11. Cont…d
Handicap- a long term disadvantage which adversely
affects individual’s capacity to achieve the personal
economic independence. i.e. normal for ones peer.
Aims of Nursing
1. Promoting wellness
Wellness- is the achievement of one maximum
attainable potential.
2. Preventing illnesses- the main objectives are
To reduce the risk for illness
To promote good health habit
To maintain optimal functioning
3. Restoring health
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12. Cont…d
Providing direct care of the person.
4. Facilitating coping
The goals of health cannot always be met. The nurses
also facilitate patient& family coping with altered
function, life crisis& death.
Roles of Nursing
To meet aims of nursing nurses use knowledge, skill&
critical thinking.
To provide knowledgeable care the nurse uses cognitive,
technical, interpersonal& ethical competencies
essential to nursing practice.
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13. Nurses
– Care giver
– Communicator
– Teacher
– Counselor
– Leader
– Researcher
– Advocator
– Manager
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14. Guide lines for nursing practice
• ANA congress for nursing practice stated that “A
profession must control its practice to guarantee
the quality of its service to the public.”
• Nursing controls & guarantees its practice through
• Standards of Nursing practice; defines the actives of
nurses that are specific and unique to nurses.
• Nursing practice acts; are laws established to
regulate the practice of nursing.
• Licensure
• Nursing process
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15. NURSING PROCESS
• The nursing process is a systematic, patient
centered, goal oriented methods of caring that
provides frame work for nursing practice.
• Nursing is independent scientifically based and
creative required knowledgeable component and
independent profession.
• Characteristics of Nursing Process
• 1. Systematic- each nursing activity is a part of an
ordered sequence of activities. Each activity
depends on the accuracy of the activity that
precedes it & influences the action that follows it.
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16. Cont..d
• 2. Dynamic- no one step in nursing process is a
one time phenomenon.
• There is Overlapping and interaction among steps
in some nursing situations, all five stages occur
almost simultaneously.
• Interpersonal- nursing process insures that nurses
are patient centered rather than task centered.
Always at the heart of nurse is human being.
• The nursing process encourages nurses to work
together to help patient use their strengths to
meet all their human needs.
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17. Cont..d
4. Goal oriented- nursing process offers a means
for nurses & patients to work together to
identify specific goals to determine which goals
are the most important to the patient and to
match them with appropriate nursing action.
5. Universally applicable- the nursing process
offers direction for all the activities carried out
by the nurse when caring for well or ill, any age
at any practice setting.
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18. Benefits of nursing process
• When used well, the nursing process achieves for
the patient
• scientifically based holistic individualized care
• provides opportunity to work collaboratively with other nurses
• provides continuity of the patient’s care
• nurses who use nursing process achieves a clear
and efficient plan of action by which they process
can achieve the best results for the patients.
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19. Documenting the nursing process
• The ability to communicate clearly in writing is a
critical nursing skill.
• Accurate, concise, timely & relevant
documentation provides all the members of the
care giving team with a picture of the patient.
• Legally speaking, a nursing action not
documented is not performed.
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20. Cont..d
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21. Steps of nursing process
• Assessment
• Nursing diagnosis
• Planning
• Implementation
• Evaluation
1. Assessment; is the systematic & continuous
collection, validation, & communication of
patient data.
Data (information)-reflects how health function is
enhanced by health promotion or
compromised by illness.
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22. Cont..d
• Database: - includes all pertinent patient information
collected by the nurse. This enables a comprehensive
and effective plan of care to be designed and
implemented.
• Data collection is a vital step in nursing process
because the remaining step depends on the
assessment data.
• Nursing assessments focuses on the patient’s response
to health problems
Data collection
• Data collection takes place during every nurse patient
interaction.
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23. Cont..d
• Types of data- there are two types of data.
• Subjective (covert data) or symptoms; Data
that are not verified by other person. E.g.
nausea, headache, abdominal pain .
• Objective data (overt data or sign)-
observable& measurable data.
