15 National Comprehensive Training On Standards of Nursing Practice

Standards of Nursing Practice Course- Participant Manual
National
Comprehensive Participants’
Training on Standards Manual
of Nursing Practice
August, 2017
1
FOREWORD
The development of the Standards of nursing/midwifery Care Practice in Ethiopia is an
important milestone in the history of nursing/midwifery in this country. Standards are an
essential tool for unifying the nursing/midwifery profession and setting criteria by which
nursing practice can be measured.
The standards will also promote accountability and good quality of nursing/midwifery care.
Evidence suggests that when high quality nursing/midwifery services are available, there is a
corresponding reduction of maternal, neonatal and inpatient morbidity and mortality.
The Standard of nursing/midwifery Care Practice in Ethiopia defines the expectations placed
on registered nurses/midwives, underpinned by principles such as quality, equity, access, and
collaboration. The standards have an emphasis on patient -centered care and seek to ensure
that nursing services are affordable, appropriate to local needs and sustainable over the long
term.
It is our hope that all nurses in Ethiopia adhere to the standards set out in this document and
strive to contribute to the ongoing development of high quality client‘s health services in our
country. Healthcare quality continues to be a subject of intense criticism and debate. Nurses
are important part of each patient‘s care; they provide continuous care to patients by assessing
the patient, answering questions, giving medications and treatments, and assisting with
medical procedures
Nurses/midwives have the responsibility to help patients understand the care they will receive
and what the patients must do to cooperate in their care. They have the responsibility to
explain to patients what they should and shouldn‘t do as they go through treatment and
recovery, and they must quickly respond to patients in need. They are a key part of any
healthcare team, and the way they perform their jobs has a real impact on healthcare quality.
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ACKNOWLEDGEMENTS
The Federal Ministry of Health would like to acknowledge ICAP GNCP for the technical and
financial support of the development, editing and printing of Standards of Nursing Practice
training manual.
The Ministry also acknowledges the following experts and their organization for their high
contribution in the revision and development of the training material. Additionally, the
Ministry expresses its deep gratitude to Dr. Nicola Ayres for her valuable contribution in
editing the materials.
Name Organization
Sr Gezashegne Denekew FMOH
Sr Tirist Mehari FMOH
Dr. Nicola Ayres FMOH
Abduraham Ali ICAP
Muluneh Haile ICAP
Abebaw Derso CHAI
Kefelegn Zemedkun Madawelabu university
Dr Biftu Geda (PhD) Haramay University
Eshetu H/Silassie (Assistant Prof) University of Gondar
Fikadu Balcha (Assistant Prof) Jimma Univeristy
Yoseph Tsige (Assistant Prof) Addis Ababa University
Leuel Deribe Addis Ababa University
Sr Alemenesh Mandesh ENA
Tesfaye Bedru Private consultation
Simon Genet Aleret Hospital
Hareya G/Medhin Ayder University Hospital
Tsedale Mengiste Tirunesh Bejing Hospital
Tsedale Tilahun Zeweditu Memorial Hospital
Sr.Hermela Demissie St Paulos Med College Hospital
Sr Belayenesh Birmeka Sabiyan Prm. Hospital, Dire Dawa
Sr Fasica Birhanu Bishoftu General Hospital
Agezegn Asgid Wochamo University
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LIST OF ACRONYMS AND ABBREVIATION
ANA American Nursing Association HSTP Health Sector Transformational Plan
CU- ICAP Colombia University, International ICN International Council of Nursing

Center for HIV/AIDS Program
CNA Canadian Nurse Association ISTC In Service Training Center
CPD Continuing Professional Development KPI Key Performance Indicator
EHMI Ethiopian Hospital Management NNTWG National Nursing Technical Working

Initiative Group
EHRIG Ethiopian Hospital Reform NOCI Nursing Outcome Identification

Implementation Guidelines
EHAQ Ethiopian Hospital Alliance for RN Registered Nurse

Quality
EHSTG Ethiopian Hospital Service SMT Senior Management Team

Transformations Guidelines
ENA Ethiopian Nurses Association SOAP Subjective data, Objective data,

Assessment and Plan
FHP Functional Health Pattern SOP Standard Operating Procedures
FMHACA Food, Medicine, Health care

Administration Control Authority
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TABLE OF CONTENTS
Table of Contents
FOREWORD ..................................................... ERROR! BOOKMARK NOT DEFINED.
Acknowledgement ......................................................................................................... II
List Of Acronyms And Abbreviation ........................................................................... III
Table Of Contents ......................................................................................................... IV
About This Manual .................................... ERROR! BOOKMARK NOT DEFINED.
The Training Modules..................................................................................................... 2
Core Competencies For Trainees .................................................................................... 3
Introduction ..................................................................................................................... 4
Rationale For Revising The Manual ............................................................................... 1
Training Course Syllabus ................................................................................................ 6
Overview Of Hospital Services .................................................................................... 15
Module I: Operational Standards Of Nursing Practice ................................................. 20
SESSION 1.1 : OPERATIONAL STANDARDS OF NURSING PRACTICE .................... 21
SESSION 1.2. IMPLEMENTATION GUIDELINE ...................................................... 25
SESSION 1.3: IMPLEMENTATION CHECKLIST AND INDICATORS .......................... 40
Module -II Nursing Ethics ............................................................................................ 47
MODULE DESCRIPTION ................................ ERROR! BOOKMARK NOT DEFINED.
MODULE OBJECTIVE: ................................... ERROR! BOOKMARK NOT DEFINED.
SESSION 2.1. INTRODUCTION TO NURSING ETHICS ............ERROR! BOOKMARK NOT
DEFINED.
SESSION 2.2 : ETHICAL PRINCIPLES ................. ERROR! BOOKMARK NOT DEFINED.
SESSION 2.3. NURSING VALUES AND MORAL VALUES ........ERROR! BOOKMARK NOT
DEFINED.
SESSION 2.4. ETHICAL DILEMMA IN NURSING AND ETHICAL DISTRESS......... ERROR!
BOOKMARK NOT DEFINED.
SESSION 2.5: ETHICAL DECISION MAKING IN THE NURSING PRACTICE ........ ERROR!
BOOKMARK NOT DEFINED.
SESSION 2.6: LEGAL ASPECTS OF THE NURSING PRACTICE ...... ERROR! BOOKMARK
NOT DEFINED.
SESSION 2.7: NURSING CODE OF ETHICS ........ ERROR! BOOKMARK NOT DEFINED.
Module III - Communication In Nursing .................................................................. 100
DESCRIPTION OF THE MODULE .......................................................................... 100
LEARNING OBJECTIVES ....................................................................................... 100
SESSION 3.1. BASICS OF COMMUNICATION AND ITS SIGNIFICANCE IN NURSING ..... 101
SESSION 3.2 IMPLEMENTATION GUIDANCE AND DOCUMENTATION........................ 122
Module IV: Nursing Process ....................................................................................... 139
MODULE DESCRIPTION ..................................................................................... 139
MODULE OBJECTIVE ......................................................................................... 139
MODULE CONTENT ........................................................................................... 139
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SESSION 4.1. INTRODUCTION TO NURSING PROCESS .......................................... 140

SESSION 4.2. NURSING ASSESSMENT .................................................................. 145
The Eleven Gordon’s Functional Health Patterns ......................................... 154
Pattern 1: Health Perception And Health Management................................. 154
Pattern 2: Nutrition And Metabolism ............................................................. 155
Pattern 3: Elimination .................................................................................... 156
Pattern 4: Activity And Exercise ..................................................................... 164
Pattern 5: Sleep And Rest Pattern .................................................................. 181
Pattern 6: Cognitive - Sensory-Perceptual Pattern ........................................ 181
Pattern 7: Self-Perception And Self-Concept ................................................. 189
Pattern 8: Roles And Relationships ................................................................ 189
Pattern 9: Sexuality And Reproduction .......................................................... 190
Pattern 10: Coping And Stress Tolerance ...................................................... 191
Pattern 11: Values And Belief......................................................................... 191
VALIDATING DATA......................................................................................................... 152
ORGANIZING (CLUSTERING) DATA ................................................................................. 152
DATA INTERPRETATION ................................................................................................. 153
RECORDING AND REPORTING ........................................................................................ 153
SESSION 4.3 NURSING DIAGNOSES ................................................................................. 193
Introduction..................................................................................................... 193
Nursing Diagnosis Versus Medical Diagnosis ............................................... 194
Types Of Nursing Diagnoses .......................................................................... 195
Collaborative Problems .................................................................................. 199
Rules For Writing Diagnostic Statements For Actual And Risk Nursing
Diagnoses ........................................................................................................ 198
Avoiding Errors When Writing Diagnostic Statements .................................. 198
SESSION 4.4. PLANNING: OUTCOME IDENTIFICATION ..................................................... 201
Introduction..................................................................................................... 201
Establishing Nursing Priorities ...................................................................... 202
Setting Goals ................................................................................................... 204
Identify Patient Expected Outcomes ............................................................... 205
SESSION 4.5. PLANNING: NURSING INTERVENTION/INSTRUCTION .................................... 210
BY THE END OF THIS SESSION, TRAINEES WILL BE ABLE ................................... 210
DESCRIBE NURSING INTERVENTION ................................................................... 210
DESCRIBE TYPES OF NURSING INTERVENTION.................................................... 210
WRITE NURSING INSTRUCTIONS/ORDERS ........................................................... 210
Introduction..................................................................................................... 210
Nursing Instructions/Orders ........................................................................... 211
SESSION 4.6. IMPLEMENTATION .................................................................................... 213
SESSION 4.7. NURSING EVALUATION .............................................................................. 216
Annexes................................................................................................................................... 215
ANNEX 1. EXAMPLE OF NURSING SERVICE MANAGERIAL STRUCTURE ............................. 215
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ANNEX 2: NURSE DIRECTOR JOB DESCRIPTION .............................................................. 216

ANNEX 3. HEAD NURSE JOB DESCRIPTION ..................................................................... 218
ANNEXES 4: PAIN ASSESSMENT SCALE............................................................................ 222
ANNEX 5: LOC FOR PEDIATRICS .................................................................................... 223
ANNEX 6: NURSING PROCESS FORMAT ........................................................................... 224
Annex 7. Trainee Assessment Check List. Blood Pressure .................................................... 238
Annex 8. Competency Checklist For Radial Pulse ................................................................. 241
Annex 9. Competency Checklist For Body Temperature ....................................................... 242
Annex-10 Competency Checklist For Assessment Of Respiration ........................................ 243
Annex 11. Nanda-Approved Nursing Diagnoses 2015-2017 ................................................. 244
Annex 12. Sample Nursing Process On A Patient With Fibular Fracture Secondary To Car
Accident .................................................................................................................................. 251
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ABOUT THIS MANUAL

This manual is a resource for trainers who lead training in standards of nursing practice. It
contains all the instructions and materials needed to enable trainers to help trainees develop
the knowledge and skills necessary to provide high quality nursing care services.
Trainers should keep this manual with them each day they prepare and facilitate sessions.
The Training Package
The training package includes participant manual, facilitator‘s guide and power point
presentation. The content contained in this trainee‘s manual is drawn directly from a reference
manual for nurses and health care managers in Ethiopia, of Version 2. Dec 2011 Addis Ababa
Ethiopia, in a much updated form.
Participant Manual: The participant manual is designed to provide all information needed to
conduct the course in a logical manner. It serves as the ―text‖ for the participants and the
―reference source‖ for the trainer.
Facilitator’s Guide: The facilitator‘s guide is for use by course facilitators. It provides an
outline of the training and guidance on how to conduct each session.
Approach to Training
This training package is grounded in two specific principles. First, the training methodologies
used here are grounded in competency based skills acquisitions and learner centered,
participatory learning based on the principles of adult education. Second, the participant
manual and facilitator‘s guide are divided into modules. A modular approach to the
organization of this training content allows trainees and organizers the flexibility to tailor
individual course to the specific needs of different training participants and situations.
Learners utilizing the materials in this training meet knowledge-based objectives through
theoretical training contained in the modules. Each module includes the presentation of
information, active practice through participatory activities such as role plays, video show
group work and case studies. Skills- based objectives are addressed by simulated practice with
coaching and feedback in the classroom.
Rationale for revising the Manual
Quality and equity of health care is one of the four interrelated transformation agendas set by
the HSTP which was built upon the sucesses and challenges of the successive HSDPs
implemented over the last 20 years. A national health care quality strategy will be developed
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to guide our investment towards safer, more effective, more accessible, and more equitable
care for every Ethiopian by 2020 (FMOH-HSTP, 2015). In addition, Ethiopian is estimated
have a population of around 100 million and there are over 50,000 nurses in the country. The
number of clients with chronic non-communicable diseases are increasing therefore requiring
an increasing demand for quality nursing care (FMOH-HRH Strategic Plan, 2016). In
addition, with existing communicable diseases especially HIV/AIDS and TB, they make a
double burden among health care workers. That is why FMOH gives attention for the
competency of nursing professionals who make the majority of the health care professionals.
This manual is a resource for trainees who are actively involved in training Standards of
Nursing Practice. It contains all the four sequential modules with different sessions, exercises,
practical examples and annex materials needed to enable trainees to use and develop
additional knowledge and skills necessary to provide high quality nursing services.
The major reasons for revision of this manual are as follows
1. The previous training package lacked facilitators guide
2. Operational standards extracted from EHRIG should be revised as per
EHSTG
3. The old model five step approach of Nursing process should be revised into
new six step international approach
4. The length of previous training was short to address gaps
5. The practical session was less emphasized in the previous course
This manual is a resource for trainees who are actively involved in training on standards of
Nursing practice standard. It contains all the four sequential modules with different session,
exercises, practical examples and annex materials needed to enable trainees to use and
develop additional knowledge and skills necessary to provide high quality nursing services.
Goal and objectives of the manual
Goal
The overall goal of this participant manual is to provide all information needed for trainers and
trainees to conduct the nursing practice course in a logical manner, as well as, a guide for
practicing nurses in order to provide quality nursing care for the needy
The objectives of the manual are:
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 To build the capacity of nurses in terms of knowledge, attitude and practice in order to
provide holistic quality nursing care
 To serve as the ―text‖ for the participants without the need for special hand-outs or
supplementary material during training period.
 To provide information to both trainers and participants that is consistent with the
course goals and objectives.
Modules in this manual
This participant manual consists of four modules. Each of the modules is interactive,
providing learners with questions and activities to make their learning as relevant, stimulating
and effective as possible. By taking time to answer all the questions and complete any
activities, learners have the opportunity to draw on their own experience, reflect on current
practice, digest new concepts and apply them to their work place.
Each module begins with learning objectives, which explain what learners will be able to do
when they have completed it. Upon completing the module, learners can then assess for
themselves whether they have achieved the objectives.
The contents for each module are summarized as follows:
Module I: Operational Standards of nursing care
 Introduces the 23 operational standards
 Details the operational standards using implementation guide
 Categorizing the 23 operational standards
Module II: Nursing ethics emphasizes on fundamentals of ethical principles, values, and
ethical dilemmas, code of ethics and legal aspects of nursing.
Module III: Communication in nursing explains
The presentation focuses on communication types, facilitators, inhibitors, barriers and
strategies of communication. It also details nursing record documentation.
Module IV: Nursing process: This is the core module which covers principles of nursing
process that includes assessment, diagnosis, outcome identification, planning, implementation
and evaluation. Physical examination is integrated with functional health patterns in
assessment part of nursing process.
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CORE COMPETENCIES FOR TRAINEES

Competence is the ability to effectively and efficiently deliver a specified professional service.
This implies that the health worker is able to practice at proficiency (mastery of learning) in
accordance with local conditions to meet local needs.
The core competences that the trainees are expected to attain after going through
this course are
 Building therapeutic nurse client relationship
 Assessing clients using history taking and physical examination in terms of Gordon‘s
approach of functional health patterns
 Formulating nursing diagnosis by using NANDA-I approach
 Developing holistic nursing care plan that address basic human needs
 Providing individualized, holistic and ethically accepted nursing care
 Evaluating whether the goals are met, partially met or unmet
 Recording and reporting nursing activities using standard protocol
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INTRODUCTION
Nursing is a profession that ensures the successful implementation of interventions that
welcome and nurture life, promotes or restores health, enables the means to a peaceful,
dignified and pain-free death. Nursing reflects the value society places on the work of nurses
and the centrality of this work for the good of society. Nursing encompasses autonomous and
collaborative care of individuals of all ages, families, groups and communities, sick or well in
all settings. It includes the promotion of health, the promotion of health, the prevention of
illness, and the care of ill, disabled and dying people (WHO, 2017).
A nurse is a person who is trained and experienced in the nursing profession and interested in
caring for the sick / well person, has completed a program of basic, generalized nurse
education and is authorized by the appropriate regulatory authority to practice nursing (ICN
1987).
The Federal Ministry of Health (FMOH) has long acknowledged the critical contribution of
Nurses and Midwives in improving health outcomes of individuals, families and communities.
In acting as individuals, members and coordinators of inter-professional teams, nurses and
midwives bring people–centered care close to the communities where they are needed most,
thereby contributing greatly to improving the health outcomes of those under their care as
well as improving the overall cost effectiveness of health care services.
Similarly, patient safety and quality health outcomes will be highly compromised if services
delivered by other healthcare professionals are not duly supported and complemented by a
competent nursing workforce. In recognition of this important role of the nursing profession
and services they provide, the Federal Ministry of Health (FMOH) has incorporated Nursing
Standards (NS) as one chapter in the Ethiopian Hospital Services Transformation Guideline
(EHSTG).
There are essential guidelines and checklists to check how the nurses perform their duties
professionally and how they exercise the care, cure and co-ordination aspects of nursing. As
an independent profession, nursing has increasingly set its own standards for practice which
we call Standards of Nursing Practice. As a result, nursing services complement and support
other health care services and are a subsystem of health services that are provided by a range
of personnel globally who share common attributes like caring, supporting, comforting,
advocating and educating clients.
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TRAINING COURSE SYLLABUS
Course description
This seven days training course is developed to equip nurses and midwives with knowledge,
skill and the right attitude to enable them to deliver scientifically sound, ethically acceptable
and holistic quality care.
Course goals
 To provide the trainees with the knowledge and clinical skills needed to respond
appropriately to patients‘ health care needs.
 To provide the trainees with the decision-making skills needed to respond appropriately to
patients‘ health care needs
 To influence in a positive way the attitudes of the trainees towards client centered and
ethically accepted nursing care.
 To provide the trainees with the interpersonal communication skills needed to build
therapeutic relationship with clients.
Course Objectives
By the end of this course, the trainees will be able to:
 Describe nursing Operational Standard Practices
 Demonstrate Nursing Code of conduct and Ethics
 Employ client centered effective communication
 Apply the nursing process in clinical setting.
Training methods
 Interactive Presentation
 Small and Large group Discussion
 Daily Recap
 Group work /practice
 Brainstorming
 Demonstration
 Role play
6
 Case studies
 Video Show
 Practicum
Training materials
 National trainees and trainer guide
 Nursing process format ,
 Updated NANDA list
 Audiovisuals on physical examination
 Job aid for physical examination procedures
 Course evaluation formats
 Knowledge assessment questionnaire
 Gowns
 Vital sign equipments and checklists
 Flip charts/white board and Markers
 LCD projector, Laptops, computer
Trainee selection criteria
Trainee selection is based on the national IST guidelines.
For basic training, nurses and or midwives who are actively involved on the day to day
health service activities and have an interest to be trained and provide the nursing care
service after training will be selected from hospitals/health care facilities.
For TOT training, nurses and or midwives who undergo basic training in standards of
nursing practice and actively involved on the day to day health service activities and
have an interest to be trained and provide the nursing care service after training will be
selected from hospitals/health care facilities. .
Trainer qualification criteria/ requirement
In competency-based training, the responsibility for meeting learning objectives is shared by
the trainer and each trainee. The role of the trainer is to facilitate learning. The trainer guides
trainees during the training toward the acquisition of new or improved skills in standards of
7
nursing practice and also seeks to influence trainee attitudes by serving as a role model. In
selecting trainers to use this training package, the following criteria should be considered:
 Demonstrated proficiency in application of nursing Process. The trainer must have
knowledge and skills in the selected areas of standards of nursing practice to be taught in
this training.
 The trainers must have received training of trainers‘ course on standards of nursing
practice.
The trainer of standards of nursing practice must have experience using the mastery learning
approach to provide the training, which is conducted according to adult learning principles—
learning is participatory, relevant, and practical—and uses behavior modeling, is competency-
based, and incorporates humanistic training techniques. The trainers for this course must be
aware of basic principles of transfer of learning to help the trainees, transfer the new
knowledge and skills in nursing practice and improve job performance.
It is strongly recommended that at least three clinical trainers conduct this course. The trainers
can divide roles and responsibilities according to their expertise, such as sharing the roles of
―coach‖ and ―facilitator‖ throughout the course.
Methods of course evaluation
Trainee evaluation
 Pre- and post-course knowledge assessment
 Skill assessment of observed practice during role plays and practicum
 trainer and trainees demonstration of FHP and through physical examination
 Skill assessment of application of nursing process
 Attendance 100%
Course evaluation
 Daily evaluation
 End course evaluation
Post training evaluation
 Integrated supportive supervision and Mentorship
Course duration
 The total duration for this training is seven days
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Suggested class size

Assuming role plays and other group activities, a class room that accommodates 20-25 is
recommended.
Trainer to trainee ratio
Ratio of trainers to trainees will be 1:6
Course venue
This training will be provided at health facilities or accredited CPD centers /IST centers
Certification criteria
 Trainees are expected to score 75% and above for Basic training and 85% and above
for TOT to qualify for certification.
Composition
 Suggested training composition:
 20-25 participants per classroom
 3-4 trainers per classroom
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Course Agendas
Days Time Topics Facilitator

8:30-9:00 AM Registration
9:00-9:40 AM  Opening remark: Welcome and
introduction,
 Group norms , Expectations
 Goals ,objectives ,schedule
 Review of course materials
9:40-10:30 AM Pre-test
10:30-10:45 AM Tea Break
10:45-11:30 AM Presentation and discussion:
Overview and Introduction of the Course
Day 1

Operational standards of Nursing Practice
12:30-2:00 PM Lunch Break
2:00- 2:40 PM Operational standards of Nursing Practice
2:40 -3:30 Group work :
Categorizing operational standards of
nursing practice
3:30-3:45 PM Tea Break
3:45-4:45 PM Presentation and discussion:
Operational standards of Nursing Practice:
Implementation guide
4:45-5:00 PM Day Summary
8:30-8:40AM Day one Recap
8:40-9:20AM Presentation and discussion:
Day 2
Introduction to Ethics
Ethical principles
10
10:45AM– 11:15PM Group Activity on case studies

Ethical principles
Nursing Values
11:45-12:30PM Presentation and discussion:
Ethical dilemma and Ethical distress in
nursing practice
12:30 -2:00PM Lunch Break
2:00-2:30 PM Group Activity on case studies
Ethical dilemma and Ethical distress in
nursing practice
Ethical Decision Making in the Nursing
Practice
3:00-3:30 PM Group Activity on case studies:
Ethical Decision Making in the Nursing
Practice
3:30-3:45 PM Tea break
3:45-4:20 PM Presentation and discussion :
Legal Aspects of the Nursing Practice
4:20-4:45 PM Presentation and discussion :
Legal Aspects of the Nursing Practice
8:30-8:40AM Day two Recap
8:40-10:00 AM Presentation and discussion :
Day 3
Communication in nursing
10:00-10:30AM Group Activity:
Elements of communication
10:30-10:45 AM Tea break
7 Cs of communication
10:45AM– 11:30AM VIDEO SHOW :
Therapeutic relation ship
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11:30 -12:30 PM Presentation and discussion:

Documentation and reporting
Introduction to nursing process
Nursing Assessment
3:45-4:45 PM Presentation and discussion
 Integration of history taking and
physical examination with FHP
 Health perception and management up
to nutrition and metabolism
4:45-5:00 Day Summary & Recap
8:30-8:40 AM Day three Recap
8:40-10:00 AM Presentation and discussion
Nursing Assessment : Elimination pattern
10:00 -10:30 AM VIDEO SHOW:
Nursing Assessment : Elimination pattern
Nursing Assessment : Activity and
exercise
2:00-2:30 PM VIDEO SHOW:
Nursing Assessment : Activity and
exercise
Nursing Assessment : Sleep and rest up to
Day 4
cognitive and perceptual

3:30 -3:45 PM Tea break
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Self-perception/self-concept up to value
and belief
4:45-5:00 Day Summary and Recap
8:30-8:40 AM Day four Recap
8:40-9:20 AM Clinical practice:
Nursing Assessment
9:20-10:30AM Clinical practice:
Nursing Assessment
10:45-12:30 PM Clinical practice:
Day 5
Nursing Assessment
2:00-3:30 PM Group presentation
Nursing Assessment
3:30 -3:45 PM Tea Break
3:30-4:45 Group presentation
Nursing Assessment
4:45-5:00 Day Summary and Recap
Nursing diagnosis
10:45-12:30 PM Nursing diagnosis
12:30-2:00PM Lunch Break
Day 6
2:00-3:30 PM Group activity:

Writing Nursing diagnosis for cases from
hospital
Planning : Outcome identification
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8:30-10:00 AM Planning (Nursing

Intervention/Instruction)
10:00-10: 30AM Implementation and evaluation

Day 7
10:45-12:30 PM Group Presentation: developing nursing

care plan based on cases from hospital
12:30-2:00PM Lunch Break
2:00-2:40 PM Post-test
3:00-4:45 PM Discussion : The way forward
4:45-5:00 PM Closing Remark
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OVERVIEW OF HOSPITAL SERVICES
Modern medicine in Ethiopia began to be practiced by government at the beginning of the 20th
Century. The Russian Mission established the 1st hospital in Addis Ababa in 1897. The first
government sponsored hospitals were established in Harar and Addis Ababa (Menelik II
Hospital) in 1909.Subsequently, majority of the hospitals were built in urban centers but still
not enough.
Situation of Hospital Services in Ethiopia before 2006

Evaluation of the hospital services in Ethiopia in 2006 indicated that hospital services are
characterized by:
 Lack of comprehensive care
 Poor quality of care
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 Inefficient &inaccessible services

 Inadequate attention to delivery and emergency
 Management not customer oriented
Policy Responses by FMOH
 The earliest modern efforts to improve the quality of government hospitals throughout
Ethiopia began in 2006 with the Ethiopia Hospital Management Initiative (EHMI),
envisioned by the then Minister of Health, Dr. Tedros Adhannon, and supported by the
Clinton Health Access Initiative in collaboration with the Yale Global Health
Leadership Institute. The EHMI resulted in the creation of the Ethiopian Hospital
Reform Implementation Guidelines (EHRIG), which built on both the Business
Process Reengineering (BPR) and Hospital Blueprint efforts, as well as the Masters in
Hospital and Healthcare Administration (MHA) degree program. Subsequently, the
country developed a hospital performance monitoring system based on the
achievement of Key Performance Indicators (KPI) and the Ethiopia Hospital Alliance
for Quality (EHAQ) to spread best practices and promote collaborative learning in
government hospitals nationally. EHAQ has focused on patient satisfaction, labor and
delivery management, and provides a national framework for continuous quality
improvement in hospitals across Ethiopia.
 The Ethiopian Hospital Transformation Guidelines (EHSTG) builds on and expands
the Ethiopian Hospital Reform Implementation Guidelines (EHRIG) and is consistent
with the Health Sector Transformation Plan (HSTP). The EHTG, which is consistent
with the national focus on quality improvement in health care, contains a common set
of guidelines to help hospital Chief Executive Officers(CEOs), managers, and
clinicians (care providers) in steering the consistent implementation of these
transformational systems and processes in hospitals throughout the country. The
EHSTG focuses on selected management and clinical functions, including new
individual service specific chapters for Emergency Medical, Outpatient and Inpatient
Services, Nursing and Midwifery, Maternal, Neonatal and Child Health and Teaching
Hospitals‘ Management. These guidelines also incorporate recent lessons from the
operationalization of the EHRIG, as well as, new national initiatives such as the
Guidelines for the Management of Federal Hospitals in Ethiopia, Hospital
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Development Army (HDA), Clean and Safe Hospital (CASH), and Auditable
Pharmaceutical Transaction and Service (APTS).
2006 2010 2012

EHMI EHRIG EHAQ
2008 2011 2014

Blue HPMI CASH
Print
 2006 : Ethiopian Hospital management initiative

 2010: The Ethiopian Hospitals Reform Implementation Guidelines launched
 2011-2012: Hospital Performance Monitoring Framework introduced with KPI
reports, site visits and review meetings
 2012 The Ethiopian Hospital Alliance for Quality (EHAQ) launched.
 2014 The CASH initiative lunched
EHRIG Overview
 Document developed to solve the problem related to hospital service
 Led by FMOH
 Participation of over 62 different bodies including government offices, RHBs,
hospitals, NGOs
 EHRIG had two volumes and 13 management areas
EHRIG has been revised into EHSTG
 It contains
 20 chapters
 197 operational standards with their distinct verification criteria.
 Minimum standards for patient satisfaction
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Rational for EHRIG revision

 Some standards are already met by most hospitals and a need to revise/upgrade
them
◦ Laboratory service management
◦ Pharmacy service management
 Some standards were incomplete
◦ A need to harmonized academic activities with patient centered care
 Some services were not covered
◦ Radiologic service
◦ Rehabilitative and palliative care services
 Did not include the context of teaching hospitals
 Has to be aligned with the HSTP transformation agendas
◦ New indicators
 Some services were packed in one chapter
◦ Patient flow chapter packing liaison, emergency, outpatient, inpatient services
 Incorporated learning from CASH, HDA etc
Quality
 Quality is the extent to which health services:
• Improve desired health outcomes and its provision involved
• clinical evidence basis
• Client/patient centeredness
• good communication
• shared decision making
 Six domains of health care quality:
1. Safe - avoiding harm to patients from care that is intended to help them.
2. Effective – improve pt outcome
3. Patient-Centered – based on unique patient's needs.
4. Timely - reducing waiting times and harmful delays for patients and providers.
5. Efficient - avoiding waste of equipment, supplies, ideas and energy.
6. Equitable - providing care that does not vary across intrinsic personal characteristics
18
Module I: - Operatonal
Standards of Nursing Practice
19
Module I: Operational Standards of Nursing Practice
Module description: This module is designed to give an opportunity for trainees to analyze
the 23 operational standards of nursing care and categorize them into three expectations.
Course objective: At the end of the course, the trainees will be able to analyze operational
standards of nursing practice to apply nursing process in the direct quality of patient care.
Enabling objectives: at the end of the course, the trainees will be able to:
 Define Nursing
 Describe Standard
 Explain Nursing standard
 Identify the 23 operational standards of nursing practice
 Differentiate the three categories of operational standards of nursing practice
Outline
 Session 1.1 Operational standards of nursing practice
 Session 1.2 Implementation guideline
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Session 1.1 : Operational Standards of Nursing Practice

Session objectives
After completing this session, the trainee will be able to
 Describe Standard And Nursing Standards
 Identify the 23 Operational Standards of Nursing Practice
 Differentiate the three categories of Operational Standards of Nursing Practice
1.1.1 Introduction
Nurses play a pivotal role in any hospital encompassing the largest workforce in a hospital.
Nurses act as direct caregivers who serve a hospital twenty-four hours a day, seven days a
week. This gives nurses a unique perspective on both patient care and hospital operations.
Given the complexities of hospital management and the direct relationship between hospital
operations and patient care, nursing responsibilities have expanded to include a greater
managerial role. This includes the increased role in hospital leadership and contributing to
effective decision-making within the overall hospital structure, as well as within case teams,
wards/units or departments.
1.1.2 Operational Standards

Operational standards are generally accepted rules, models, patterns, measures and are a
minimum level or range of performance or quality considered acceptable by professionals. As
an independent profession, nursing has increasingly set its own standards for practice. This is
called standards of nursing care. The standards guide and assure clients that they are receiving
high-quality care and that the nurses know exactly what is necessary to provide nursing care.
They are also measurements to determine whether the care meets the standards.
1.1.3 Operational standard for nursing practice

The operational standards below have been extracted from the Ethiopian Hospital Service
transformational Guidelines/EHSTG document, which all hospitals should fully implement to
ensure proper nursing care.
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1. The hospital has established nursing/midwifery service management structures and job
descriptions that detail the roles and responsibilities of each nursing and midwifery
professional, including reporting relationships.
2. The hospital has a nursing and midwifery workforce plan that addresses nurse /midwife
staffing requirements and sets minimum nurse /midwife to patient ratios in each service
area.
3. The hospital has written policies describing the responsibilities of nurses and midwives for
the nursing process including the admission assessment, diagnosis, planning,
implementation and evaluation of nursing/midwifery care.
4. All admitted and emergency patients/clients have a nursing/midwifery care plan that
describes holistic nursing/midwifery interventions to address their needs. The plan is
regularly reviewed and updated as required.
5. All hospital nurses/midwives comply with the professional code of conduct and ethics
which governs their professional practice.
6. The hospital has established guidelines for verbal and written communication about
patient/client care that involves nurses/midwives and their patients/clients, families, other
case team professionals of the disciples, including verbal orders and timely documentation
of accomplished activities.
7. The hospital has standardized procedures for the safe and proper administration of
medications by nurses or designated clinical staff.
8. The hospital has established nursing/midwifery care practice audit program, including the
documentation of completed audits and resulting practice improvements.
9. The hospital implements regular nursing/midwifery eight hours‘ shift, hourly rounds, and
central medication cabinet or room.
10. The hospital has a centralized nursing/midwifery station set-up in each ward with adequate
space, equipment and consumables.
Additionally, trainers and nurse practitioners should consider the operational standards
below at a regional/local level when implementing the national guidelines to enable nurses
to fully address the holistic needs of patients under their care.
11. Hospitals should provide on a regular basis complete uniforms for all nursing staffs who
are assigned or allowed to work in the facility.
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12. Nurses ensure delegation of nursing care to nursing students and assistants is appropriate,
safe and in the best interests of the person in the care of a nurse.
13. Nurses should work with others to protect and promote the health and wellbeing of those
under their care.
14. Nurses should take part in the ongoing continuing professional development (CPD)
required by their professional body and maintain a CPD portfolio.
15. Nurses should find solutions to conflicts caused by deep moral, ethical and other beliefs
arising from a request for nursing service through dialogue with patients /employer and or
professional body.
16. All nurses should be in full uniform as designated by hospital guidelines
17. Nurses should be open and honest, act with integrity and uphold the reputation of their
profession.
18. Nurses should care for all patients equally and without prejudice to age, gender, and
economic, social, political, ethnicity, religious or other status and irrespective of their
personal circumstance.
19. Nurses should not disclose confidential information relating to their patients and /or about
their matters and conditions unless in line with the Ethiopian law and / as required by
their professional body /employing hospital.
20. Nurses should seek verbal or written informed consent from their patients or their
relatives/next of kin (for incompetent patients) before any procedure.
21. Nurses adhere to and provide information on infection prevention practices to patients,
clients, family members and other caregivers, as appropriate.
22. Nurses may not receive gifts, favors or hospitality of any kind from patients, caregivers,
or visitors at any time including prior to or after the provision of care.
23. Hospitals have appropriate arrangements to ensure nurses access clinical supervision and
support and participate in regular clinical audit and reviews of clinical services.
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Activity 1
Duration: 30 minutes
Group work:
- Categorize the operational nursing standards according in to the following three
categories
o Expectations of nurses from hospital (10)
o Expectation of hospital from nurses (6)
o Expectation of patient from nurses (7)
o
Session summary
o
 o
Standard is the benchmark of achievement
 o Expectation
Nursing of professionally
standards are patient from nurses (7) expressions of the range of acceptable
developed
variations from a norm or criterion
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Session 1.2. Implementation Guideline/Handout
Session objectives
After completing this session, participants will be able to
 Describe how to implement each operational standard
 Prepare organogram to show managerial structure for nurses
 Indicate job description for nurses
1.2.1 Organizational Support for Nursing/Midwifery Function

Nurses/midwives play a pivotal role in any health facility. Encompassing the largest
workforce in hospitals, nurses/midwives act as direct caregivers who serve a
hospital twenty-four hours a day, seven days a week. This gives a unique
perspective on hospital operations. Nurses/midwives should be allowed to assume
managerial roles that will enable them to make decisions affecting patient/client care
at the case team, unit and department levels.
1.2.2 Organizational structure of the Nursing and Midwifery Service

Nurses and midwives play a pivotal role in any hospital. Encompassing the largest
workforce in a hospital, nurses/midwives act as direct caregivers who serve a
hospital twenty-four hours a day, seven days a week. This gives nurses/midwives a
unique perspective on both patient care and hospital operations. Given the
complexities of hospital management and the direct relationship between hospital
operations and patient care, nursing/midwifery responsibilities have expanded to
include a greater managerial role. This includes assuming an increased role in
hospital leadership and contributing to effective decision-making within the overall
hospital structure, as well as within case teams, wards/units or departments.
Nursing/Midwife Director is a member of the senior management team (SMT) and
responsible for the overall function of nursing and midwifery activities in the
hospital. Head nurses/midwives are responsible for the overall function of nursing
and midwifery activities in each ward and accountable to the Nursing/Midwifery
Director.
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Managerial structure
Although planning is the key to effective management, the organizational structure
furnishes the formal framework in which the management process takes place. The
organizational structure should provide an effective work system, a network of
communications, and identity to individuals and the organization and should consequently
foster job satisfaction. The organization contains both formal and informal structures.
Types of organizational structures:

A. The formal organizational structure:
It describes positions, tasks, responsibilities and relationships among people in their
positions in the different departments in the organization, and presented in diagrammatic
form called organizational chart (see Annex 1).
B. Informal organizational structure:
- It describes the personal and social relationships that do not appear on the
organizational chart.
- It helps members to meet their personal objectives and provides social
satisfaction.
- It also has its own channels of communication, which may distribute
information more broadly and rapidly than the formal communication system.
- The informal organizational structure is important to management, thus, the
supervisor should be aware of its existence, study its operating techniques, and use it
to meet the organizational objectives.
Organizational chart:
It is a diagram shows the different positions and departments, and the
relationships among them. It is used to show:
- The formal organizational relationships.
- Areas of responsibility.
- Persons to whom one is accountable.
- Channels of communication.
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Advantages of an organizational chart:

- It provides a quick visual illustration of the organizational structure.
- It provides help in organizational planning.
- It shows lines of formal authority, responsibility and accountability.
- It clarifies who supervises whom and to whom one is responsible.
- It emphasizes the important aspect of each position.
- It facilitates management development and training.
- It is used to evaluate strengths and weakness of current structure.
- It provides starting points for planning organizational changes.
- It describes channels of communication.
1.2.3 Job description

Job descriptions clarify what an employee is responsible for and what is expected of them
(See Annex 2 and 3).
Essential Elements of Job Descriptions
- General statement describing the concept and specific duties of the position
- Classification title, position number, geographic location, division and work unit of the
position, name and title of supervisor, and effective date of duties.
- If supervisor position, list classifications supervised.
- General statement describing the nature of the unit in context with the
department/program
- Description of the positions supervisory reporting relationship.
- List of typical essential and marginal functions/duties, grouped in related categories
- Duties broken down by percentage of time spent on each task or group of similar tasks
- Signature and date of employee and supervisor.
1.2.4 Team Work

Nursing practice requires teamwork, an on-going interaction between members of
the multidisciplinary team, the patients, patients‘ relatives and hospital managers. In
working with colleagues and hospital management, the nurse must:
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- Collaborate with the patient and their caregivers,

- Work with colleagues in formulation of overall goals, plans and decisions
related to patients,
- Work with other members of the multidisciplinary team in caring for patients,
- Consult with other health care providers on patient care, as appropriate,
- Make referral, including provisions for continuity of care, as appropriate,
- Collaborate with other disciplines in teaching, consultation, management, and
research, activities as opportunities arise,
- Participate in an organized health development army, and
- Nurses/midwives should assume responsibility for monitoring, evaluating and
reporting of their activities within the Health Development Army.
It is essential that within a case team, ward/unit or department there exists a clear
management structure that delineates the ultimate roles and responsibilities within
the given team and clinical setting, determining who has clear authority over certain
decision-making processes.
1.2.5 Clinical supervision and delegation

1.2.5.1 Clinical supervision
Clinical supervision is ―a formal process of professional support and learning
which enables individual practitioners to develop knowledge and competence,
assume responsibility for their own practice and enhance client/patient protection and
safety of care‖.
It has also been defined as ―an ongoing professional relationship with an experienced
practitioner, to engage in guided reflection on current practice in ways designed to develop
and enhance that practice in the future‖
Effective processes for nursing clinical supervision will enable hospital to improve the quality
of nursing care, to promote patient safety and to contribute to the professional development of
our nursing staff. This document provides guidelines for the Clinical Supervision of Nursing
Staff within
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Model of Clinical Supervision

The interactive model of supervision developed by Proctor (1986) identified three functions
for clinical supervision supportive, educative and managerial.
 Supportive: This aims to support and enable nurses to understand and manage the
emotional stress of clinical practice.
 Educative: This approach aims to develop the skills and evidence based practice of the
nurse/s.
 Managerial: This focuses on performance monitoring of the nurse/s professional and
operational practice. It aims to promote nursing compliance with policies, protocols,
procedures and standards and nursing contribution to clinical audit.
Function and Tasks of Clinical Supervision
Function Task
 supportive  To counsel
 To consult
 educative  To set up learning relationship
 To teach
 managerial  To monitor administrative aspects
 To monitor professional and ethical issues
 To evaluate
A supervisory relationship can also be described as one of ‗monitoring, development and

support‘.
Monitoring
Developing Supporting
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Some supervisees will require one aspect more than another depending on the nature of their
work, for example supervisees working within critical care will perhaps need a greater
emphasis on monitoring, while supervisees working in stressful situations such as mental
health nursing or palliative care may need a more supportive type of supervision.
Application of Clinical Supervision within Nursing

It is in individual job descriptions and within individual case teams in the local health care
facility that the format of Clinical Supervision will be agreed on, and clarification of the roles
of team leaders/coordinators /managers, clinical supervisors and supervisees will be identified
and made explicit. Senior Managers (Matron, Case Team Leaders etc) are expected implement
Clinical Supervision for nursing staff following these guidelines. The role of clinical
supervision for individual clinical staff should be determined collaboratively between the staff
member (supervisee) and his/her line manager.
Clinical supervisor recruitment