• Can be verified by other person. E.g. vital sign
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24. Cont..d
• Purpose of nursing assessment
• To establish base line data
• To determine the patients normal function
• To determine presence or absence of dysfunction
• To determine patients strength
• Steps of nursing assessment
• Data collection
• Validation
• Organizing (clustering data)
• Documentation of data
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25. Cont..d
• Characteristics of data
– Complete; all the patient data needed to understand
the patients’ health problem should be identified.
– Factual or accurate
– Relevant
Sources of data
– Primary Source:-is the most reliable information
obtained from the patient.
– Secondary Sources:-information obtained from:
Support people& patient records
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26. Cont..d
• Data collection methods
• Observation:-is the conscious and deliberate use
of the senses to gather data
• Interview:-is the planned communication to
obtain nursing history
• Physical assessment:-is the examination of the
patient for objective data. The nurse’s physical
assessment focuses primarily on the patient’s
functional abilities rather than pathologic
conditions and their causes.
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27. Cont...
• Methods of assessment are:
•Nursing health history
•Physical assessment
•Diagnostic evaluation
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28. Types of Nursing Assessment
• Depending on the clinical condition, patient
status, time valuable and purpose, it is classified
into:-
• Initial(admission) assessment:- is performed w/n
the patient is admitted to hospital.
• Purpose:-To establish a complete database for
problem identification and care planning.
• To identify functional health patterns those are
problematic
• To evaluate the patient health status
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29. Cont..d
2. Focused Assessment:-the nurse gathers data about
a specific problem that has already been identified.
• Purpose:-to identify new or over looked problems
• The nurse determines if the problem still exists
• Weather the status of the problems has changed
3. Emergency assessment:-When physiologic or
psychological crisis presents or takes place in life
threatening situations where the preservation of
life is the top priority. E.g. ABCs
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30. Cont..d
4. Time Lapsed assessment:-is scheduled to compare a patient’s
current status to base line data obtained.
• Purpose:-to evaluate any changes in patient’s functional
health
• Performed when substantial periods of time have elapsed
between assessments.
• Problems Related to Data collection
• Inappropriate organization of the data base
• Omission of relevant data
• Commission of irrelevant data
• Error of data
• Failure to establish rapport and partnership
• Failure to update database
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31. Cont..d
• Data Validation:-is the act of confirming or verifying.
• Purpose:-to keep the data from error, bias, or
misinterpretation
2. Nursing Diagnosis:-is the clinical judgment about individual,
family, or community responses to actual or potential health
problems that the nurse is licensed and competent to treat.
OR
• Is a statement that describes the human response (health
state or actual/potential altered interaction pattern) of an
individual or group that the nurse can legally identify and
for which the nurse can order definitive interventions to
maintain the health state or to reduce, eliminate, or prevent
alterations.
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32. Cont..d
• Nursing diagnosis focuses on un healthy responses to
health and illness, but
• Medical Diagnosis:-identify diseases; describe a problem
which directs the primary treatment.
• Medical diagnosis remain the same as long as the disease
is present but
• Nursing diagnosis may change from day to day as the
patient’s response changes.
• Steps of nursing diagnosis
• Analyzing and interpreting data
• Identifying client problem
• Formulating Nursing Diagnosis
• Documenting Diagnosis
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33. Types of Nursing Diagnosis
• Actual:-describes a clinical judgment that the nurse
has validated b/c of the presence of major defining
characteristics; problem is present at the moment
(experienced).
• Potential (risk):- describes a clinical judgment that
an individual or group is more vulnerable. Nurse
determines that the patient is more vulnerable to
develop.
• possible/probable: - problem may be present. The
nurse suspects that a health problem exists but
need to gather more data to confirm the diagnosis.
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34. Cont..d
4. Wellness: - clinical judgments about an individual,
family, or community in transition from it a
specific level of wellness to higher level of
wellness.
5. Syndrome: - comprises a cluster of actual or risk
nursing diagnosis that is predicted to present b/c
of a certain situation or event.
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35. Parts of Nursing Diagnosis
• Problem Statement:-describes a physiological or
psychological response to a health problem. When
writing use: altered, disturbed, decreased, excessive,
dysfunctional…etc
• Etiology Statement:-describes contributing factors
that influence development of the response.
Identifies the physiologic, psychological, sociologic,
spiritual, and environmental factors believed to be
related to the problem as either a cause or a
contributing factor.
• Etiology identifies the factor that maintain the un
healthy patient state and prevent the desired change,
thus directs the nursing intervention. Unless the
etiology is correctly identified, nursing actions may be
inefficient and ineffective. 35

36. Cont..d
• 3. Defining Characteristics:-the subjective and objective
data that signal the existence of the actual health
problem.
• Writing Nursing Diagnosis
• The actual nursing diagnosis has data that support and
the presence of the problem. It has three parts:
• Problem (NANDA) + related to etiology + as evidenced
by defining characteristics.
• E.g. Ineffective airway clearance related to weak cough
and incision pain, as evidenced by poor or no cough
effort.
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37. Cont..d
• 2. The high-risk nursing diagnosis- indicates the clients
at risk for this response, although it is not yet present.
• It has only two parts:-Problem (NANDA) and related to
etiology.
• It has no defining characteristics.
• E.g. .high- risk for impaired skin integrity related to
advanced age, immobility, confinement to bed
• 3. Possible/probable-has possible problem and factor.
• E.g. .possible sexual patterns related to partner’s
diagnosis of herpes
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38. Cont..d
• 4. Diagnostic statements for wellness nursing
diagnoses are one- part, containing the diagnostic
label.
• e.g -Readiness for enhanced family process.
• -Readiness for enhanced nutrition
• 5. Syndrome nursing diagnoses usually are one-
part diagnostic statements with the contributing
factors contained in the diagnostic lable.
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39. Cont..d
NANDA has five syndrome diagnoses:
- Rape trauma syndrome.
- Disuse syndrome.
- Post -trauma syndrome.
- Relocation stress syndrome.
- Impaired environmental Interpretation syndrome.
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40. Guidelines for Writing Nursing Diagnosis
• Phrase the nursing diagnosis a patient’s problem or
alteration in health state rather than as a patient need
• Use “related to” rather than “caused by” or “due to”
• Write the diagnosis in legally advisable terms
• Use non-judgmental language
• Do not reverse the cause with the problem
• Single nursing diagnosis should contain only one
specific problem
• Avoid medical diagnosis
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41. Cont..d
8. The problem and etiology should be expressed in
terms of that can be change
9. Check the diagnosis to make sure the problem
statements patient goals and that the etiology will
direct the selection of nursing measures
10. Defining characteristics should follow the
etiology and be lining by the phrase “as evidenced
by” or “as manifested by”
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42. 42
Focusedon physical illness Holisticcare approach
Focusedon actual healthproblem Actual and potential

43. 43
Impaired Skin Integrity related to prolonged
pressure on bony prominence as manifested
by (AMB) Stage II pressure ulcer over coccyx, 3
cm in diameter.
Risk for Impaired Skin Integrity related to
inability to turn self from side to side in bed.
Possible Self-Esteem Disturbance related to
recent retirement and relocation.
Potential for Enhanced Nutrition.

44. 44

45. Nursing planning
• Planning involves a series of steps in which the
nurse and the client prioritize problems , set
goals and expected out comes to resolve or
minimize the identified problems of the client.
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46. Outcome Identification and Planning
• The planning phase involves several tasks:
–The list of nursing diagnoses is prioritized.
–Priorities are classified as high
(psychological or Physiological).
–Intermediate (non- emergency, non- life
threatening) or
– low (needs that may not be directly
related to a specific illness but may affect
their future well- being).
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47. Cont…d
– Client-centered long- and short-term goals and out-comes
are identified and written.
– Specific interventions are developed.