Clinical supervisors should have the following characteristics:
 Expertise: This recognition may be either informal or formal through skills and
experience in one‘s clinical role. Informal recognition may come primarily from peers.
Formal recognition occurs through status and training, and possible senior or advance
practitioner positions held within the hospital.
 Experience: The clinical supervisor will be recognised as having a breadth and depth
of experience in his/her field of expertise.
 Acceptability: It is of prime importance that the clinical supervisor is acceptable to
those he/she supervises.
 Training: It is desirable that all clinical supervisors receive appropriate training to
provide them with the theories and models underpinning the principles of clinical
supervision, the use of documentation, to practice experience at facilitating clinical
supervision and to give opportunities for reflection on their own skills and areas for
development.
The Clinical Supervisor may be the immediate line manager of the employee or could be
another assigned individual. If the supervisor is not the line manager then the roles of the line
30
manager and clinical supervisor should be clearly known so that there is no confusion or
misunderstanding between all parties.
Every nurse providing individual supervision or facilitation of a group should preferably have
undergone preparation for the role. Experienced nurses will need to identify how this learning
and development is provided to ensure that clinical supervisors are adequately prepared for the
role and should identify further development needs in their own supervision.
The provision of clinical supervision

Each Department/Case Team should establish Clinical Supervision using one of the following
approaches:
 One-to-one supervision = This is the most common form of clinical supervision. The
supervisor is an expert from the same or another discipline. This may be the line manager,
in which case clinical supervision will form part of the regular one to one support and
operational monitoring function of supervision.
 Group supervision = This model of clinical supervision is with an expert supervisor from
the same or another discipline; and can be utilised as peer review or action learning sets.
 Network supervision = This form of clinical supervision is a group of people with similar
expertise, who do not work together on a day-to-day basis.
Developing a Working Agreement and how to supervise
Clinical supervision is a relationship and a commitment to regular clinical supervision
meetings is essential. Clinical supervision is most effective when sessions last for a minimum
of 1 hour, occur on a regular basis (at least 4 to 6 weekly) and are held away from the day to
day workplace free from interruptions. 1
The question on how to supervise should include:
 First meeting- the supervisor should focus on the nurse‘s understanding of his/her job
description. He/she could then be asked if he/she believes they have the skills and
knowledge for the job. If not, what needs to be done. Nurses could also be asked about the
past month work experience (or the time period since last meeting) and to highlight any
successes, problems or stresses they faced. The first supervision should finish with both
31
the supervisor and supervisee agreeing on an action plan that will address nursing care
practice issues/developmental needs identified during the supervision session.
 Second and subsequent meetings - The supervisor and the supervisee should review the
action plan agreed at the first supervision session. This will inform the focus of the
supervision
Record Keeping
A record of the clinical supervision meetings may be maintained depending on the purpose of
the clinical supervision. Any records must respect and maintain confidentiality of the
patients/clients. Supervisees should be encouraged to maintain their own record of supervision
and Supervisors should maintain a record so that they can follow up and build on previous
discussions.
Confidentiality and Professional Responsibility and Accountability

It is important to remember that the supervisor‘s ultimate responsibility and accountability
remain with the welfare of the patient or client. Lines of accountability and responsibility need
to be clearly defined at the outset of the clinical supervision, during the negotiation of the
contract between the supervisor and supervisee. If the supervisor becomes concerned about
the practice of the supervisee, the supervisor is accountable to address it. In the first instance
the supervisor should raise his/her concerns with the supervisee. However if, for whatever
reason, the supervisee refuses to admit or recognise the problem or issue, it will be necessary
for the supervisor to present the issue to a higher authority, such as the Department/Case
Team Head, Human Resource Director or CEO, depending on the nature of the problem. In
such circumstances this most probably will mean breaking confidentiality with the supervisee.
Such action should only be taken after first informing the supervisee.
1.2.5.2 Delegation
Nurses/midwives may delegate tasks and responsibilities to junior nurses/midwives,
student nurses/midwives or parallel position nurses/midwives. Before delegating,
he/she must ensure that anyone they delegate to, is able to carry out the responsibility
of what she/he delegates, and must provide adequate supervision to ensure that the
outcome of any delegated task meets required standards.
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1.2.6 Nursing/Midwifery Workforce Plan

Shortages of appropriate nursing/midwifery staff or inappropriate distribution of
available staff adversely affects the quality of patient care. Inappropriate workforce
planning has been related to staff dissatisfaction and nurse/midwife turnover, patient
mortality, hospital-acquired infections, and the risk of needle- stick injuries.
The hospital should establish a nursing/midwifery workforce plan that:
- Establishes minimum nurse/midwife to patient ratios for each inpatient
ward/service, taking the skill mix of staff into consideration,
- Identifies priority areas where the nurse/midwife count must at all times meet
the minimum ratio requirements (for example intensive care/high
dependency units, post-operative recovery, emergency department, labor and
delivery etc.), and
- Establishes a procedure for transferring nurses/midwives across clinical settings,
or calling in extra nurses/midwives from home in order to maintain minimum
nurse to patient ratios, especially in the priority areas.
To determine the minimum nurse/midwife staff ratio the following factors to be
considered include:
- The severity of the clinical condition of patients,
- The intensity of nursing/midwifery care needed, for example the frequency of
nursing interventions such as observations, medication administration, wound
care, stoma care, bathing etc..,
- The number of admissions and discharges,
- The availability of technology (patient monitors, beepers etc…),
- The skill mix of staff, availability and responsibilities of caregivers
There should be a minimum of a registered professional nurse/midwife in-charge of

each ward/unit that has relevant knowledge, skills and experience with compassion and
respect to manage a ward/unit and the nursing /midwifery staff therein. The
nurse/midwife management team, together with hospital management should
determine the minimum nurse/midwife to patient ratio for the unit. The ratio should
be kept under review and amended as necessary.
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The nursing/midwifery workforce plan should also consider the role of nurses/midwives in
outpatient and specialist clinics and the nursing/midwifery contribution to hospital
management and governance structures (such as quality committees, infection prevention
committees etc.)
1.2.7 CPD and Professional Portfolio

The Professional Portfolio contains the four steps:
1. Self-Assessment of your learning needs,
2. Planning your learning goal,
3. Implementation of your plan, and
4. Self-Evaluation of what you have achieved.
This process is designed to encourage nurses to reflect in an effort to gain more from their
learning. It is assumed that nurses are learning on a regular, if not daily, basis simply by
virtue of practicing. The Portfolio provides a format for nurses to track all of those day-to-day
learning activities in the Learning Log. These activities might include:
 In-services‘ training
 Grand rounds
 Reading journal articles
 Online searches on nursing related practice areas
 Conferences /workshops
 Discussion with colleagues or physicians
Nurses need to maintain a professional Portfolio because it:

 Supports nurses‘ progression throughout their nursing career.
 Serves as an evaluation tool that guides professional development.
 Offers a showcase for nurse performances related to essential knowledge, skills and
dispositions.
 Allows the nurse to demonstrate growth and proficiency in regard to operational
standards of nursing care practice.
 Facilitates collaboration and interaction through the sharing of on line projects and
discussion of teaching skills.
34
 Provides a forum for publication and dissemination of artifacts that support instruction.
 Meets regulatory requirements.
Please refer Teaching Portfolio in the diagram below as an example
Teaching Portfolio
I am excited to be working with children and really making a difference in their lives.
I remember being so upset in class as a child because I did not understand what was being talked
about in the classroom. A dedicated teacher helped me by recognizing my learning disability and
finding ways to assist me. I owe my success to this amazing teacher who changed my life.
Those experiences made me who I am today and I am now helping others. I assist children
making the transition to our school systems here in the United States both academically and
culturally. I love my job and am very proud to be in this position making a difference.
I come to this profession with definite beliefs in mind in relation to who I will be as a successful
teacher, employee, and member of your community. I am a teacher who most importantly embraces
the development of a trusting environment with my students. In my opinion, students only open up
to learning beyond the borders of basic requirements when trust is present. One of the skills I will
utilize in building the before mentioned environment is found in the ability to communicate
efficiently with one‘s students. I will not only provide educational data from the curriculum, but am
a good listener willing to respond in kind to all ideas presented by the classroom community. I will
also respond well to change in being open to learning from others in trying new approaches in lesson
construction and delivery.
My teaching methodologies main objective is to inspire learning of content as well as

developing the skills necessary for students to explore content and draw intelligent conclusions
independently. I am committed to inspiring this critical exploration through stimulating teamwork
amongst peers, being aware of different learning styles, teaching across subject boundaries,
providing individualized accommodations, involving students in goal setting where appropriate, and
being able to recognize and seize the moment when teachable moments occur. All of these
approaches can be fostered through creative lesson planning.
Source: Kimberly Smith, http://www.portfoliogen.com/pgsample1/

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1.2.8 Provision of Resources

Hospitals should ensure that nurses/midwives have access to and are trained on how
to use resources (including equipment and consumables) correctly and cost-
effectively. Nurses/midwives are responsible for forecasting stock-outs of
nursing/midwifery formats and other consumables on the ward, and should
inform the appropriate party of the need for additional resources to prevent stock
out.
1.2.9 Nursing Process
The nursing process is an organized, systematic and holistic approach through which
nursing/midwifery care provision is organized to achieve patient/client centered
care. The nursing process involves Assessment, Diagnosis, Planning,
Implementation and Evaluation of care (ADPIE). This should be done in
collaboration with the patient/client, family and community. Assessment: the
nurse/midwife collects comprehensive data pertinent to the patients‘/client‘s health
or situation.
Admission Assessment
A nurse/midwife collects and documents critical data regarding patient/client health status.
This assessment remains accessible to the entire health care team during the course of the
client/patient stay and beyond, in order to assist the team in determining proper client care
and treatment. In the nursing assessment, the nurse gathers and examines both Subjective
and Objective data within eight hours of patient admission.
Subjective data are what the patient/client actually states (e.g. "I'm tired").
These are his/her feelings and perceptions.
Objective data are concrete, observable information and investigation.
Ongoing nursing assessment
• Collects data on what is currently (during each shift) happening with the patient
• Data can be objective or subjective
– Objective: blood pressure, pulse, temperature
– Subjective: patient‘s symptoms, what the patient reports
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1.2.10 Nursing/midwifery practice audit program

The nursing/midwifery practice audit program should be part of the overall hospital quality
improvement program. Nursing/midwifery practice audit is one of the tools to ensure the
clinical effectiveness of nursing/midwifery care patients/clients receive. See chapter 19
EHSTG for more information on clinical audit process.
Purposes of Nursing Audit
- Evaluates nursing/midwifery care patients/clients receive.
- Promotes quality improvement of nursing/midwifery care.
- Improves quality of record keeping.
- Focuses on care provided and not on care provider.
- Contributes to research.
There are two methods of Nursing/midwifery audit:
1. Retrospective Review - this refers to an in-depth assessment of the quality of care after the
patient has been discharged. The patient‘s chart is the source of data.
Retrospective audit is a method for evaluating the quality of nursing care by examining the
nursing care, as it is reflected in the patient care records for discharged patients. In this type of
audit, specific behaviors are described then they are converted into questions and the examiner
looks for answers in the record. For example, the examiner looks through the patient's records
and asks:
- Was the problem solving process used in planning nursing care?
- Was patient data collected in a systematic manner?
- Was a description of patient's pre-hospital routines included?
- Were laboratory test results used in planning care?
- Did the nurse perform a physical assessment? How was the information used?
- Did the nurse write nursing orders? And so on.
2. Concurrent Review - this refers to the evaluations conducted on behalf of patients who
are still undergoing care. It includes assessing the patient at the bedside in relation to a pre-
determined criterion; interviewing the staff responsible for this care and reviewing the
patient‘s record and care plan.
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Criteria Development Method:

- Define patient population
- Identify a time framework for measuring outcomes of care
- Identify commonly recurring nursing problems presented by the defined patient
population
- State patient outcome criteria
- State acceptable degree of goal achievement
- Specify the source of information
- Determine the design and type of data collection tool
1.2.11 Standard Operational Procedure (SOP)

An SOP is a procedure specific to your operation that describes the activities necessary to
complete tasks in accordance with health service regulations, provincial laws or even just your
own standards for running your service.
Standard Operational Procedure can create,
• Efficiencies, and therefore profitability
• Consistency and reliability in service delivery
• Fewer errors in all service areas
• A way to resolve conflicts between service provider and client
• A healthy and safe environment
• Protection of employers in areas of potential liability and personnel matters
• A roadmap for how to resolve issues – and the removal of emotion from
troubleshooting – allowing needed focus on solving the problem
• A first line of defense in any inspection, whether it be by a regulatory body, a partner
or potential partner, a client, or a firm conducting due diligence for a possible purchase
• value added to your service should you ever wish to sell it
Developing an SOP is about systemizing all of your processes and documenting them
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Steps in developing Standard Operational Procedures

 Designate a responsible person/persons
 Research the evidence
- Literature
- Ask other hospitals
 Write the SOP in standard format
 Publish in a SOP Manual
 Educate
Standard Operational Procedure standard format

• Policy/Purpose: statement that defines what the policy is about and the reason
for it
• Equipment: list necessary equipment to do the procedure
• Procedure: Outlines and describes each step
• Documentation: Defines how, where and how often the procedure should be
documented.
• Sources: List of references
• Approval: Usually Matron or Policy and Procedure Committee
Summary
 Procedure for the implementation of each operational standard described

Managerial structure for nurses prepared and job description indicated
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Session 1.3: Implementation Checklist and Indicators/Handout
Session objectives
After completing this session, the trainee will be able to
 Develop checklist for monitoring and evaluation
 Identify in addition, indicators for implementation
1.3.1 Assessment Tool for Operational Standards
 In order to determine if the Operational Standards of Nursing /Midwifery care
standards have been met by the hospital an assessment tool has been developed
which describes criteria for the attainment of a Standard and a method of
assessment. This tool can be used by hospital management or by an external body
such as the RHB or FMOH to measure attainment of each Operational Standard.
1.3.2 Implementation Checklist

 The following Table can be used as a tool to record whether the main
recommendations outlined above have been implemented by the hospital. This tool
is not meant to measure attainment of each Operational Standard, but rather to
provide a checklist to record implementation activities.
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Table 1. Nursing/Midwifery Care Standard Checklist

Y N
1. There is a system for coordinating and managing nursing staff. e o
2. Job descriptions for nursing positions have been developed. s
3. A nursing workforce plan has been developed.
4. The hospital‘s nurse staff requirements are defined in the nursing workforce
5. plan. to patient ratios for each service area are defined in the nursing
Nurse
6. workforce
There plan. policy for the nursing process.
is a written
7. Nurses complete nursing admission assessments for inpatients.
8. Nurses complete a nursing care plan for inpatients.
9. There are written guidelines for nursing verbal and written communication.
10. There are written guidelines for medication administration.
11. There is an established nursing/midwifery care practice audit program.
12. Nurses implement regular nursing/midwifery hours (eight)‘ shift.
13. Nurses conduct nursing care based on hourly rounds*.
14. There is a central medication room or cabinet.
15. There is a centralized nursing/midwifery station set-up in each ward.
*Hourly rounding can be defined as ―a systematic, proactive nursing intervention designed to

anticipate and address the needs of hospitalized patients.‖
1.3.3 Nursing/Midwifery Care Standards’ Indicators
In addition, the following indicators should be monitored on a regular basis to assess

the effectiveness/outcomes of implementation of the recommendations provided in this
module.
41
Table 2. Nursing and Midwifery service standards process indicator

Quality statements Quality measures score Remark/verification
criteria’s
Nursing and midwifery service standard 1: Each ward has all the necessary facilities,
equipment and supplies needed to provide a quality nursing service
NMS1.1 well equipped Nurses‘ stations should have 1
nursing station is visibility of patients and of
established in each circulation paths.
ward The nurse station has organized 1
and efficient chart filing systems
in to a shelf
Should have dressing 1
room/corner with personal
lockable locker for all of the
nurses working in the ward
The nursing /midwifery station 2 0 if all available except
has Enough space to functional computer and
accommodate telephone
 Computers with printer and
internet access 2 if all available
 Telephones
 Shelf for
 Reference books,
guidelines and policies
 Patient cards and different
formats
 Table
 Comfortable chair
 Access to clean drinking
water
 Hot plates/electrical hot pot
medical equipments for nursing 2 0 if two or more are
diagnosis or intervention use – missed
see annex 1 if only one missed
2 if all available
Medication Preparation Areas 1 0 if either refrigerator or
with functional hand washing
 Small under counter sink is not available
refrigerator. 1 if both are available
 Hand washing sink with
disinfectant.
Nursing guidelines are availed 1 0 if one of them is not
 Nursing process available
 Nursing communication
 Safe drug administration
42
NMS1.2 Medication Central or room cabinet for 2 Give 0 if any drug or

stores are available for medication store based on the supply is at bedside
each ward or room patient bed number despite the presence of
central or room cabinet
NMS1.3 Skill lab is the hospital has skill laboratory 2 0 if two or more missed
established for staff and student nurses and 1 if only one missed
all the necessary teaching aids 2 if all present
are available – see annex
Nursing and midwifery service standard 2: The hospital has functional Nursing midwifery
management
NMS2.1 The hospital Matron/ nursing director is a 1 0 if letter is available but
has a Matron/ Nursing member of SMT the matron or nurse
midwifery director and director is not regularly
functional participate in SMT
nursing/midwifery meeting
management The nursing management has 1 DOCUMENT REVIEW
annual operational plan
Induction or orientation is given 5 DOCUMENT REVIEW
for all newly recruited Verify if it was done for
nurses/midwives all in the previous quarter
Regular refreshment training is / last month for new
given for all nurses/midwives at ones
least quarterly
NMS2.2 The Nursing management conducts 2 DOCUMENT REVIEW

nursing/midwifery monthly nursing management Verify if it was done last
management conducts meeting month
QI projects for Nursing midwifery round team 22 See minutes of each
identified nursing established and made at least working day last month
midwifery service once nursing round a day and 1 for each day
quality gaps Nursing management develops 2 DOCUMENT REVIEW
action plan for identified gaps in Verify if it was done last
each meeting month
Nursing management 2
implemented the action plan
developed
Nursing and midwifery service standard 3: Quality nursing midwifery service is ensured for
all patients
NMS3.1 There is written evidence of a 10 CHART REVIEW
comprehensive nursing compilation of data based on
midwifery assessment Gorden‘s functional model
is done for all patients including
 demographic details
 Health Perceptions-
Health Management
43
Pattern
 Nutritional-Metabolic
Pattern
 Elimination Pattern
 Activity-Exercise Pattern
 Cognitive-Perceptual
Pattern
 Sleep-Rest Pattern
 Self-Perception and Self-
Concept Pattern
 Roles and Relationships
Pattern
 Sexuality-Reproductive
Pattern
 Coping and Stress
Tolerance Pattern
 Values and Belief Pattern
Nursing assessment is completed 10 Each ward should be
within 8 hours patient‘s arrival handovering register
between runners bring
admitted patients from
liaison office and nurses
in the ward. Time of
arrival of patient should
be registered and the
nurse and runner both
has to sign on it. The
absence of a handovering
register or untimed
nursing assessment will
make the score 0
All entries in the nursing process 10 CHART REVIEW
should be legible, dated and
signed
NMS3.2 correct nursing The formulated actual and/ or 10 CHART REVIEW
midwifery diagnosis is potential nursing diagnosis go
made for all patients with the nursing assessment
(subjective and objective data)
• Problem, Etiology and
Signs(PES) for actual
problem and
• Problem and Etiology
(PE) for potential or risk
nursing diagnosis)
Nursing diagnosis is listed based 10 CHART REVIEW
44
on their priority
The nurses/midwifes formulated 10 CHART REVIEW
nursing diagnosis based on
revised NANDA list.
The expected goal/outcomes for 10 CHART REVIEW
each nursing diagnosis are
SMART
The expected goal/outcome are 10 CHART REVIEW
consistent with nursing diagnosis
The nursing intervention/nursing 10 CHART REVIEW
order are clear, understandable
and consistent with expected
goal/outcome
The nursing interventions are 10 CHART REVIEW
prioritized
NMS3.3 nursing The interventions are 10 CHART REVIEW
midwifery interventions implemented/recorded according
are implemented to the treatment plan
Counseling/information given to 10 CHART REVIEW
the patient is recorded according
to plan
NMS3.4 nursing The outcome measured at the end 10 CHART REVIEW
midwifery evaluation is of the nursing intervention (all
done after each changes of subjective and
intervention objective markers are reviewed
and documented on the progress
shit)
The nursing plan is revised 10 CHART REVIEW
based on clients health status
change
The outcome measured at the end 10 CHART REVIEW
of the nursing intervention (all
changes of subjective and
objective markers are reviewed
and documented on the progress
shit)
NMS3.5 proper All physician order contains, 10 CHART REVIEW
communication system • Name of patient 0 if one
is established b/n nurses • Date and time bullet is
and nurses/physicians • Drug name absent or
• Drug dose, frequency, incorrect
duration of treatment
• Root of administration
• Name and signature of
physician
The physician written orders are 10 CHART REVIEW
45
dated & timed, and signed by

nurse when transcribed and
administered
Verbal orders are signed by 2 10 CHART REVIEW
nurses
Verbal orders are signed by 10 CHART REVIEW
physician within 24 hours
There is nursing round for each 10 CHART REVIEW
shift?
Does the hospital provide 10 Observation and
complete uniforms for document review
nurses/midwives and do
nurses/midwives comply with the
institutions dress code?
Are nurses /midwives in 10 Observation
complete uniform at all times at
working place
Patient records conform to the 10
following requirements: 0 if one
 Legible bullet is
 Dated absent or
 Name and signed after each incorrect
entry/attendance
 Errors crossed with a single
line and errors initialed
 Patient‘s name and medical
record number on each page
 Abbreviations are contained
within a locally agreed
glossary
NMS3.6 All nursing Formats are put in the client chart 10 CHART REVIEW
and other formats are in logical sequence (V/S sheet,
put in logical sequence Input output monitor, physician
assessment form, nursing
assessment form, nursing
diagnosis form, nursing care plan
form, nursing intervention and
medication administration form,
nursing progress/evaluation form,
discharge form)
Nursing and midwifery service standard 4: Patient centered nursing midwifery service is
given to all patients
NMS4.1 All patients There is a system to involve all 10 CLIENT INTERVIEW
are involved in the plan patients when changes to
of care nursing/midwifery services are
proposed
46
All patients are provided with 10 CLIENT INTERVIEW

information about arrangements
for first contact
All patients are informed about: 10 CLIENT INTERVIEW
 access to services
 how to make a complaint
 consent to treatment
 discharge planning
NMS4.2 All patients During treatment sessions, 10 CLIENT INTERVIEW
were approached with patients are introduced the name
dignity and respect, of the nurse or midwifes
addressed by name and responsible for his/her care and
encouraged to ask all patients are addressed by their
questions name
Staffs are polite and considerate 10 CLIENT INTERVIEW
All patients are given all the 10 CLIENT INTERVIEW
privacy they need
All patients are given the chance 10 CLIENT INTERVIEW
to ask questions
NMS4.3 All patients All patients felt involved in 10 CLIENT INTERVIEW
are informed of deciding about their treatment
treatment outcomes and plan (informed consent) and all
discharge plan are told about what they could
achieve at the end of their
treatment
the results of the 10 CLIENT INTERVIEW
assessments/procedures are
explained to all patients
If patients are left alone during 10 CLIENT INTERVIEW
treatment session, they are told
how to call for help
During discharge, all patients felt 10 CLIENT INTERVIEW
involved in the plans for their
discharge and given appointment
instruction
During discharge, all patients are 10 CLIENT INTERVIEW
given enough advance warning
for their discharge and all the
plans for their discharge went
smoothly
47
Table 3. Nursing/Midwifery Care Standards outcome Indicators

S/N Indicators Formula Frequency Comment
Pressure sore incident rate Number of pressure Quarterly HMIS
1. sores/number of
admissions*100
Attrition rate of nursing staff Total number of nurses Quarterly HMIS
leaving/total number of
2. nurses at beginning of
reporting period * 100
Attrition rate of midwifery Total number of midwives Quarterly HMIS
staff leaving/total number of
3. nurses at beginning of
4. a) Cumulative number of reporting period of
a) Total number * 100
nursing Quarterly HMIS
nursing staff who received in staff with in-service training
service training from the beginning of year
to the end of reporting
b) % of nursing staff who period
received in service
training b) Cumulative number of
nursing staff who received
training/ Total number of
5. a) Cumulative number of nurses a) Totalatnumber
beginning
of of year Quarterly HMIS
midwifery * 100
midwifery staff with in-
staff who received service training from the
in service training beginning of year to the end
of reporting period
b) % of midwifery staff
who received in service b) Cumulative number of
training midwifery staff who
received training/ Total
6. In patient satisfaction survey : number of nurses
Total number at
of inpatients Biannual Survey tool
% of respondents who beginning of year
who respond ‗always * 100
or
answer ‗always or usually‘ usually‘ to the questions
to the following questions: listed/ Total number of
a) During this health inpatients respondents*100
facility stay, how
often did nurses treat
you with courtesy
and respect?
b) During this health
facility stay, how
often did nurses
listen carefully to
you?
c) During this health
facility stay, how
often did nurses
48
explain things in a
way you could
understand?
7. Healthcare Total number of patients Quarterly

acquired infection rate with an infection
arising >48 hours after
admission during reporting
period /total number of
admissions during reporting
period *100
8. Surgical site a. Total number and Quarterly

Infection percentage of patients
with elective Caesarean
section who developed post
op wound infection
b. total number and

percentage of patients with
clean surgical procedure
who developed surgical site
infection
Quarterly
49
References
1. World Health Organization (WHO) definition of nursing, 2017
2. American Nursing Association (ANA) definition of nursing, 2015
3. Ethiopian Hospital Reform Implementation Guideline, 2011
4. Ethiopian Hospital Strategic Transformational Plan, 2016
5. Proctor, Clinical supervision module for nursing 1989
6. https://www.scribd.com/doc/46802062/8-the-Organizational-Structure-of-Nursing-
Service-Department accessed April 30, 2017
7. https://www.rochester.edu/working/hr/employment/creating_job_desc.pdf accessed April
30/2017
8. https://www.brampton.ca/EN/Business/BEC/resources/Documents/What%20is%20a%20
Standard%20Operating%20Procedure(SOP).pdf accessed April 29/207
45
Module -II Nursing Ethics
46
Module -II Nursing Ethics

Module Description
This module is designed to equip trainees with the required knowledge, attitude and practice
regarding essential components of the nursing ethics. The course will address the principles of
nursing ethics, nursing values, and ethical dilemmas, legal issues in nursing, ethical decision-
making and professional code of ethics. The course will also enable nurses to provide quality
nursing care by influencing their attitude positively.
Module Objective:
Up on completion of this module the trainees will be able to demonstrate ethical principles and
use appropriate ethical decision-making approaches.
Enabling objectives:
After completing this module, the trainees will be able to:
 Describe ethics
 Describe ethical principles
 Discuss ideal nursing ethical competencies
 Describe elements ethical dilemma and distress
 Apply Ethical decision-making models to solve ethical dilemmas
 Discuss legal issues in relation to the nursing practice
 Demonstrate sound ethical decision making ability
 Describe code of ethics
Session outline
Session-1: Introduction to Nursing Ethics
Session 2: Nursing Ethical principles
Session 3: Nursing Values
Session 4: Ethical Dilemmas and Ethical distress in Nursing
Session 5: Ethical Decision Making in the Nursing Practice
Session 6: Legal Aspects of the Nursing Practice
Session 7: Nursing Code of Ethics
47
Session 2.1. Introduction to Nursing Ethics
Session Objectives
 Define Nursing Ethics
Activity 2.1: Probing question

What is Ethics?
Definition:
The word ethics is derived from the Greek word ―ethos‖, which means custom or guiding beliefs.
Ethics determines the characteristics of a profession and is also called as a ―code of conduct‖.
Nursing ethics provides the professional standards for nursing activities, which protect the nurses
and the patients from legal and ethical issues.
Ethics- Rules of conduct recognized in respect to a particular class of human actions or a

particular group.
Ethics (sometimes called morals or moral philosophy):

 is concerned with fundamental principles of right and wrong and what people ought to do
 inform our judgments and values and help individuals decide on how to act
Guidance on acting ethically is informed by accepted ethical theories, principles and
frameworks.
The International Council of Nurses Code of Ethics is grouped into four distinct areas. These
four distinct areas define the responsibilities of the individual nurse and nursing as a whole. The
four areas are: to promote health, to prevent illness, to restore health, and to alleviate suffering.
Nursing also embraces human rights and provides care without regard to conditions of race or
culture. In nursing, the patient may be an individual, a family, or a community (ICN).
A theme common to the ANA (2001) and ICN (2006) code is a focus on the importance of
compassionate patient care aimed at alleviating suffering.
The American Nurses Association wrote the Code of Ethics for Nurses in order to serve the
following purposes:
48
 As a statement of the ethical obligations and duties of every person who chooses to enter
the profession of nursing.
 To act as the nonnegotiable standard of ethics
 To serve as an expression of the understanding on nursing‘s commitment to society.
Summary
Ethics is rules of conduct recognized in respect to a particular class of human actions or a
particular group. It is concerned with fundamental principles of right and wrong and
what people ought to do. Ethics inform our judgments and values and help individuals
decide on how to act
49
Session 2.2: Ethical Principles

Session Objectives
• Identify principles of nursing

• Describe different principles of nursing
Ethical principles provide criteria on which to base judgments in relation to ethical theories.
Ethical principles include:
Activity: 2.2.1
State Principles of Ethics You Know
Beneficence – doing or promoting good.

 Compassion; taking positive action to help others; desire to do good; core principle of
our patient advocacy.
 Beneficence is doing or active promotion of good. This is done by:
 Providing health benefits to the clients.
 Balancing the benefits and risks of harm.
 Considering how a client can be best helped.
Example: An elderly patient falls at home and has a fractured hip. In the emergency room, the
nurse acts to provide pain medication as soon as possible in an act of beneficence.
Non-maleficence - to do no harm
 Avoidance of harm or hurt; core of medical oath and nursing ethics.
 Often in modern times, non-maleficence extends to making sure you are doing no harm
in the beneficent act of using technology to extend life or in using experimental
treatments that have not been well tested.
 Avoiding deliberate harm, risk of harm that occurs during the performance of nursing
actions.
 Considering the degree of risk permissible.
50
 Determining whether the use of technological advances provides benefits that outweigh
risks.
Example: When this elderly person above received pain medication (an act of beneficence) there
are complications that could arise. Practitioners recognize that using a narcotic may cause
confusion. When obtaining the consent for her hip surgery, we want to make certain that the
patient is alert enough to understand the risks and benefits of the procedure. We must balance
the beneficence of providing the medication quickly with the possible maleficence of obtaining
consent when patient does not have the capacity to make the decision for surgery.
Autonomy
 The third ethical principle, autonomy, means that individuals have a right to self-
determination, that is, to make decisions about their lives without interference from
others. What are some of the ethical issues to be raised when applying this principle to
interstate nursing practice?
 Respecting a client‘s rights, values and choices is synonymous to respecting a person‘s
autonomy. Informed consent is a method that promotes and respects a person‘s
autonomy. For a client to make an autonomous decision and action, he or she must be
offered enough information and options to make up his or her mind free of coercion or
external and internal influences. In clinical settings, this is promoted by proving informed
consent to the client.
Example: In clinical situations nurses respect a patient’s autonomy, where the patient is allowed
the freedom of choice regarding treatment, such as in deciding whether he/she wishes to be
intubated during an exacerbation of COPD, or deciding when he/she wishes to forgo further
dialysis. If a patient lacks capacity for such a decision and has an advance directive, the person
who has the durable power of attorney can make the decision.
Justice
 Derived from the work of John Rawls, this principle refers to an equal and fair
distribution of resources, based on analysis of benefits and burdens of decision. Justice
implies that all citizens have an equal right to the goods distributed, regardless of what
they have contributed or who they are.
51
 Justice is the promotion of equity or fairness in every situation a nurse encounters. The
following nursing implications promote justice:
 Ensuring fair allocation of resources. (example: appropriate staffing or mix

of staff to all clients)
 Determining the order in which clients should be treated. (example: priority
treatments for the clients in pain)
Example: A hospital organization wishes to donate low or no-cost pediatric dental services to
the community. There are openings for 45 children per month. Justice requires a fair method
that is free from bias, to determine who will receive these services.
Veracity – duty to tell the truth
 It requires the health care provider to tell the truth and not intentionally deceive or
mislead clients. After decision is made, the nurse should be truthful to the patient. Tell
him the decision and why they chose it. Sometimes nurses can give false Reassurance, or
tell the patient something different just to shut the patient up or spare the patient from
worrying too much.
Fidelity- duty to keep promises
 This principle requires loyalty, fairness, truthfulness, advocacy, and dedication to our
patients. It involves an agreement to keep our promises. Fidelity refers to the concept of
keeping a commitment and is based upon the virtue of caring.
Example: A patient asks the nurse not to reveal the fact that she is dying or give
her diagnosis to his family. The nurse asks why she does not want her family
advised. The patient explains that her family is very emotional and has stated they
would do everything to keep her alive, even if it required long-term mechanical
ventilation. The patient has explained multiple times that she does not want
mechanical ventilation. The nurse recognizes that keeping of this information in
confidence, while supporting the family, is an example of exercising fidelity.
Privacy and Confidentiality
 The fifth ethical principle relates to privacy and confidentiality. Privacy belongs to each
person and, as such, it cannot be taken away from that person unless he/she wishes to
share it. Confidentiality, on the other hand, means that the information shared with other
52
persons will not be spread abroad and will be used only for the purposes intended. A
patient's sharing of private information imposes a duty of confidentiality on health care
providers. That duty means providers will share information only on a need-to-know
basis.
Paternalism
 Healthcare professionals make decisions about diagnosis, therapy, and prognosis for the
patient. Based upon the health care professional‘s belief about what is in the best interest
of the patient, he/she chooses to reveal or withhold patient information in these three
important arenas. This principle is heavily laden as an application of power over the
patient.
 Described as a dominant attitude of one over another --- providers who were expected to
make the best decision for the patient. Some of the nurses who has been with the facility
for a long time expressed their opinions, which was ―We follow the rule, let the physician
make the decision, We follow his order‖ This type of ethical principle can be tricky
sometimes. Because some physicians decisions/orders aren‘t always the right decision.
Example: Patient has repeatedly voiced fear over receiving a diagnosis of
lung cancer, as he believes this is a death sentence. His primary care
physician decides not to reveal the diagnosis to the patient after he says he
would kill himself if he had lung cancer.
To practice in an ethically sound professional manner it is necessary to balance ethical
considerations, with professional values and relevant legislation. The essence of ethical practice
at all levels involves an individual, or team identifying what the legal, ethical and professional
standards required are and how these can be caring and compassionately applied to the
challenges of clinical practice.
53
Activity 2.2.2 Case Studies
Read the following case studies in group and answer the question that follows it
Case Study 2.2.1

An ill-appearing 2-years-old with fever and stiff neck appears to have meningitis. His
parents refuse a lumbar puncture on the grounds that they have heard spinal taps are
extremely dangerous and painful.
Discussion Questions:
a. What is the ethical issue?
b. What should you do?
54
Case Study 2.2.2

The nurses in a critical care unit had been under a great deal of stress from very ill patients, a high
census, and frequent staff illnesses during a 2-week period. On one particular evening, two nurses
recognized that they were developing the symptoms of an upper respiratory infection that had been
affecting other members of the staff. Because they had three post-op patients needing one-on-one
care and were receiving another admission from the emergency room, the nurses solicited
medication from the house staff in order to suppress their symptoms and ―keep going.‖ Although
they were able to remain working on the unit and not contribute to an already critical staffing
situation, they recognized that they might be causing harm by communicating their illnesses to
already vulnerable patients and by risking making mistakes while under the influence of
medications (antihistamines).
The two nurses contemplated the alternatives. They were convinced that the additional risk to the
patients was quite small, and they believed that the patients were in real need of the one-on-one care
that could only be provided if they remained on duty. They concluded that, on balance, the good
they could do exceeded the risk of harm, but they wondered: Is there a special obligation for health
professionals to avoid harm?

55
Case Study 2.2.3

After reviewing the needs of all patients on a medical /surgical nursing care unit, night nurse
Martha decides that she must set priorities for her time among four needy patients. One,
Mrs. Aster, is an 83-year-old woman with a cerebrovascular accident who is semi-comatose and
inevitably dying but who needs suctioning every 15 to 20 minutes. The second, Mr. Bewketu, 47
years old, was admitted with gastrointestinal bleeding and has already had several bloody stools.
The third, 52-year-old Mr. Haillu, is a recently diagnosed diabetic with unstable blood sugar
levels receiving insulin per IV and requiring frequent vital sign checks. The fourth, 35-year-old
Mr. Mersha, is a patient who learned today that he has inoperable cancer with metastasis to the
spine. He has been suicidal in the past.e Nurse realizes that these patients have different needs.

Should her decision be based entirely on how much she can benefit each patient or on how much
need each patient has? Should she spread her time equally among all the patients? How should
Case Study 2.2.4
she decide about allocating her time?
The night-shift nurse, pages the resident on call when a newly admitted female patient (for
observation following a car accident, age 46, history of asthma) develops anxiety, wheezing,
increased blood pressure, and tachycardia. By the time the sleepy and somewhat disoriented
resident comes to the unit, the patient has severe shortness of breath. The Nurse has alerted the
ICU and is prepared to intubate the patient. The resident takes over and decides to do a hasty
tracheotomy before transporting the patient to the ICU. While doing the tracheotomy, he severs
a major blood vessel, and the patient loses a great deal of blood. A trach tube is put in place,
however, and the patient is quickly prepared for transportation to the ICU. At this point, The
Nurse realizes that the portable oxygen tank does not seem to be functioning properly. The
patient remains oxygen deprived and is brought to the ICU. The patient never gains
consciousness and dies 6 hours later. The death is not related to injuries from the car accident.
Discussion Questions: a. What is the ethical issue?

her she should tell him the truth about the mistakes that were made in the care and treatment of
his wife.
56
Case Study 2.2.5
Nurse Alem and Martha have been colleagues for a long time—they have worked together at the
same hospital for 6 years. Since obtaining a divorce, however, Martha personality has changed. She
often makes silly comments or giggles at inappropriate times. At other times, Martha is very
irritable and resorts to taking medication for her ―nerves.‖ Nurse Alem suspects that her friend is
developing a drug dependency. Her suspicion is confirmed one day when Martha asks Alem to
work for her while she sleeps off the effects of some medication. Martha acknowledges that she has
been taking cocaine but asks Alem not to tell other nurses about the nature of her problem. Alem
promises not to tell.
The next day, however, Alem finds Martha asleep in a chair in an empty room when she should be
taking care of a patient. Does Alem have an obligation to break the promise she made to Martha in
order to protect their patients from unsatisfactory levels of nursing care? How much respect for
confidentiality can one expect from a fellow nurse?
Discussion Questions: a. What is the ethical issue?
Summary
Ethical principles provide criteria on which to base judgments in relation to ethical
theories. Ethical principles include: Beneficence, Non-maleficence, Autonomy, Justice,
Veracity, Fidelity, Privacy and Confidentiality and Paternalism
57
Session 2.3. Nursing values and moral values
Session Objectives:
 Explain nursing values

 Discuss ideal nursing ethical competencies
Activity 2.3.1 : Point of reflection
 Why do you think being a nurse is important, worthwhile and worth striving for?
 What do you think the nurse should value most and why?
 Have you ever felt you are maintaining these values? If not why and what should
be done to maintain these values?
Definition of nursing values
Nursing care is usually provided at an individual level, involving both task aspect and a
relational aspect. The person in need of nursing care may require support, guidance and active
help with something (objective aspect), which, in addition, must be provided in an agreeable
manner (relational aspect).
Nurses provide appropriate nursing care based on the values they have selected. These values
form a framework to evaluate their activities influencing their goals, strategies, and function.
These values can also be counted as a resource for nurses‘ conduct toward clinical ethical
competency and their confrontation with contemporary ethical concerns.
Values are unwritten standards, ideals, or concepts that give meaning to a person‘s life and that
often serve as a guide for making decisions and setting priorities in daily life. Values are viewed
as ―what is important, worthwhile and worth striving for‖ and made who we are as individuals.
How individual personal values are protected is impacted by the society, culture, morals and
beliefs (Horton et al 2007). Values are related and overlapping. It is important to work toward
keeping in mind all values in the code at all times for all people in order to uphold the dignity of
all.
Values are also beliefs that are considered to be socially and personally desirable and therefore
are recognized as being important in organizations. If there is any conflict between personal
58
values and organization values, nurses can be challenged and tend not to follow a directive or
requirement with which they disagree. Societal, organizational and personal values all influence
the way people operate in large institutions.
Value could be explicated in terms of degrees between polar opposites such as, for example,
socially useful/useless, prestigious/low-status, fulfilling/unfulfilling, skillful/unskilled,
respected/disrespected, opportunities for advancement/dead-end, requiring certain (named)
virtues/not requiring certain (named) virtues, supported/unsupported, autonomous/dependent and
so forth.
The term professional nursing values refers to the attitudes, beliefs, and priorities of nurses that
ultimately functions as a guide and motivation in interactions with patients, colleagues, and other
professionals (Leners, Roehrs, Piccone, 2006). They are the guiding beliefs and principles that
influence your work behaviour. Professional nursing values, while individually held, are shared
among nurses, so that a duty to self that is jeopardized in the work setting for one nurse may by
circumstances apply to all nurses in that setting. Healthcare professionals need an awareness of
their values and an understanding of how those values influence their behaviour and its impact
on humanistic care.
Ideal Nursing Ethical Competencies