– The entire plan of care is recorded in the client’s record.
• Once the list of nursing diagnoses has been developed
from the data, decisions must be made about priority.
• Critical thinking enables the nurse to make decisions
about which diagnoses are the most important and
need attention first.
• There are a number of frameworks used to prioritize
nursing diagnoses; however, those diagnoses involving
life-threatening situations are given the highest priority.
• For example, the following nursing diagnoses would be
stated in this order of priority: 47

48. Cont…d
• Ineffective Airway Clearance related to excessive,
thick secretions and pain secondary to surgery
and inability to cough effectively
• Risk for Injury (falls) related to unsteady gait
• Imbalanced Nutrition: Less Than Body
Requirements related to nausea and vomiting
• Client-centered goals are established in
collaboration with the client whenever possible.
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49. Goal
• A goal is an aim, intent, or end.
• Goals are broad statements that describe the
intended or desired change in the client’s
behavior.
• If the client or significant others are unable to
participate in goal development, the nurse
assumes that responsibility until the client is able
to participate.
• Client-centered goals assure that nursing care
• is individualized and focused on the client.
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50. Expected outcomes
• Expected outcomes are specific objectives related to the goals
and are used to evaluate the nursing interventions.
• They must be measurable, have a time limit, and be realistic.
• Once goals and expected outcomes have been established,
nursing interventions are planned that enable the client to
reach the goals.
• Examples of goals setting
• Nursing diagnosis :Knowledge deficit regarding postoperative
care at home.
• Goals: Client will state four postoperative risks before
discharge
• Expected outcome : Client will identify need to
drink 2-3 liters of fluid every day
Client will name three signs of infection
Client will demonstrate aseptic wound care 50

51. Nursing intervention
• A nursing intervention is the activity that the nurse will
execute for and with the client to enable
accomplishment of the goals.
• Nursing interventions refer directly to the related
factors in the actual nursing diagnoses and the risk
factors in risk nursing diagnoses.
• If the nursing interventions can remove or reduce the
related factors and the risk factors, the problem can be
resolved or prevented.
• Nursing interventions also refer to the diagnostic label
for possible diagnoses and focus on data needed to
confirm or eliminate the diagnosis.
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52. Cont…d
• For each nursing diagnosis there may be a
number of nursing interventions.
• Nursing interventions are individualized and
are stated in specific terms.
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53. Implementation
• Implementation involves the execution of the
nursing plan of care derived during the
planning phase.
• It consists of performing nursing activities
that have been planned to meet the goals set
with the client.
• Nurses may delegate some of the nursing
interventions to other persons assigned to
care for the client.
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54. Evaluation
• Evaluation, the fifth step in the nursing process, involves
determining whether the client goals have been met,
partially met, or not met.
• If the goal has been met, the nurse must then decide
whether nursing activities will cease or continue in order
for status to be maintained.
• If the goal has been partially met or not been met, the
• nurse must reassess the situation.
• Data are collected to determine why the goal has not
been achieved and what modifications to the plan of care
are necessary.
• There are a number of possible reasons that goals are not
met or are only partially met, including:
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55. Cont…d
– The initial assessment data were incomplete.
– The goals and expected outcomes were not
realistic.
– The time frame was too optimistic.
– The goals and/or the nursing interventions
planned were not appropriate for the client.
– Evaluation is an ongoing process.
– Nurses continually evaluate data in order to make
informed decisions during other phases of the
nursing process.
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56. Revision
• Case study 1 exercise
• Ato Hialu has been admitted to the hospital with car
accident. He is sin bed and could not be able to take
care of himself. He has not passed stool for the last 3
days. He has severe pain and is not sleeping well. He
has an open wound on the fractured leg and is not
taking food. He lives with his wife, three young
children and works as taxi driver which he describes as
very stressful. (Musculo- skeletal problems)
• Which of the assessment discussed is most
appropriate at the time of his admission?
• Do nursing care plan to mr hailu which includes all of
the five phasess.
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