1. What are the characteristics of an ideal nurse?
2. To what extent nurses are applying these characteristics?
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The ethical competencies identified to characterize a well-defined, ideal nurse comprise 10
competencies divided into 3 major categories:
1. Moral integrity: 2. Communication:

i. Honesty i. Mindfulness and
ii. Truthfulness and truth telling, ii. Effective listening; and
iii. Benevolence 3. Concern:
iv. Wisdom and i. Advocacy
v. Moral courage; ii. Power and
iii. Culturally sensitive care
Moral Integrity
Moral Integrity
“State of being, acting like, and becoming a certain kind of person. This person is
honest, trustworthy, consistently doing the right thing and standing up for what is right
despite the consequences” (Laabs’s, 2011).
 Moral integrity is the quality and wholeness of character, it is necessary to realize full
human flourishing.
 People with moral integrity follow a moral compass and usually they do not vary by
appeals to act immorally.
 People with moral integrity:
 Pursue a moral purpose in life,
 Understand their moral obligations in the community, and
 Are committed to following through regardless of constraints imposed on them by their
workplace policies.
 Nurses of good character consistently use their intellectual ability and moral propensity
accompanied by pragmatic application to execute good and right actions.
 A person with moral integrity manifests
i. Honesty
ii. Truthfulness and truth telling,
iii. Benevolence,
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iv. Wisdom, and
v. Moral courage.
i. Honesty
 Nurses perceived honesty as a virtue related to facts, metaphors, ethics, and
communication, and they perceived truth telling as a palpable feature in trusting
relationships.
 Honesty, in simple terms, is being ―real, genuine, authentic, and bona fide‖ (Bennett,
1993)
 Honesty is a well thought out and rehearsed behaviour that represents commitment and
integrity.
 Nurses must
 Stay true to their word.
 Stay committed to their promises to patients and
 Follow through with appropriate behaviours, such as returning to patients‘
hospital rooms as promised to help them with certain tasks.
 Honesty is also about being honest with one‘s self
 Nurses need to establish a routine checkpoint system of ongoing self-evaluation to retain
and improve honesty in actions and relationships with patients and others.
ii. Truthfulness and truth telling

 Are there ever circumstances when nurses should be morally excused from telling
the truth to their patients?
 Truthfulness is,
 The intermediate state between imposture (excessiveness) and self-deprecation
(deficiency).
 Being genuine in all words and deeds and is never false or phony.
 A truthful person speaks in a way that symbolizes who the person really is.
 Truth telling in the healthcare environment, means nurses are usually ethically obligated
to tell the truth and are not intentionally to deceive or mislead patients
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 Are there ever circumstances when nurses should be morally excused from telling
the truth to their patients?
 Some reasons nurses or physicians might avoid telling the full truth include the
following:
 They are trying to protect patients from sad and heart-breaking news,
 They do not know the facts, or
 They state what they know to be untrue about the situation rather than admit
everything they know to be true.
Activity 2.3.5: Point of reflection
Case study 2.3.1
In one rural hospital you are the nurse caring for a woman with low socioeconomic status scheduled for a
hysterectomy because of uterine cancer. The community knows her surgeon as having a bad surgical record
in general, but especially in performing hysterectomies. The woman previously heard gossip to this effect
and asks you about it before her surgery because she is apprehensive about using the surgeon. You know at
least one legal suit has been filed against him because you personally know the woman involved in a case
of a botched hysterectomy.
 Discuss these options and any other ideas you may have regarding this case. As a nurse who wants
to be committed to an ethical nursing practice, what actions might you consider in this difficult
circumstance? Be as objective as possible.
iii. Benevolence
 Benevolence is a ―morally valuable character trait, or virtue, of being disposed to act to
benefit others‖ (Beauchamp, 2013, Part 1, para. 2).
 Some people believe benevolence surpasses the act of compassion.
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 Nurses who use benevolence as a central motivating factor do not just perform acts of
kindness in a haphazard fashion when the opportunity arises; they seek out ways to
perform acts of kindness rather than only recognizing ways to do good
Benevolence
Altruistic, kind-hearted, caring, courteous, and warm-hearted are characterizations of

a benevolent person; also, in definitions of compassionate care, kindness and benevolence,
among others, are common descriptors.
iv. Wisdom
 It requires calculated intellectual ability, contemplation, deliberation, and efforts to
achieve a worthy goal.
 Wisdom is an excellence of genuine quality that develops with intellectual
accomplishment, and practical expertise (Broadie, 2002).
 Nurses must have the feature of intellectual accomplishment and the proclivity to seek
the right and the good
v. Moral Courage
 Nurses with moral courage stand up for or act upon ethical principles to do what is right,
even when those actions entail constraints or forces to do otherwise.
 If nurses have the courage to do what they believe is the right thing in a particular
situation, they make a personal sacrifice by possibly standing alone, but they will feel a
sense of peace in their decision.
 If nurses are in risky ethical situations, they need moral courage to act according to their
core values, beliefs, or moral conscience.
 For nurses to act with moral courage means they choose the ethically right decision, even
when under intense pressure by administrators, co-workers, and physicians.
 Examples of having moral courage are:
 Confronting or reporting a peer who is stealing and using drugs at work;
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 Confronting a physician who ordered questionable treatments not within the
reasonable standard of care;
 Confronting an administrator regarding unsafe practices or staffing patterns;
 Standing against peers who are planning an emotionally hurtful action toward
another peer; and
 Reporting another nurse for exploitation of a patient or family member, such as
when a nurse posts a picture or a story of a patient on a social networking site.
Concern
 The competency of concern means that nurses feel a sense of responsibility to think about
the scope of care important for their patients; sometimes a sense of worrying about the
health or illness of patients prompts nurses to action.
i. Advocacy
 A general definition of advocacy is pleading in favour of or supporting a case, person,
group, or cause, but many variations on the definition of advocacy exist.
 Three central characteristics of patient advocacy related to professional nursing ethics
are: in their concept analysis:
 Safeguarding patients‘ autonomy
 Acting on behalf of patients
 Championing social justice in the provision of health care (Jezewski, 2006)
 Nurses are to be advocates for patients and their rights; for public and community social
justice areas of health care, policy, and economics; and for each other.
 Barriers to nursing advocacy (Hanks, 2007)
 Conflicts of interest between the nurse‘s moral obligation to the patient and the
nurse‘s sense of duty to the institution
 Institutional constraints
 Lack of education and time
 Threats of punishment
 Gender-specific, historical, critical social barrier related to nurses‘ expectations of
a subservient duty to medical doctors.
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ii. Power
 Nurses with power have the ability to influence persons, groups, or communities.
 Because nurses participate in and direct activities involving patient care, they are in
powerful positions to improve quality in patient care and oversee professional nursing
practice standards.
 As nurses integrate and use their power in a ―collaborative, interdisciplinary effort
focused solely on the patients and families that the nurse and care team serve and with
whom they partner‖ (Ponte et al., 2007).
Properties of a powerful professional practice
 Acknowledge their unique role in the provision of patient- and family-centered care.
 Commit to continuous learning through education, skill development, and evidence
based practice.
 Demonstrate professional comportment [manner in which one conducts oneself] and
recognize the critical nature of presence.
 Value collaboration and partner effectively with colleagues in nursing and other
disciplines.
 Actively position themselves to influence decisions and resource allocation.
 Strive to develop an impeccable character: to be inspirational, compassionate, and
have a credible, sought-after perspective (the antithesis of power as a coercive
strategy).
 Recognize that the role of a nurse leader is to pave the way for nurses‘ voices to be
heard and to help novice nurses develop into powerful professionals.
 Evaluate the power of nursing and the nursing department in organizations they
enter by assessing the organization‘s mission and values and its commitment to
enhancing the power of diverse perspectives.
Source: Quoted from Ponte, P. R., Glazer, G., Dann, E., McCollum, K., Gross, A.,
Tyrell, R. . . . Washington, D.
(2007). The power of professional nursing practice—an essential element of patient
and family centered care. The Online Journal of Issues in Nursing, 12(1)
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iii. Culturally Sensitive Care

 Culturally sensitive care means nurses must first have a basic knowledge of culturally
diverse customs and then demonstrate constructive attitudes based on learned knowledge
(Spector, 2012).
 Cultural competence is the adaptation of care in a manner that is consistent with the
culture of the client and is therefore a conscious process and nonlinear. (Purnell, 2002, p.
193)
 The following cultural assessment is an easy and quick approach based on ASK
(Awareness, Sensitivity, And Knowledge):
1. What is the patient‘s ethnic affiliation?
2. Who are the patient‘s major support persons and where do they live?
3. With whom should we speak about the patient‘s health or illness?
4. What are the patient‘s primary and secondary languages, and speaking and reading
abilities?
5. What is the patient‘s economic situation? Is income adequate to meet the patient‘s
and family‘s need? (Lipson & Dibble, 2005)
Summary
Values are viewed as ―what is important, worthwhile and worth striving for‖ and made
who we are as individuals. Values are also beliefs that are considered to be socially and
personally desirable and therefore are recognized as being important in organizations.
The term professional nursing values refers to the attitudes, beliefs, and priorities of
nurses that ultimately functions as a guide and motivation in interactions with patients,
colleagues, and other professionals.
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Session 2.4. Ethical Dilemma and Ethical Distress in Nursing
Session objectives
 Describe elements of ethical dilemma and distress

 Apply Ethical decision-making models to solve ethical dilemmas and distress
2.3.1. Ethical dilemmas

1. Have you ever felt difficulty to choose between two or more options that will
affect the outcome of the patient you care for?
2. Have you sometimes withhold information from a patient or his families because
of fear of its adverse effect?
3. Have you ever felt frustration because all possible options have both positive and
negative consequences?
Ethical dilemmas is situations arising when equally compelling ethical reasons both for and
against a particular course of action are recognized in which the appropriate choice in the
situation is unclear and a decision must be made
It is a situation in which a person must choose between two options that will affect the outcome
of the case. Although each option can be justified as ―good,‖ both have pros and cons. Therefore,
when one option is selected or implemented, it creates uncertainty in the outcome of the case
(Butts & Rich, 2013).
Exercising moral accountability means the nurse will make a reasoned judgment about what is
right and will act accordingly. An individual nurse‘s determination of what is right may or may
not be the same decision that others, including those to whom the nurse is accountable, believe is
the right decision.
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In fact, many ethical dilemmas are regular occurrences in the clinical setting. Many ethical
dilemmas arise related to situations such as inadequate staffing protection of patients‘ rights,
unethical practices of health care professionals, end-of-life decision making, and breeches in
confidentiality (Ulrich et al, 2010).
The ethical decision-making process provides a method for nurses to answer key questions about
ethical dilemmas and to organize their thinking in a more logical and sequential manner.
The DECIDE model to achieve morally and ethically sound decisions., as described by
Thompson et al. (2003), constitutes the following process shown in Table 7.3.
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•Firstly identify the ethical issue.

Define •Is the individual involved competent or incompetent?
the •What are the patient’s rights?
problem
•What principles are relevant to the case?
•Which principles should be given priority?
•Is the patient autonomous?
Ethical •Are the patient’s best interests the precedence?
review •Apply beneficence, Non-maleficence to uphold the best possible outcome for the patient.
•What options are available?

•What is the alternative?
•What is the potential for beneficial outcomes for this patient?
Consider •What is the potential for producing distressful side effects in this patient?
the •Have the essential facts about the disease process and the likely outcome of the
options proposed treatments been explained to the patient and family?
•What are the patient’s goals and values? What is the impact of the proposed treatment
on the patient or family members?
•What are the consequences of the action?

Investigate •Which is the most ethical thing to do?
outcomes •What are the benefits and the burdens of the treatment
Decide • Having decided on the best option available, establish a specific plan, act
on decisively and effectively
action
• Having withdrawn, withheld or initiated a course of action

Evaluate • Monitor the results of the decision.
results
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Reflect on a situation that commonly recurs in your practice setting that creates ethical dilemma
for you and your staff. Then think through the following questions.
1. Is the ethical dilemma truly a situation where there are more than one options and you
face difficulty to choose one? To what degree does the situation the interest of different
parties (families, other professionals) complicate the scenario?
2. What was your final decision and what was its consequence? Was your decision effective
and what would be done differently if not? What would need to change to resolve ethical
dilemma and is such change possible?
Ethical/Moral distress

 Have you ever felt like you knew the best thing to be done for a patient but felt that
you could not do it?
 Have you sometimes wanted to ―break the rules‖ because there were policies and
procedures that prevented you from doing what you thought was best in a situation?
 Have you ever felt frustration because you sensed that the patient‘s voice wasn‘t
being heard when decisions were being made about care?
 When what we think we would do differs from what we think we should do (i.e., the
ethically right decision/course of action) either our moral agency is deficient, moral
distress is present or some combination of deficient moral agency and moral distress are
operative.
Moral/ethical distress is an emotion that occurs when nurses have identified and
know what right response is called for, but institutional or other constraints make it
almost impossible to pursue the right course of action (Jameton, 1984).
 The constraints may include

 Legal rules,
 Institutional policies,
 Lack of decision-making authority, and
 Lack of recognition of the individual‘s moral agency.
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 Nurses may experience moral distress as they analyze a situation; they may not always be
able to articulate the ethical components but will describe feeling that something ―is not
right.‖
 When experienced, moral distress has situational, cognitive, action, and feeling
dimensions, as well as short- and long-term effects. It results in :
 Significant physical and emotional stress, which contributes to nurses‘ feelings of
loss of integrity and dissatisfaction with their work environment.
 It affects relationships with patients and others and can affect the quality,
quantity, and cost of nursing care.
 Groups of people who work together in situations that cause distress may experience
 Poor communication,
 Lack of trust,
 High turnover rates,
 Defensiveness, and
 Lack of collaboration across disciplines.
 An environment of good communication and respect for others is essential for decreasing
the likelihood of experiencing moral distress
 Moral distress is linked to
 Incompetent or poor care,  Ineffective policy,
 Unsafe or inadequate staffing,  Futile care,
 Overwork,  Unsuccessful advocacy,
 Cost constraints,  The current definition of brain death,
 Low job satisfaction  Objectification of patients, and
 Nurses turnover  Unrealistic hope
The American Association of Critical-Care Nurses (AACN) ethics work group developed a
call-to-action plan titled Four A‘s to Rise Above Moral Distress (2004) as a guide to identify
and analyze moral distress:
1. Ask appropriate questions to become aware that moral distress is present.
2. Affirm your distress and commitment to take care of yourself and address moral
distress.
3. Assess sources of your moral distress to prepare for an action plan.
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4. Act to implement strategies for changes to preserve your integrity and authenticity.
Reflect on a situation that commonly recurs in your practice setting that creates moral distress for
you and your staff. Then think through the following questions.
1) Is the moral distress truly a situation where individuals know what is right to do but
are prevented from doing so because of variables beyond their control? To what
degree does deficient individual or corporate moral agency complicate the scenario?
2) Another way to think about the preceding question, is leaving this unit or hospital the
only way to resolve the distress? What would need to change to resolve the distress
and is such change possible? What would it take to bring about needed change and
who might facilitate such changes?
Activity 2.4.5: Case studies
Read the following case studies and answer questions that follow it
Case study 2.4.1
Nurse Mekonin works in home health care nursing. She visits a gentleman, Mr. Dinka,
who had a stroke. His son and daughter check on him and run shops for him, but he
lives alone and eats frozen microwave dinners. His appearance and his home are
unkempt and disheveled. When checking his medication, Nurse Mekonin discovers
that he has nearly full bottles of antihypertensive and anticoagulant medications. He
said he sometimes forgets whether he has taken them and figures it is better to skip
them than take a double dose. Despite pillboxes, schedules, and other reminders, he
does not regularly take his medication. His blood pressure is 230/150. Nurse Hunt
begins to call the physician to report her findings and Mr. Dinka asks her not to, saying
he does not want any more medication, hospitalization, or therapy. He wants to be left
alone.
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Case study 2.4.2

The Patient Stephanie is a 39-year-old female with a history of intravenous drug abuse and
HIV/AIDS, with a most recent CD4 count of 9/mL, who presented to the Emergency Department
with acute onset of upper abdominal pain and bright red hematemesis since the morning of
admission. She reported noticing easy bruising and gum bleeding over the past several weeks, but
no overt blood loss until the current episode. She also had an increasingly poor appetite and a 20-
pound weight loss over the last two months.
The medical team consulted the GI and hematology services, and ordered Stephanie to be nil per
os (nothing by mouth) and to receive IV fluids, transfusion of red blood cells for her anemia, and
platelets in an attempt to stop further blood loss. When the team attempted to obtain informed
consent for the transfusion of blood products, Stephanie agreed to transfusion of red blood cells,
but refused to accept transfusion of platelets. The team explained to Stephanie that the units of
platelets were necessary to help prevent further bleeding, but she still refused to allow them. When
pressed for her reasoning behind the decision, she stated ―because that‘s what I want,‖ and
wouldn‘t clarify the matter any further.
Case study 2.4.3
The Nurse Expected to Go Along with the Doctor’s Deception
Martha is registered nurse (RN) and the nurse manager, walks onto an oncology unit. Alem, a
bedside nurse, comes up to her and screams, ―I‘ve had it! Dr. Lema. is telling Mr. Walde family
that all is well and ordering another round of chemo and everyone except Mr. Walde and his family
know that he is dying! Ms. Martha knows that Dr. Lema has a reputation for not knowing the
limitations of medicine and for inappropriately treating those who are actively dying with life-
sustaining medical technology. The words hospice and palliative care just do not seem to be in his
lexicon—not to mention ―dying‖. Unfortunately, Dr. Lema has a huge practice (and generates
beaucoup bucks for the hospital) and his patients seem to like his cheerful presence.
Earlier efforts to get him to change his practice have been unfruitful. Alem, the nurse who just
screamed, has been a passionate patient advocate, but you have noticed recently that her efforts to
advocate for patients have been subdued. This time she tells you in no uncertain terms that she does
not want to care for any of Dr. Lema patients— which would be a scheduling nightmare.
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Case study 2.4.4
Acting in the doctor's interests
'I felt part of the whole conspiracy' Mr Robel was an 82-year-old who had had emergency
abdominal surgery. During surgery, he had breathing difficulties, which necessitated the
insertion of a mini-tracheostomy tube. On his return to the ward, his condition was very
poor and it was decided that he should not be resuscitated in the event of an arrest. Later
that evening I noticed that one of the sutures anchoring the tracheostomy tube was
missing and I repeatedly asked the doctor to come and replace it. Later, when attending
Mr Robel. I saw that the tube was missing. The doctor came to the ward and an X-ray
revealed that the tube was lying in the patient's right bronchus. The medical team decided
to perform a bronchoscopy, but to do so needed consent. They called the man's son and
told him a further investigation was essential and naturally, he gave his consent.
During the procedure Mr Robel. arrested and was resuscitated after which he was
transferred to the intensive care unit. After 24 hours, he was returned to the ward and died
a few hours later. This patient was kept alive to save the houseman and his son was totally
unaware of the risks or exactly why his father had to go to theatre. I knew what was
happening, but I felt powerless to say anything. When Mr Robel. died, I was unable to
comfort his son as I felt part of the whole conspiracy.
Summary
Ethical dilemmas is situations arising when equally compelling ethical reasons both for and
against a particular course of action are recognized in which the appropriate choice in the
situation is unclear and a decision must be made. The DECIDE model helps to achieve morally
and ethically sound decisions.
Moral/ethical distress is an emotion that occurs when nurses have identified and know what right
response is called for, but institutional or other constraints make it almost impossible to pursue
the right course of action
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Session 2.5: Ethical decision making in the Nursing practice
Session objectives
At the end of this session, participants will be able to:
 Identify appropriate ethical decision making procedures

 Demonstrate sound ethical decision making ability

1. What is ethically sound decision with respect to the nursing practice?
2. What ethical concerns have you been faced during your nursing
practice?
Introduction
Clinical situations that raise ethical questions are a challenge to navigate. Often, there are
multiple clinical facts to consider. In addition, patient values and preferences and the concerns
and values of family must be taken into account. In some cases a decision is needed quickly.
Ideally, when faced with these difficult clinical situations, we would use a systematic
approach that ensures success in reaching an ethical decision or recommendation.
The four quadrants (topics) approach
 The four topics method was developed to provide clinicians with a framework for sorting
through and focusing on specific aspects of clinical ethics cases and for connecting the
circumstances of a case to their underlying ethical principles. Each topic—medical
indications, patient preferences, quality of life, and contextual features—represents a set
of specific questions to be considered in working through the case (see the table below).
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MEDICAL INDICATIONS PATIENT PREFERENCES

Beneficence and Nonmaleficence Respect for Patient Autonomy
 What is the patient‘s medical problem?  Is the patient mentally capable and legally
History? Diagnosis? Prognosis? competent? Is there evidence of capacity?
 Is the problem acute? Chronic? Critical?  If competent, what is the patient stating about
Emergent? Reversible? preferences for treatment?
 What are the goals of treatment?  Has the patient been informed of benefits and
 What are the probabilities of success? risks, understood this information, and given
 What are the plans in case of therapeutic consent?
failure?  If incapacitated, who is the appropriate
 In sum, how can the patient benefit by surrogate? Is the surrogate using appropriate
medical and nursing care, and how can harm standards for decision making?
be avoided?  Has the patient expressed prior preferences
(eg, advance directives)?
 Is the patient unwilling or unable to cooperate
with medical treatment? If so, why?
 In sum, is the patient‘s right to choose being
respected to the extent possible in ethics and
law?
QUALITY OF LIFE CONTEXTUAL FEATURES
Beneficence, Nonmaleficence, and Respect for Loyalty and Fairness
Patient Autonomy  Are there family issues that might influence
 What are the prospects, with or without treatment decisions?
treatment, for a return to normal life?  Are there provider (physician, nurse) issues
 What physical, mental, and social deficits is that might influence treatment decisions?
the patient likely to experience if treatment  Are there financial and economic factors?
succeeds?  Are there religious or cultural factors?
 Are there biases that might prejudice the  Are there limits on confidentiality?
provider‘s evaluation of the patient‘s quality  Are there problems of allocation of resources?
of life?  How does the law affect treatment decisions?
 Is the patient‘s present or future condition  Is clinical research or teaching involved?
such that his or her continued life might be  Is there any conflict of interest on the part of
judged as undesirable? the providers or the institution?
 Is there any plan and rationale to forgo
treatment?
 Are there plans for comfort and palliative
care?
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Activity 2.5.2: Case studies
Case study 2.5.1

Purpose: the purpose of this case scenario is to enable participants to solve ethical issues
by applying the four topic approach.
Instruction: First, read the case scenario for 2-3 minutes individually and then work in
groups to analyze the case using the for topic/quadrant approach. Finally, reflect the
decision of the group.
A 76 year old male admitted to a large teaching hospital. He was diagnosed 6 months ago
with metastatic cancer which has spread from his lungs and liver to his GI tract and bones.
His physician had decided that further chemotherapy would be useless and ordered for the
patient to be kept on comfort measures and pain medication. A continuous morphine-
sulphate IV drip was delivered to help control the pain; however, it helped him little. A
friendly and happy person by nature, as the cancer spread, the patient would cry out in pain
and ask the nurses not to move him. The nurses has told him the benefits of the position
change and the all the potential risks of immobility. Being over 1.7 meter tall and
underweight, his bony prominences became reddened and sore. He would shout so loudly
when he was turned that the nurses wondered whether they were hurting him or helping
him. It has been clearly stated that all bed ridden patients must be turned to another
position every two hours unless contraindicated because of medical condition. What shall
be done? Should the nurses continue turning the patient every 2 hours or stop the patient‘s
movement?
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Session 2.6: Legal Aspects of the Nursing Practice

Session objectives
 describe general legal concepts of nursing

 discuss legal issues in relation to the nursing practice
Activity 2.6.1 Case study
Case study 2.6.1
Purpose: the purpose of this case scenario is to enable participants reflect their opinion
about legal issues in nursing.
Instruction: Read the case study individually for 2-3 minutes and then discuss the issue
with the participant next to you. Finally, reflect your opinion to the large group.
An actress develops stage IV non-Hodgkin‘s lymphoma. The health care team informs
her that neither surgery nor local radiation will be appropriate. She agrees to undergo
combination chemotherapy. No one from the team informed her about the potential
adverse effects of the chemotherapy since there is no alternative. The usual and the
recommended dose of chemotherapy are given and the patient loses her hair and develops
neuropathy from the vincristine. She is not able to work because of her appearance. She
open file on the court.
Discussion questions
a. What do you think the most likely outcome of the charge?

b. What is the legal issue?
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General legal concepts of nursing
Law
Law can be defined as those rules made by humans who regulated social conduct in a formally
prescribed and legally binding manner. Laws are based upon concerns for fairness and justice.
Law governs the relationship of private individuals with government and with each other.
Types of law
1. Public law: it deals with an individual‘s relationship to the state.

 Sources include constitutional, administrative and criminal
1.1. Constitutional law: set of basic laws that defines the powers of the government
 Nurse maintain rights as individual
1.2.Administrative law: developed by groups who are appointed to governmental
administrative agencies (e.g. nurse practice act)
1.3.Criminal law: acts or offences against the welfare or safety of the public (e.g.
criminal code)
2. Civil law: it deals with crimes against a person or persons
2.1.Contract law: the enforcement of agreements among private individuals (e.g.
employment contracts)
2.2.Tort law: the enforcement of duties & rights among independent of contractual
agreements. It is a civil wrong committed on a person or property stemming from
either a direct invasion of some legal right of the person, infraction of some public
duty, or the violation of some private obligation by which damages accrue to the
person.
Examples of tort law include
 Negligence and malpractice
 Assault & Battery
 Invasion of privacy
 Defamation
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 Fraud
Functions of law in nursing
1. It provides a framework for establishing which nursing actions in the care of client are
legal
2. It differentiates the nurses‘ responsibilities from those of other health professionals
3. It helps the boundaries of independent nursing action
4. It assists in maintaining a standard of nursing practice by making nurses accountable
under the law
Activity 2.6.2 Case study
Case study 2.6.2
Purpose: the purpose of this case scenario is to enable participants reflect their opinion
about legal issues in nursing.
Instruction: Read the case study individually for 2-3 minutes and then discuss the
issue with the participant next to you. Finally, reflect your opinion to the large group.
A 70 years old woman admitted to a hospital with gastroenteritis and dehydration.

There is no indications in the chart of her having dizziness. She also does not inform
the nurses of her dizziness. She asks to be brought to the bathroom. She is left alone on
the toilet when she becomes lightheaded, faints, hits her head against a wall and
sustaining a laceration. The patient and the family opens file on the court.
a. What do you think the most likely outcome of the charge?

b. What is the legal issue?
Negligence and malpractice
 Malpractice refers to the behaviour of a professional person‘s wrongful conduct,

improper discharge of professional duties, or failure to meet the standards of
acceptable care which result in harm to another person.
 Negligence (breach of duty) is the failure of an individual to provide care that a
reasonable person would ordinarily use in a similar circumstance.
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Assault and Battery
 Assault is the intentional & unlawful offer to touch a person in an offensive, insulting
or physically intimidating manner.
 Battery is the touching of another person without the person‘s consent
Selected legal aspects of nursing practice

1. Informed consent: it is an agreement by a client to accept a course of treatment or a
procedure after being fully informed of it.
 Consents are either express or implied. Express consent should be oral or written. If
the procedure is more invasive and/or the potential for risk to the client is great, a
written permission is needed.
 Implied consent exists when the client‘s nonverbal behaviour indicates agreement
such as in positioning their bodies for an injection or when their vital signs are
recorded.
 Obtaining informed consent for specific medical or surgical procedure is the
responsibility of the person who performs the procedure.
 Information to be given during informed consent:
 Diagnosis or condition that requires treatment
 Purpose of treatment
 What the client can expect to feel or experience
 The intended benefits of the procedure
 Possible risks
 Advantages and disadvantages of alternatives to treatment (including no
treatment)
 Major elements of informed consent
 The consent must be voluntary
 The consent must be given by a client who is capable and competent to
understand
 The client must be given enough information to be the ultimate decision maker
2. Delegation: it is the transfer of responsibility for the performance of an activity from
person to another while retaining accountability for the outcome.
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 When delegation is to occur, the nurse needs to determine the answers for the
following questions:
 Does the Nurse practice act (if any) permit delegation?
 Is there a list of procedure a nurse can delegate?
 Are there guidelines explaining the nurse‘s responsibilities when delegating?
3. Violence, Abuse, and Neglect
 Violent behaviour can include domestic violence, human abuse, and sexual abuse
 Neglect is the absence of care necessary to maintain the health and safety of a client
nurses are in position to identify and assess cases of violence
 When an injury appears to be present resulting from abuse, neglect, or exploitation,
the nurse must report the situation to the appropriate authority.
Legal responsibilities in nursing
1. Common-sense precautions
 Follow accepted procedures. Protect from possible lawsuits by always performing
procedures as taught and as outlined in the procedure manual of the healthcare
facility.
 If these policies are incorrect or inadequate, work to improve them through the proper
channels.
2. Be competent in practice
 Always responsible for own behaviour. Refuse to perform procedures for which have
not been prepared.
 Ignorance is not a legal defence.
 Neither will lack of sleep or overwork be accepted as a legal reason for carelessness
about safety measures or mistakes.
3. Ask for assistance
 Always ask for help if unsure about how to perform a procedure.
 Do not assume responsibilities beyond those of level
 Admitting that do not know how to perform a procedure is always better than
attempting to do it and injuring someone.
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 Question any physician‘s order that do not understand, cannot read, or in which
believe an error exists
4. Document well
 The health record is the written and legal evidence of treatment.
 The record is to reflect facts only, not personal judgements.
 Careful and accurate documentation is vital for each client‘s welfare.
 Careful documentation is perhaps the most important thing can do protect against an
unjustified lawsuit.
 If do not document a treatment or medication, legally the measure is considered no
to have been done.
5. Do not give legal advice to clients
 The laws governing personal and property rights of an individual are many and
complex. Never attempt to advise a client on legal rights or financial matters.
6. Do not accept gifts
 Accepting gifts from the client is unwise for several reasons. Some clients are
considered vulnerable adults (e.g. mentally ill, retarded, or confused individuals).
 Moreover, exchange of gifts could compromise professional position, and could be
accused of coercing the client.
Examples of healthcare related laws in Ethiopia (handout)
1. The revised penal code (Proclamation No.414/2004)
Article 69: Professional Duty
An act done in the exercise of a professional duty is not liable to punishment when it is in
accordance with the accepted practice of the profession and the doer does not commit any
grave professional fault.
Article 520: Mismanagement of hazardous wastes and other materials
Whoever:
a) fails to manage hazardous wastes or materials in accordance with the relevant laws; or
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b) fails to label hazardous wastes or materials; or

c) unlawfully transfers hazardous wastes,
Is punishable with fine not exceeding five thousand birr, or rigorous imprisonment not
exceeding three years, or with both.
Article 537: Refusal to provide medical assistant
Any doctor, pharmacist, dentist, veterinary surgeon, midwife or nurse, or any other person
lawfully entitled to render professional attention and care, who, contrary to his duty and
without just cause refuses to provide his services in a case of serious need, whether from
indifference, selfishness, cupidity, hatred or contempt or any other similar motive, is
punishable with fine, or, where the crime is repeated, with simple imprisonment not exceeding
six months.
Article 559: Injuries cause by negligence

(1) Whoever, by criminal negligence, causes another to suffer common injury to person
or to health is punishable with simple imprisonment not exceeding six months, or
fine not exceeding one thousand birr.
2. FMHACA directive (Proclamation No. 661/2009)
Article 33: Requirement of professional license
1) No person shall practice as a health professional without having obtained a
professional practice license issued by the appropriate organization.
Article 34: Standards of care and scope of practice
 Any health professional shall practice his profession in accordance with the
standards of healthcare and scope of professional practice set by the executive
organization.
Article 35: Code of conduct
 Any health professional shall perform his professional duties in accordance with
the relevant code of ethics
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Article 36: Duty to report

1) Any health professional or any other person who is aware of the existence of
professional malpractice shall report the same to the appropriate regulatory
organization.
Article 37: Information of patients and obligation of health institutions
1) Any health professional shall fully record personal health information generated
during each encounter with a patient within a health institution
2) Any health institution shall have the duty to ensure that the records of personal
health information referred to sub-article (1) of this article are kept and
maintained properly.
3) Any personal information of a patient shall be confidential unless it is requested
for a legitimate purpose authorized by law.
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Session 2.7: Nursing code of Ethics (Handout)

Session objectives
 Explain the nursing code of ethics
Probing question
What is nursing code of ethics?
Introduction
A code of ethics stands as a central and necessary mark of a profession. It functions

as a general guide for the profession‘s members and as a social contract with the
public that it serves.
Nurses’ professional code of Ethics
1. The nurse practices with compassion and respect for the inherent dignity, worth, and
personal attributes of every person, without prejudice.
1.1 Respect for human dignity
 A fundamental principle that underlies all nursing practice is respect for the
inherent dignity, worth, and human rights of all individuals.
 Nurses consider the needs and respect the values of each person in every
professional relationship and setting; they lead in the development of changes in
public and health policies that support this duty.
1.2 Relationships with Patients
 Nurses establish relationships of trust and provide nursing services according to
need, setting aside any bias or prejudice.
 When planning patient, family and population centered care, factors such as
lifestyle, culture, value system, religious or spiritual beliefs, social support system
and primary language shall be considered.
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 Such considerations must promote health, address problems and respect patient
decisions. This respect for patient decisions does not require that the nurse agree
with or support all patient choices.
1.3 The Nature of Health
 Nurses respect the dignity and rights of all human beings regardless of the factors
contributing to the health status.
 The worth of a person is not affected by disease, disability, functional status, or
proximity to death.
 Nurses assess, diagnose, plan, intervene, and evaluate patient care in accord with
individual patient needs and values.
 Respect is extended to all who require and receive nursing care whether in the
promotion of health, prevention of illness, restoration of health, alleviation of
suffering, and provision of supportive care to those who are dying.
1.4 The Right to self-determination
 Respect for human dignity requires the recognition of specific patient rights, in
particular, the right of self-determination.
 Patients have the moral and legal right to determine what will be done with their
own person; to be given accurate, complete, and understandable information in a
manner that facilitates an informed decision; to be assisted with weighing the
benefits, burdens, and available options in their treatment, including the choice of
no treatment; to accept, refuse, or terminate treatment without deceit, undue
influence, duress, coercion, or prejudice; and to be given necessary support
throughout the decision-making and treatment process.
 Nurses include patients or surrogate decision-makers in discussions, provide
referrals to other resources as indicated, identify options, and address problems end
of life and should be actively involved in related research, education, practice, and
policy development.
1.5 Relationships with Colleagues and Others
 Respect for persons extends to all individuals with whom the nurse interacts.
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 Nurses maintain professional, respectful and caring relationships with colleagues

and are committed to fair treatment, integrity-preserving compromise, and the
resolution of conflicts.
 In every role, the nurse creates a moral environment and culture of civility and
kindness, treating others, colleagues, employees, co-workers, and students with
dignity and respect. This standard of conduct includes an affirmative duty to act to
prevent harm.
2. The nurse’s primary commitment is to the patient, whether an individual, family,
group, community, or population.
2.1 Primacy of the Patient’s Interests
 The nurse‘s primary commitment is to the recipients of nursing and healthcare
services—the patient—whether individuals, families, groups, communities, or
populations.
 Any plan of care must reflect the fundamental commitment of nursing to the
uniqueness, worth and dignity of the patient.
 Addressing patient interests requires recognition of the patient‘s place within the
family and other relationships. When the patient‘s wishes are in conflict with
others, nurses help to resolve the conflict. Where conflict persists, the nurse‘s
commitment remains to the identified patient.
2.2 Conflict of Interest for Nurses
 Conflicts of interest may arise in any domain of nursing activity including clinical
practice, administration, education, consultation and research.
 Nurses must examine the conflicts arising between their own personal and
professional values and the values and interests of others including those who are
also responsible for patient care and healthcare decisions, and perhaps patients
themselves.
 Nurses address these conflicts in ways that ensure patient safety and promote the
patient‘s best interests while preserving the professional integrity of the nurse and
supporting interdisciplinary collaboration.
 Changes in healthcare financing and delivery systems may create conflict between
economic self-interest and professional integrity. Bonuses, sanctions, and
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incentives tied to financial targets may present such conflict. Any perceived or
actual conflict of interest should be disclosed to all relevant parties and, if
indicated, nurses should withdraw from further participation.
2.3 Collaboration
 The complexity of healthcare requires effort that has the strong support and active
participation of all health professions.
 Nurses should actively foster collaborative planning to provide high quality,
patient-specific health care.
 Nurses are responsible for articulating, representing and preserving the unique
contribution of nursing to patient care and the nursing scope of practice. The
relationship with other health professions also needs to be clearly articulated,
represented and preserved.
2.4 Professional Boundaries
 The nature of nursing work is inherently personal.
 Within their professional role, nurses recognize and maintain appropriate
personal relationship boundaries.
 Professional relationships are therapeutic in nature yet at times remaining within
professional boundaries can be tested.
 In all communications and actions nurses are responsible for maintaining
professional boundaries and for seeking the assistance of peers or supervisors in
managing difficult situations or taking appropriate steps to remove themselves
from the situation.
3. The nurse promotes, advocates for, and protects the rights, health and safety of the
patient.
3.1 Protection of the Rights of Privacy and Confidentiality
 Privacy is the right to control access to and disclosure or nondisclosure of information
pertaining to oneself, and to control the circumstances, timing, and extent to which
information might be disclosed.
 The need for health care does not justify unwanted or unwarranted intrusion into
people‘s lives.
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 Nurses safeguard the individual‘s, families‘, and community‘s right to privacy. The
nurse advocates for an environment that provides sufficient physical privacy, including
privacy for discussions of a personal nature.
 Nurses also participate in the maintenance of and policies and practices that protect
both personal and clinical information at institutional and societal levels.
 Confidentiality pertains to the nondisclosure of personal information that has been
communicated within the nurse–patient relationship.
 Central to that relationship is an element of trust and an expectation that personal
information will not be divulged without consent.
 The nurse has a duty to maintain confidentiality of all patient information, both
personal and clinical in the work setting and off duty in all venues, including social
media or any other means.
3.2 Protection of Human Participants in Research
 Stemming from the right to autonomy or self-determination, individuals have the right
to choose whether or not to participate in research as a human subject.
 Participants or legal surrogates must receive sufficient and materially relevant
information to make informed decisions and to understand that they have the right to
decline to participate or to withdraw at any time without fear of adverse consequences
or reprisal.
3.3 Performance Standards and Review Mechanisms
 Professional nursing is a process of education and formation that involves the ongoing
acquisition and development of the knowledge, skills, dispositions, practice
experiences, commitment, relational maturity, and personal integrity essential for
professional practice.
 Nurse educators must ensure that basic competence and commitment to professional
practice exist prior to entry into practice.
 Nurse managers and executives similarly ensure that nurses have the required
knowledge, skills, and dispositions to perform clinical responsibilities requiring
preparation beyond the basic academic programs. In this way nurses— individually,
collectively and as a profession—are responsible and accountable for nursing practice
and professional behavior.
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3.4 Professional Competence in Nursing Practice

 Nurses must lead in the development of policies and review mechanisms to promote
patient health and safety, reduce errors, and create a culture of excellence.
 When errors occur, nurses must follow institutional guidelines in reporting errors to
the appropriate authority and ensure responsible disclosure of errors to patients.
3.5 Protecting Patient Health and Safety by Action on Questionable Practice
 Nurses must be alert to and take appropriate action in instances of incompetent,
unethical, illegal, or impaired practice or any actions that place the rights or best
interests of the patient in jeopardy.
3.6 Patient Protection and Impaired Practice
 Nurses must protect the patient, the public, and the profession from potential harm
when a colleague‘s practice appears to be impaired.
 When another‘s practice appears to be impaired, the nurse‘s duty is to take action to
protect patients and to ensure that the impaired individual receives assistance.
4. The nurse has authority, accountability, and responsibility for nursing practice,
makes decisions, and takes action consistent with the obligation to provide optimal
care.
4.1 Authority, Accountability, and Responsibility
 Nurses bear primary responsibility for the nursing care that their patients and clients
receive and are accountable for their own practice.
 Nursing practice includes independent direct nursing care activities, care as ordered by
an authorized healthcare provider, delegation of nursing interventions, evaluation of
interventions, and other responsibilities such as teaching, research, and administration.
 In each instance, nurses have the authority and retain accountability and responsibility
for the quality of practice and for compliance with state nurse practice acts, and
standards of care.
4.2 Accountability for Nursing Judgments, Decisions, and Actions
 In order to be accountable, nurses act under a code of ethical conduct that includes
adherence to the scope and standards of nursing practice and such moral principles as
fidelity, gratitude, and respect for the dignity, worth, and self-determination of
patients.
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 Nurses are accountable for judgments made and actions taken in the course of
nursing practice, irrespective of other providers‘ directives or institutional policies.
 Systems and technologies that assist in clinical practice are adjunct to, not
replacements for, the nurse‘s knowledge and skill.
 The nurse retains accountability and responsibility for nursing practice even in
instances of system or technological failure.
4.3 Responsibility for Nursing Judgments, Decisions and Actions
 Nurses are accountable for their judgments, decisions, and actions; but, in
compromising circumstances, responsibility may be borne by both the nurse and the
institution.
 Nurses accept or reject specific role demands and assignments based on their education,
knowledge, competence, experience, and assessment of patient safety.
 Nurses have a responsibility to define, implement, and maintain standards of
professional practice.
 Nurses must plan, establish, implement, and evaluate review mechanisms to safeguard
patients and nurses. These include peer review processes, credentialing processes, and
quality improvement initiatives.
 Nurses are responsible for assessing their own competence. When the needs of the
patient are beyond the qualifications or competencies of the nurse, consultation and
collaboration must be sought from qualified nurses, other health professionals, or other
appropriate resources.
4.4 Delegation of Nursing Activities or Tasks
 Nurses are accountable and responsible for the assignment or delegation of nursing
activities. Such assignment or delegation must be consistent with institutional policy,
and nursing standards of practice.
 Nurses must make reasonable effort to assess individual competence when delegating
selected nursing activities. This assessment includes the evaluation of the knowledge,
skill, and experience of the individual to whom the care is assigned; the complexity of
the assigned tasks; and the nursing care needs of the patient.
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 Nurses are responsible for monitoring the activities and evaluating the quality and
outcomes of the care provided by other healthcare workers to whom they have
delegated tasks.
 Nurses may not delegate responsibilities such as assessment and evaluation; they may
delegate interventions.
5. The nurse owes the same duties to self as to others, including the responsibility to
promote health and safety, preserve wholeness of character and integrity, maintain
competence, and continue personal and professional growth.
5.1 Duty to Self and Others
 Moral respect accords moral worth and dignity to all human beings regardless of
their personal attributes or life situation. Such respect extends to oneself as well: the
same duties that we owe to others we owe to ourselves.
 Self-regarding duties primarily concern one self and include promotion of health
and safety, preservation of wholeness of character and integrity, maintenance of
competence, and continuation of personal and professional growth.
5.2 Promotion of Personal Health, Safety, and Well-Being
 As professionals who assess, intervene, evaluate, protect, promote, educate, and
conduct research for the health and safety of others and society, nurses have a duty
to take the same care for their own health and safety.
 Nurses should model the same health maintenance and health promotion measures
that they teach and research, seek health care when needed, and avoid taking
unnecessary risks to health or safety in the course of their customary professional
and personal activities.
 A healthy diet and exercise, maintenance of family and personal relationships,
adequate leisure and recreation, attention to spiritual or religious needs, and
satisfying work must be held in balance to promote and maintain the health and
well-being of the nurse.
5.3 5.3 Wholeness of Character
 Nurses have both personal and professional identities that are integrated and
embrace the values of the profession, merging them with personal values.
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 Wholeness of character pertains to all professional relationships with patients or

clients.
 When nurses are asked for a personal opinion, they are generally free to express
an informed personal opinion as long as this maintains appropriate professional
and moral boundaries and preserves the voluntariness of the patient.
 It is essential to be aware of the potential for undue influence attached to the
nurse‘s professional role.
 Nurses assist others to clarify values in reaching informed decisions, always
avoiding coercion, manipulation, and unintended influence.
 When nurses care for those whose personal, condition, attributes, lifestyle, or
situations are stigmatized, or encounter a conflict with their own personal beliefs,
nurses still render respectful and competent care.
5.4 Preservation of Integrity
 Personal integrity is an aspect of wholeness of character; its maintenance is a self
regarding duty.
5.5 Maintenance of Competence and Professional Growth
 Maintenance of competence and professional growth involve the control of one‘s
own conduct in a way that is primarily self-regarding.
 Competence affects one‘s self-respect, self-esteem, and the meaningfulness of
work.
 Nurses must maintain competence and strive for excellence in their nursing
practice, whatever the role or setting.
 Nurses are responsible for developing criteria for evaluation of practice and for
using those criteria in both peer and self-assessment.
 To achieve the highest standards, nurses must evaluate their own performance
and participate in substantive peer review.
 Continual professional growth, particularly in knowledge and skill, requires a
commitment to lifelong learning.
5.6 Personal Growth
 Nursing care addresses the whole person as an integrated being; nurses should
also apply this principle to themselves.
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 Activities that broaden nurses‘ understanding of the world and of themselves

affect their understanding of patients; those that increase and broaden nurses‘
understanding of nursing‘s science and art, values, ethics, and policies also affect
the nurse‘s self-understanding.
 Thus, in continuity with nursing ethics‘ historic and enduring emphasis, nurses
are encouraged to read broadly, continue life-long learning, engage in personal
study, seek financial security, participate in a wide range of social advocacy and
civic activities, and to pursue leisure and recreational activities that are enriching.
6. The nurse, through individual and collective action, establishes, maintains, and
improves the moral environment of the work setting and the conditions of
employment, conducive to quality health care.
6.1 The environment and moral virtue and value
 Virtues are universal, learned, and habituated attributes of moral character that
predispose persons to meet their moral obligations; that is, to do what is right.
 There is a presumption and expectation that we will commonly see virtues such
as integrity, respect, temperance, and industry in all those whom we encounter.
 Virtues are what we are to be and make for a morally ―good person‖.
 There are more particular attributes of moral character, not expected of everyone,
that are expected of nurses. These include knowledge, skill, wisdom, patience,
compassion, honesty, and courage. These attributes describe what the nurse is to
be as a morally ―good nurse‖.
 Nurses must create, maintain, and contribute to morally good environments that
enable nurses to be virtuous. Such a moral milieu fosters mutual respect,
communication, transparency, moral equality, kindness, prudence, generosity,
dignity, and caring.
6.2 The Environment and Ethical Obligation
 Virtues focus on what is good and bad in whom we are to be as moral persons;
obligations focus on right and wrong or what we are to do as moral agents.
 Obligations are often specified in terms of principles such as beneficence or
doing good; non maleficence or doing no harm; justice or treating people fairly;
reparations, or making amends for harm; fidelity, and respect for persons.
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 Nurses, in all roles, must create, maintain, and contribute to practice

environments that support nurses and others in the fulfillment of their ethical
obligations.
 Environmental factors include all that contribute to working conditions. These
include but are not limited to: clear policies and procedures that set out
professional ethical expectations for nurses; uniform knowledge of The Code of
Ethics for Nurses with Interpretive Statements; and associated ethical position
statements.
6.3 Responsibility for the Healthcare Environment
 Nurses are responsible for contributing to a moral environment that demands
respectful interactions among colleagues, mutual peer support, and open
identification of difficult issues that includes on-going formation of staff in
ethical problem solving.
7. The nurse, whether in research, practice, education, or administration, contributes to
the advancement of the profession through research and scholarly inquiry,
professional standards development, and generation of nursing and health policies.
7.1 Contributions through Research and Scholarly Inquiry
 All nurses must participate in the advancement of the profession through
knowledge development, evaluation, dissemination, and application to practice.
 Knowledge development relies chiefly, though not exclusively, upon research
and scholarly inquiry.
 Nurses engage in scholarly inquiry in order to expand the body of knowledge
that forms and advances the theory and practice of the discipline in all its
spheres.
7.2 Contributions through Developing Maintaining, and Implementing Professional
Practice Standards
 Practice standards must be developed by nurses and grounded in nursing‘s
ethical commitments and body of knowledge.
 These standards must also reflect nursing‘s responsibility to society.
7.3 Contributions through Nursing and Health Policy Development
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 Nurses must lead, serve, and mentor on institutional or agency policy committees
within the practice setting.
 Nurse educators have a particular responsibility to foster and develop students‘
commitment to professional and civic values and to informed perspectives on
nursing and healthcare policy.
8. The nurse collaborates with other health professionals and the public to protect and
promote human rights, health diplomacy, and health initiatives.
8.1 Health is a Universal Right
 The nursing profession holds that health is a universal human right and that the
need for nursing is universal.
 The right to health is a fundamental right to a universal minimum standard of
health to which all individuals are entitled. Such a right has economic, political,
social, and cultural dimensions.
8.2 Collaboration for Health, Human Rights, and Health Diplomacy
 The nursing profession commits to advancing the health, welfare, and safety of
all.
 This nursing commitment reflects the intent to achieve and sustain health as a
means to the common good so that individuals and communities here and abroad
can develop to their fullest potential and live with dignity.
8.3 Obligation to Advance Health and Human Rights
 Through community organizations and groups, nurses educate the public;
facilitate informed choice; identify conditions and circumstances that contribute
to illness, injury and disease; foster healthy life styles; and participate in
institutional and legislative efforts to protect and promote health.
 Nurses collaborate to address barriers to health, such as poverty, homelessness,
unsafe living conditions, abuse and violence, and lack of access by engaging in
open discussion, education, public debate and legislative action.
 Nurses must recognize that health care is provided to culturally diverse
populations in this country and across the globe.
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9. The profession of nursing, collectively through its professional organizations, must

articulate nursing values, maintain the integrity of the profession, and integrate
principles of social justice into nursing and health policy.
9.1 Articulation of Values
 Their professional associations and organizations represent individual nurses.
These groups give united voice to the profession.
 It is the responsibility of a profession collectively to communicate, affirm, and
promote shared values both within the profession and to the public.
 The profession‘s organizations communicate to the public the values that nursing
considers central to the promotion or restoration of health, prevention of illness,
and alleviation of suffering.
 Through professional organizations, the nursing profession must reaffirm and
strengthen nursing values and ideals so that when those values are challenged,
adherence is steadfast and unwavering.
9.2 Integrity of the Profession
 The profession‘s integrity is strongest when its values and ethics are evident in
all professional and organizational relationships.
 Nursing must continually emphasize the values of justice, fairness, and caring
within the national and global nursing communities, in order to promote health in
all sectors of the population.
 Together, nurses must bring about the improvement of all facets of nursing,
fostering and assisting in the education of professional nurses in developing
regions across the globe.
 The values and ethics of the profession must be evident in all professional
relationships whether interorganizational, or international.
9.3 Integrating Social Justice
 Nurses must be vigilant and take action to influence legislators, governmental
agencies, non-governmental organizations, and international bodies in all related
health affairs for addressing the social determinants of health.
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Publishing Company. New York. 2007
 Nursing. Springer Publishing Company. Springer Publishing Company. New York. 2007
 Schumann JH, Alfandre D. Clinical ethical decision making: the four topics approach.
Semin Med Pract 2008; 11:36–42. Available at www.turner-white.com.
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MODULE III:
COMMUNICATION
IN NURSING
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MODULE III - COMMUNICATION IN NURSING
Description of the module

This module is designed to enable the trainees to be competent communicators during nursing
and midwifery care practice. Trainees will be able to use a wide range of effective
communication strategies and skills which are necessary to establish interpersonal relationship
with physicians and nursing staffs, clients, and their families.
Module objective: After completion of this module the trainee will be able to:
 Utilize client cantered effective communication
Learning Objectives
After completion of this module the trainee will be able to:
 Discuss communication and its significance in nursing
 Explain the benefits of communication
 Describe elements of the communication process
 Discuss barriers to effective communication
 Describe the therapeutic communication skills
 Integrate effective communication skills into clinical practice.
 Manage documentation according to national protocols
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Session 3.1. Basics of communication
Session objectives
At the end of this session the participants will be able to:
 Discuss communication and its significance in nursing
 Explain the benefits of communication
 Describe elements of the communication process
 Describe modes of communication
 Analyze characteristics of an therapeutic communication
 Describe the therapeutic communication skills
 Discuss barriers to therapeutic communication
 Describe the 7 C‘s of communication
3.1 An overview of communication and its significance in nursing
Activity 3.1. Think pair share

 With whom and how do nurses communicate every day?
 Instruction: Think individually on the above question for 1 minute and then discuss the
issue with the participant next to you. Finally, reflect your opinion to the large group.

Communication is process of transferring, sharing or exchanging verbal (overt) and
nonverbal (covert) messages, feelings and ideas thereby people create a relationship by
interacting with each other. It should be accurate, timely and effective. Quality of patient care
depends on the caregiver‘s ability to communicate with patient and with colleagues
Communication is a complex process of sending and receiving verbal and non-verbal
messages, it allows the exchange of information, feelings, needs, and preferences and it uses
source/sender and receiver encode and decode message in a cyclic pattern as communication
channels.
Communication is fundamental to all nursing and interpersonal relationships. Nurses can use
this dynamic and interactive process to motivate, influence, educate, facilitate mutual support,
and acquire essential information necessary for survival, growth and an overall sense of well-
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being. It is essential for nurses to develop and maintain competent communication and
interpersonal skills.
3.1.1 Benefits of Communication
Activity 3.2: Group discussion
Be in group and discuss on benefits of communication within 2 minutes
Communication in nursing has the following benefits:

 It greatly contributes to the ability to provide patients with individualized care. Nurses
who take the time to understand the unique challenges and concerns of their patients
will be better prepared to advocate on their behalf and properly address issues as they
arise. This greater focus on communication frequently leads to better patient outcomes
as well.
 Patients who feel like they are receiving all of the nurse‘s attention during an
interaction are more likely to disclose the true extent of their feelings and symptoms
much quicker. Patients may also feel more satisfaction with their care if the nurse
provides them with undivided attention.
 Interpersonal communication can satisfy the innate needs of the patient as outlined in
Maslow‘s hierarchy of needs. Those needs include the feelings of safety, love and
confidence, all of which are important during a patient‘s treatment and recovery.
 Communication in nursing not only benefits the patients, but the nurses as well. Nurses
who communicate well with their coworkers tend to witness an improvement in
morale as well as job satisfaction. High turnover rates, increased stress, and lower
morale and job satisfaction are among the negative effects of poor workplace
communication.
3.1.2 Elements of the communication process
There are many models of communication. The commonly used communication model
comprises six elements:
1. The referent
2. The source-encoder
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3. The message
4. The channel
5. The receiver-decoder
6. Feedback
• Every encounter we have with another person, whether spontaneous or deliberate,

begins with an idea-a reason for engaging in a verbal exchange. The model must begin
with what idea, referent. Referent mental images within a person who desires to
convey those images to another
 ideas, thoughts, pictures, and emotions

 Encoding : translation of image into symbol
• Encoding: the process of translating images into symbols that receivers can
understand.
 Symbols often are words, pictures, sounds, or sense information
(e.g., touch or smell).
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 Only through symbols can the mental images of a sender have meaning
for others.
A referent may be one of ―a wide range of objects, situations ideas, or experiences‖ Any one
of these items or a combination of them prompts the source- encoder to initiate action in order
to convey the message engendered by the referent.
The source-encoder/sender is a term that describes one person who communicates with
another. Sender initiates the process of communication by generating a message .Our ability to
form, use and understand the messages we transmit is continually influenced by numerous
factors, it include our communication skills, our attitudes, our levels of knowledge, and our
sociocultural system. These factors are never static; indeed they are always changing, always
being modified as we change and are modified by the events that surround us. Whenever we
act in the role of the source-encoder we must consider these influences in order to understand
not only our own communication, but also the communicative behavior of others.
Our ability to transmit the experiences we encounter is limited if we do not poses the ability to
encode them in a form recognizable by others. The vocal mechanisms used in speech, the
motor skills used in writing, and the language peculiar to a specific culture are encoding skills
possessed to some degree by every human being. Similarly, the use of gestures and other
nonverbal behaviors is an encoding ability that often bridges the verbal gaps encountered by
people who speak different languages.
The ideas and experiences we have, as the source-encoder is, at this stage, still intangible. To
make them come alive we must change that intangible invention into an actual physical
product, which in the communication model is labeled the message.
All of us are aware that a message does not just appear. Every day we deliver messages of
varying kinds and lengths as if we actually knew what operations were involved. In order to
convey a message, we must arrange it so that it has some resemblance of recognizable order.
In the English language, this requirement is filled by the sentence because it is a series of
words in connected speech or writing forming the grammatically complete expression of a
single thought. The order established through sentences is the message code. Whatever the
code is – a sentence, picture or music – its expression becomes the message content. Finally, a
message can be sent unless consideration is given to the manner in which we convey the
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desired message treatment. Message treatment is the decision made in selecting and arranging
both codes and content.
Channel
• Ways to transmit or communicate the message to a receiver.
• Once decisions have been made on the codes and contents of message, we must route
the message across a channel.
• Common channels : visual channel : sight
Auditory channel
Kinesthetic channel: physical sensation mediated by touch
Because the cannel in the model involves the senses of hearing, seeing, touching, smelling
and tasting, the sensory channel selected must be appropriate to the message we wish to
convey. The receiver-decoder is one of the last links in our communication model. Behind this
label is the person to whom the message is directed, that other individual who has been
influenced by the same factors of communication, knowledge, attitudes, and socio cultural
systems as we have been. Since no two people perceive an event or share their perceptions of
that event in the same way, it is crucial to any verbal interaction that the receiver-decoder
understands what we mean to convey. Our intent is not enough. We must aim for precision in
our communication. The success with which we convey our thoughts determines how they
will be absorbed and translated by the receiver – decoder. Then the receiver provides some
form of feedback, which allows us to determine the success or failure of our communication
efforts.
Decoding: interpretation of symbol in to mental image
• Receivers must sense and interpret the symbols and then decode the information
back into images, emotions, and thoughts that make sense to them.
• When messages are decoded exactly as the sender has intended, the images of the
sender and the images of the receiver match, and effective communication occurs.
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3.1.3 Modes of communication
Nurses communicate with clients often and in various ways. Two types of communication
are verbal communication (using words) and nonverbal communication (using facial
expressions, actions, and body position). Verbal communication is sometimes differentiated
from oral communication. Effective communication occurs when words and actions convey
the same message (congruency).
Verbal Communication
Verbal communication is sharing information through the written or spoken word. Nurses use
verbal communication extensively. They converse with clients, write care plans, document
information and assessments, input data into the electronic record, and give oral or written
change-of-shift reports.
Nonverbal Communication
Nonverbal communication is sharing information without using words or language.

Nonverbal communication expresses emotions and attitudes, as well as enhancing what is
being expressed verbally. Nonverbal communication is one component of body language
and is sometimes more powerful in conveying a message than is verbal communication. If
verbal and nonverbal messages are not congruent, the receiver usually believes the nonverbal
cues. If the body language and verbal cues are not congruent, confusion occurs.
For example, Mr. H., a young diabetic client, begins clenching and unclenching his fists when
the nurse asks about his sexual activity. He says, ―Everything is fine,‖ through gritted teeth.
Later, when he trusts the nurse more, he admits that he has been impotent for the past 6
months. Often, body language provides more powerful clues than verbal language because it
points to the person‘s true feelings.
Messages expressed through body posture and movements, gestures, facial expressions, and
other forms of nonverbal behavior provide cues or suggestions to a person‘s true feelings or
beliefs. This study of body movements and posture, facial expressions, and gestures is referred
to as kinesics. The nurse must be aware, however, that nonverbal behavior has different
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meanings for different people and in different situations. The nurse must be cautious when
interpreting nonverbal cues. It is important to check with clients before making assumptions
about the meaning of their body language. Remember, Nonverbal communication includes
factors such as clothing, body ornamentation, body shape and size, and gestures.
Key Concept Be sure that your verbal and nonverbal communications give a congruent
message to clients. When verbal and nonverbal messages conflict (are not congruent), others
are most likely to believe the nonverbal message.
Key Concept In general, verbal communication is used to communicate information.

Nonverbal communication conveys feelings and attitudes. Nonverbal communication occurs
whether we want it to or not.
3.1.4 Therapeutic communication
One of the main ways nurses establish trust with patients is through communication. Because
nurses are likely to have the most direct contact with patients, effective nurse-patient
communication is critical. Nurses can utilize proven therapeutic communication techniques
that promote quality care.
What is therapeutic communication?
Therapeutic communication is an application of the process of communication to promote the
well-being of the client. Can be verbal or non verbal.
Therapeutic communication is a collection of techniques that prioritize the physical, mental,

and emotional well-being of patients. Nurses provide patients with support and information
while maintaining a level of professional distance and objectivity. With therapeutic
communication.
The therapeutic relationship includes the following:

 Developing the nurse–patient relationship based upon partnership, intimacy and
reciprocity.
 Manipulating the environment – from the macro organizational level, through to the
meso patient environment level to the micro environment and the physical features that
impact on the well-being of the patient.
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 Teaching – involving patient education and information.

 Providing comfort – physical and non-physical care.
 Adopting complementary health practices – these are creative approaches to healing
that are incorporated into nursing care.
 Utilizing tested physical interventions – incorporating intuitive approaches to care that
can be supported by inductive research approaches.
Stages of therapeutic relationship formation
A. Orientation phase
During this phase, the nurse engages the patient, and the patient is able to ask questions
and receive explanations and information. This stage helps the patient develop trust and is
where first impressions about the nurse and health care system begin to evolve.
B. Identification phase
The patient and nurse begin to work together. These interactions provide the basis for
understanding, trust and acceptance as the patient becomes an active participant in
treatment.
C. Exploitation phase
The patient takes advantages of all services offered, exploiting the nurse-patient
relationship to address treatment goals.
D. Resolution phase
As a result of effective communication, the patient‘s needs are met, and he or she moves
toward full independence. The patient no longer needs help, and the relationship ends.
Characteristics of an effective nurse patient relationship

 Intellectual and emotional bond between nurse and patient
 Respects patient as an individual
 Respects patient‘s confidentiality
 Focuses on patient‘s well-being
 Based on mutual trust, respect and acceptance
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Therapeutic Communication techniques/skills
Activity 3
1.1.1 Make a list of all the therapeutic communication technique you can think of
and categorize these into skills that:
 Assist in keeping the focus on the patient and/or carer‘.
 Demonstrate listening.
 Assist with information giving.
It is important that nurses have skills that keep the focus of communication on the patient, that
demonstrate active listening and assist with information giving. Refer to Box 1 to examples of
communication skills that are integral to nursing.
Skills that assist in keeping the focus on the patient and/or carer:
 Looking and listening for cues.
 Asking open questions. For example: ‗How are you?‘
 Asking open directive questions. For example: ‗How are you since I last saw you?‘
 Asking open questions about feelings.
 Exploring cues. For example: ‗You said you are not with it, can you tell me more
about that?‘
 Using pauses and silence.
 Using minimal prompts.
 Screening. For example: asking the question ‗Is there something else?‘ before
continuing with the discussion.
 Clarifying. For example: asking the question ‗You said you are not with it, from what
you say, it sounds like it is hard to concentrate?‘
Skills that demonstrate listening
 Reflecting.
 Acknowledging.
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 Summarizing.
 Empathizing.
 Paraphrasing.
 Checking.
Skills that assist with information giving
 Checking what information the person knows already.
 Giving small amounts of information at a time, using clear terms and avoiding jargon.
 Avoiding detail unless it is requested – do not assume people want to know.
 Checking understanding using an open question. For example: ‗I‘ve gone through
some difficult information, what sense have you made of it?‘
 Pausing and waiting for a response to what you have said before moving on.
 Checking, with sensitivity, the effect of the information you have given on the patient
or carer. For example: ‗There has been a lot of information to take in today, how are
you feeling?‘
Barriers to therapeutic communication
Activity 4
Working with a colleague, discuss and list the barriers to effective communication. One
person could consider the barriers from the healthcare professional‘s point of view and one
from the patient and/or carer‘s point of view.
Barriers to therapeutic communication are factors that hinder good communication. By

having a conscious awareness of the potential barriers to therapeutic communication it is
possible for the nurse to manage and minimize the effect of these barriers in the caring
environment.
Barriers to therapeutic communication are broadly categorized into patient and carer barriers
and health care professional barriers.
Patient and care provider ( family and significant others) barriers:
 Environment – noise, lack of privacy, no control over who is present or not present
(staff or relatives).
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 Fear and anxiety – related to being judged, being weak, or breaking down and crying.
 Other barriers – difficulty explaining feelings (no emotional language to explain
feelings), being strong for someone else, or communication cues being blocked by
healthcare professionals.
Health care professional barriers:
 Environment – high workload, lack of time, lack of support, staff conflict, lack of
privacy or lack of referral pathway.
 Fear and anxiety – related to making the patient more distressed by talking and/or
asking difficult questions.
 Other barriers – not having the skills or strategies to cope with difficult reactions,
questions and/or emotions. Thinking ‗it is not my role‘, and ‗the patient is bound to be
upset‘.
 Video show on therapeutic and non-therapeutic

relationship.)
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Box 1 – Definitions and examples of therapeutic communication skills
Skills to keep the consultation patient-focused:

Empathizing
Saying something to show you appreciate (not understand or sympathise) how the other person seems to
be feeling. For example: ‗Everything has happened so fast, no wonder you are finding it difficult to take
in.‘
Making educated guesses

Seeing or hearing something (cues) that gives you a hint about how the person is feeling. For example:
‗You are telling me you know what is going to happen, but you look a little confused.‘
Looking and listening for cues

Cues are hints and can be words, gestures or body language. Noticing verbal and non-verbal cues is
important to understanding the patient‘s needs.
Psychological focus
Recognizing and responding to emotions, feelings and concerns. Patients appreciate healthcare
professionals asking about their feelings.
Using pauses and silence

Pauses and silence provide a slower pace and will help the person to engage in the conversation and give
them time to think what they want to say.
Using minimal prompts

Small, encouraging words and gestures, for example, nodding or saying ‗go on‘.
Negotiating
Negotiating and asking permission. For example: ‗Would it be okay to talk about what is worrying you?‘
Active listening: acknowledging

Showing a response to what you are noticing or hearing. For example: ‗I can see you are very upset about
this.‘
Active listening: summarizing

A clear way to prove you have heard all the cues, concerns or questions. For example: ‗So what you told
me you are concerned about is the treatment, your husband and how long you may need to be off work.‘
Reflecting
Reflecting is a helpful way to pick up a cue. Reflection can also function like a question, but is easier for
the person to respond. Reflect back to the patient or relative their own words, or use your own words to
check that you understand. For example: ‗You have been thinking, what will happen… [pause].‘
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3.1.14 The 7 Cs of Communication: A Checklist for Clear Communication

According to the 7 Cs, communication needs to be:
 Clear.
 Concise.
 Concrete.
 Correct.
 Coherent.
 Complete.
 Courteous.
In this article, we look at each of the 7 Cs of Communication, and we'll illustrate each element
with both good and bad examples.
1. Clear
When writing or speaking to someone, be clear about your goal or message. What is your
purpose in communicating with this person? If you are not sure, then your audience won‘t be
sure either.
To be clear, try to summarize the number of ideas in each sentence. Make sure that it‘s easy
for your reader to understand your meaning. People shouldn‘t have to ―read between the lines‖
to understand what you are trying to say.
Bad Example
Hi Yidenek,
I wanted to write you a quick note about Tigist, who’s working in your case team. She’s a
great asset and I’d like to talk to you about her when you have time.
Best
Yeko
What is this email about? Well, we‘re not sure. First, if there are multiple Tigist‘s in
Yidenek‘s case team, Yidenek won‘t know who Yeko is talking about.
Next, what is Tigist doing, specifically, that is so great? We don‘t know that either. It‘s so
vague that Yidenek will definitely have to write back for more information.
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Last, what is the purpose of this email? Does Yeko simply want to have an idle chat about
Tigist, or is there some more specific goal here? There‘s no sense of purpose to this message,
so it‘s quite confusing.
Let's see how we could change this email to make it clear.
Good Example
Hi Yidenek,
I wanted to write you a quick note about Tigist Menale, who’s working in your case team.
In recent weeks, she’s helped our case team in understanding the nursing care of a TB
patient on her own time.
We’ve now got a patient with open TB, and her knowledge and skills would prove
invaluable. Could we please have her transferred to our case team to help with the holistic
nursing management of TB patients? I’d appreciate speaking with you about this. When is
best to call you to discuss this further?
Best wishes,
Yeko
This second message is much clearer, because the reader has the information he needs to take
action.
Concise
When you're concise in your communication, you stick to the point and keep it brief. Your
audience doesn't want to read six sentences when you could communicate your message in
three.
 Are there any adjectives or "filler words" that you can delete? You can often eliminate
words like "for instance," "you see," "definitely," "kind of," "literally," "basically," or
"I mean."
 Are there any unnecessary sentences?
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 Have you repeated the point several times, in different ways?
Bad Example
Hi Salem,
I wanted to touch base with you about the patient we discussed this morning. I really think
that our assessment and nursing diagnosis are definitely wrong. I think that could make a
big difference, and it would help the patient and his relatives.
For instance, if we both asses his needs, as well as plan his nursing care needs, then the
family members that we want to understand his condition are going to remember our his
needs. The impact will just be greater.
What do you think?
Adey
This email is too long! There's repetition, and there's plenty of "filler" taking up space.
Good Example
Watch what happens when we're concise and take out the filler words:
Hi Salem,
I wanted to quickly discuss the RTA patient, Ato Asres, we discussed this morning. Our
assessment and nursing diagnosis were wrong/ did not reflect his nursing care needs.
We need to involve both the patient and his relatives in the nursing process in order for
them to fully contribute, understand his condition, treatment regime and the part they have
to play in caring for him.
This would promote Asres’ compliance with his care and enable them to understand how to
prevent recurrence of his condition.
What do you think?

Adey
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2. Concrete
When your message is concrete, then your audience has a clear picture of what you're telling
them. There are details (but not too many!) and vivid facts, and there's laser-like focus.
Bad Example
Consider this patient/public notice:
―The needs you‖
A statement like this is confusing. There's no passion, no vivid detail, nothing that creates
emotion, and nothing that tells patients/public why they need them. This message isn't
concrete enough to make a difference.
Good Example
What would you do or like to see change if you’re the owner of this hospital? Have you got
any ideas or something to offer to make this hospital a place you consider a good hospital?
Yes you do! For example, you can speak or write to us on how we can make things better
here. Why not volunteer some of time to help hospital staff in many areas of your choice?
With your help in whatever capacity will make this hospital a centre of excellence and give
a sense of ownership and pride! People will stay less days/time in the hospital and More
lives will be saved! Think and Act Now!
This notice is better because there are vivid images. Patients/Public can picture the hospital
becoming a centre of excellence- and who could argue with that? And mentioning that people
will stay less days/time in the hospital is appealing and concrete to everybody. The notice has
come alive through these details.
3. Correct
When your communication is correct, it fits your patient's needs, and correct communication
is also error-free communication.
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 Do the technical terms that you use fit your patient's level of education and
knowledge?
 Have you checked your writing for grammatical errors? Remember, spell checkers
won't catch everything.
Bad Example
Hi Senait,
Thanks so much for meeting me at lunch today! I enjoyed our conservation, and I'm
looking forward to moving ahead on our case team project. I'm sure that the two-weak
deadline won't be an issue.
Thanks again, and I'll speak to you soon!
Best,
Eriteria Alem
 Are all names and titles spelled correctly?

If you read that example fast, then you might not have caught any errors. But on closer
inspection, you‘ll find two. Can you see them? The first mistake is that the writer accidentally
typed ―conservation‖ instead of ―conversation‖. This common error can happen when you are
typing too fast. The other error is using ―weak‖ instead of ―week‖. Again spell checkers won‘t
catch word errors like this, which is why it is so important to proofread everything.
4. Coherent
When your communication is coherent, it is logical. All points are connected to the main
topic, and the tone and flow of the text is consistent.
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As you can see in the example below, this email doesn't communicate its point very well.
Where is Bethlehem's feedback on Rael‘s report? She started to mention it, but then she
changed the topic to talk about Friday's meeting.
Bad Example
Rahel,
I wanted to write you a quick note about the incident report you wrote last week. I gave it
to Sr. Bicha to proof, and she wanted to make sure you knew about the case team we're
having this Friday. We'll be drafting incident reporting guidelines.
Thanks,
Bethlehem
Good Example
I wanted to write you a quick note about the incident report you wrote last week. I gave it
to Sr. Bicha to proof, and she let me know that there are a few changes that you'll need to
make. She'll email you her detailed comments later this afternoon.
Thanks,
Bethlehem
Notice that in the good example, Bethlehem does not mention Friday's meeting. This is because the
meeting reminder should be in an entirely separate email. This way, Rael can delete the report
feedback email after she makes her changes, but save the email about the meeting as her reminder to
attend. Each email has only one main topic.
5. Complete
In a complete message, the audience has everything they need to be informed and, if
applicable, take action.
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 Does your message include a "call to action", so that your audience clearly knows
what you want them to do?
 Have you included all relevant information - contact names, dates, times, locations,
and so on?
Bad Example
Hi everyone,
I just wanted to send you all a reminder about the case team meeting we're having
tomorrow!
See you then,
Genet
This message is incomplete, for obvious reasons. What meeting? When is it? Where? Genet
has left her team without the necessary information.
Good Example
Hi everyone,
I just wanted to remind you about tomorrow's case team meeting on the hospital reform nursing
implementation guidelines. The meeting will be at 10:00 a.m. in the hospital conference room.
Please let me know if you can't attend.
See you then,
Genet
6. Courteous
Courteous communication is friendly, open, and honest. There are no hidden insults or passive-
aggressive tones. You keep your reader's viewpoint in mind, and you're empathetic to their needs.
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Bad Example
Haile,
I wanted to let you know that I don't appreciate how your case team always monopolizes
the discussion at our monthly hospital staff meetings. I have a lot of projects, and I really
need time to get my team's progress discussed as well. So far, thanks to your case team, I
haven't been able to do that. Can you make sure they make time for me and my team next
month?
Thanks,
Kassaye
Well, that is hardly courteous! Messages like this can start office wide feuds. And this email
does nothing but create bad feelings, and lower productivity and morale. A little bit of
courtesy, even in difficult situations, can go a long way.
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Good Example
Hi Haile,
I wanted to write you a quick note to ask a favour. During our monthly hospital staff
meetings, your people do an excellent job of highlighting their progress. But this uses some
of the time available for my team to highlight theirs. I'd really appreciate it if you could
give my team a little extra time each week to cover their progress reports.
Thanks so much, and please let me know if there's anything I can do for you!
Best,
Kassaye
What a difference! This email is courteous and friendly, and it has little chance of spreading
bad feelings around the office.
Variations
There are a few variations of the 7 Cs of Communication:

 Credible - Does your message improve or highlight your credibility? This is
especially important when communicating with an audience that doesn't know
much about you.
 Creative - Does your message communicate creatively? Creative
communication helps keep your audience engaged.
Key Points
Most of us communicate every day. The better we communicate, the more credibility
we'll have with our clients, our bosses, and our colleagues.
Use the 7 Cs of Communication as a checklist each time you communicate. By doing
this, you'll stay clear, concise, concrete, correct, coherent, complete, and courteous.
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Session 3.2 Documentation and reporting

Session objectives
At the end of this session the participants will be able to:
 Define reporting and documentation
 Explain type of nursing record documentation
 Identify basic components of patient chart
 Describe types of verbal communication/ reporting
 Analyze characteristics of good recording
 Discuss medication management
 Identify factors associated with medication errors
 Describe characteristics of medication errors
Reporting and Documenting
Reporting is an oral, written, or computer account of patient status. It can be done between
members of health care system. Report should be clear, concise, and comprehensive.
Documentation is permanent record of patient information and care and serves the following
purpose:
Purpose:
 To communicate
 As a legal document
 For research and Statistical analysis
 For education
 For audit and quality assurance, and
 Planning client care
Characteristics of documentation
 Brief
 Factual
 Concise
 Objective
 Descriptive
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 Comprehensive
 Legally prudent
 Appropriate/relevant
Nursing Record Documentation

A. Written Communication
Patient care record/chart contains the following basic components
 Admission sheet
 Medical History and Physical Examination (Physician)
 Physician‘s order sheet
 Physician‘s progress notes
 Nurse‘s notes: care plan, progress notes, discharge planning, etc.
 Special records/reports: referrals, x-ray and laboratory results, medication and vital
sign sheets, I&O, IVF administration, etc.
 Discharge Summary
The following items are used by nurses to document a patient‘s course of treatment. It is the
nurse‘s responsibility to ensure that a patient‘s medical record is complete, containing all the
necessary forms in the proper sequence. The forms are intended to guide the entire medical
team and to become a permanent record maintained in the patient‘s medical record:
1) Clinical forms: Nurses must record patient data and findings on clinical forms that include:
 Routine Observation Sheet
 Intravenous Fluid Administration Record,
 Fluid Balance Chart
 Medication Administration Record
It is the nurse‘s responsibility to chart on the appropriate form and to make sure that the
information is timely and accurate.
2) Nursing Process Forms: Nurses should record all steps in the nursing process on the
appropriate forms :( ANNEX 6)
 Nursing Admission Assessment Form
 Nursing Problem Statement List
 Nursing Care Plan
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 Nursing Patient Progress Report
Verbal Communication
1) Nurse-to-Nurse Report: During a shift change, the off-going nurse should verbally report
to the on-coming nurse concerning the status of each patient using a standard format. The
report consists of a general synopsis of the patient, any significant events during the shift, as
well as a progress report of the work completed. Updates should be provided on IV
administration, tests done or pending, abnormal laboratory findings, and general patient
progress.
Follow the format below for performing nurse-to-nurse shift report.

 Patient name
 Patient age
 Reason for Seeking Care/Chief complaint
 Patient diagnosis: present all current diagnoses
 Current IVs
 Tests completed or pending
 Abnormal lab findings: do not report normal findings
 Events during the shift: synopsis of what occurred during the shift
 Patient progress: description of patient‘s response to any treatment or events that occurred
during the nurse‘s shift, including the patient‘s progression towards discharge
2) Nurse to Junior Nurse Report: At the start of each shift, the nurse is responsible for
reporting to the junior nurse regarding patient(s) under his/her care. Specific care information
related to bathing, ambulating, eating, toileting, and other similar concerns should be
discussed. A written checklist of tasks to be completed should be given to the junior
nurse/health assistant/student.
Use the following format for performing a nurse to junior nurse/health assistant/student report.
It is important that the assigned tasks are specific to ensure that the junior nurse/health
assistant/student is able to accomplish them during their shift.
a) Vital Signs: Describe the frequency required for assessing a patient‘s vital signs. Is it
necessary to assess them:
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 Once a shift,
 Twice a shift,
 Every hour, or
 Other unique needs.
b) Bathing: Describe the level of assistance the patient requires for bathing and changing
linens. Is the level:
 Complete assistance during both bath and bed linen changing,
 Required assistance when bringing bathing materials to the patient who must remain in
the bed while linens are changed,
 Required assistance when bringing bathing materials to the patient who is capable of
getting out of the bed while the linens are changed, or
 No assistance necessary because the patient is independent during bathing and the
patient is capable of getting out of bed while the linens are changed.
c) Activity: Describe the activity level of the patient as follows:
 Bed rest: how often does the patient need to be turned?
 Out of bed (OOB) walking: is the patient OOB at will or does he/she need assistance?
If assistance is required, please inform the aide of the frequency of OOB.
 Out of bed (OOB) to chair: what is the level of assistance required to get OOB to a
chair? If assistance is required, please inform the aide of the frequency that this should
occur and for how long.
d) Toileting: Describe the level and type of assistance the patient requires to perform the
following (if applicable):
 Out of bed to the bathroom,
 Offer the bedpan to the patient every ________ (amount of time),
 Patient uses the urinal,
 Patient has a Foley catheter, and/or
 All patient output should be recorded and communicated.
e) Diet: Describe the patient‘s type of diet and the assistance they require:
 Set up the food only,
 Set up and cut the food,
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 Feed the patient, and/or

 Record all input.
f) Safety: Describe how often the aide needs to make rounds on the patient.
3) Nurse – to – Physician Reporting
Whenever a patient‘s status changes, the physician should be informed. The status should be
reported in an objective manner, allowing for the physician‘s recommendation(s). Any
physician‘s order should then be documented in the medical record by the nurse as a verbal
order. Verbal orders from a physician to a nurse must be told to 2 nurses simultaneously in
order to ensure that instructions are clearly understood and verifiable. The transcribed order
should be signed by the physician within 24 hours.
Physician orders
Physicians provide both written and verbal forms of communication in order to direct a
patient‘s care. It is the nurse‘s responsibility to ensure that a physician‘s orders and plan for a
patient‘s care are put into action.
Physician‘s orders should be recorded by the physician on a physician order Sheet. When the
order is carried out this should be documented on the order sheet, including the date and time
that the order was carried out, and the signature of the person confirming that the order has
been completed.
Physician’s order must contain the following elements:
 Date and time
 Full name of the medication
 Dosage
 Concentration – amount and type of diluent
 Duration
 Time and frequency
 Route
 Physician signature
All physician orders, even verbal orders, must be documented.
Any/all verbal orders from a physician must be given to two (2) nurses simultaneously in
order to ensure verbal instructions are clearly understood and verifiable. The physician should
be clear about which nurse (of the two) is to implement his/her verbal orders. Once received,
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the order is immediately transcribed into the Physician Order Sheet by the implementing
nurse. The nurse who is writing the order completes the transcription by writing ―verbal
order given by (the name of the physician)/the nurse’s signature.” All verbal orders are to be
reviewed and co-signed by the physician within twenty-four (24) hours.
Characteristics of Good Recording
 Brevity – concise, complete sentences required, start with a Capital letter and end
with a period.
 Use black ink pen
 Accuracy – must be objective
 Appropriateness
 Completeness and chronology/timing
 Use of standard terminology
 Confidentiality
 Signed – sign with full name (in script) and status; i.e. Haimonot Geremew R. N.
 In case of ERROR: draw a horizontal line through the error, write the word ―error‖
above the line, sign
 Legal awareness
 Legible
 No abbreviations except those accepted in the medical/clinical field (OD, BID,
TID, etc)
 Horizontal line drawn to fill up partial line
Methods of documentation
Problem Oriented Medical Records (POMR)
POMR is a structured method of documentation that emphasizes client problems (look
example. The method is based on the nursing process and facilitates communication of client
needs.
The POMR is composed of a data -base, a numbered problem list, and progress notes referred
to as SOAP notes. The advantages of POMR charting method include the following:
a. Gives emphasis to clients‘ perception of their problems
b. Requires continuous evaluation and revisions of care plan.
c. Provides greater continuity of care among health care team members.
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d. Enhances effective communication among health care team members.

e. Increases efficiency in gathering data.
f. Provides easy to read information in chronological order.
g. Reinforces use of the nursing process.
With POMR format, the list of problems is filled in an easily accessible location and referred
to frequently. New problems are added as identified. After a problem has been resolved, the
date of resolution is recorded and a line is drawn through the problem and its number on the
problem sheet. After a problem list is developed, succeeding record entries (such as in the
progress notes) are coded by the problem number.
Problem Date Problem Resolved

1. 4/7/2002 Diarrhea 12/7/2002
2. 4/8/2002 Anxiety related to
Inexperience with
3. 4/9/2002 Post-operative routines.
4. 4/9/2002 Pain related to incisional edema
and movement of right arm
Altered body image
Progress notes follow a SOAP format including SOAPE, SOAPIE, and SOAPIER notes.
These are acronyms for subjective data (S), objective data (O), assessment (A) and plan (P).
Some also use intervention (I), evaluation (E), and response (R).
S- Includes subjective data from the client. O- Objective data that can be observed or
measured. A- is a conclusion from the subjective and objective data. Assessment is and
interpretation of the client‘s condition or level of progress. It is a statement of the status of the
diagnosis or problem. It determines whether the problem has been resolved or if further care is
required.
P- Depending on the assessment of the situation, the health care member maintains or revises
the previous plan of care. Plans may include specific orders or interventions designed to
manage the client‘s problem and goals and expected outcomes of care.
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PIE- is an acronym for problem, intervention, and evaluation. The PIE NOTE differs from
soap notes because the narrative does not include assessment data and the format requires
nurses to evaluate client outcomes.
P- Problem or nursing diagnosis applicable to client
I- Interventions or actions taken
E- Evaluation outcomes of nursing interventions and client response to nursing therapies.
S- ―I am worried about what it will be like after surgery.‖

O- Client asking frequent questions about surgery. First surgery experience. Wife present
expresses concern.
A- Anxiety related to knowledge deficit of surgery experience.
P- Explain routine preoperative preparation.
Demonstrate and explain deep breathing exercises. Provide explanation and booklet on
postoperative care
E- Expresses eagerness to learn as much as possible. B. Gebre, RN
P Anxiety related to knowledge deficit of surgery manifested by frequent questions

and first time surgery.
I Explained normal preoperative preparations for surgery. Demonstrated deep
breathing exercises. Provided booklet to client on postoperative care.
E Able to demonstrate exercises correctly. Needs review of postoperative nursing
routines. B. Gebre, RN
Examples of Progress notes written in SOAPE and PIE formats

Focus Charting- (Lampe 1988)
Focus charting structures progress notes according to the focus of the note. Examples include
a sign or symptom, a condition, a nursing diagnosis, behaviour, a significant event or an acute
change in the patient condition. Each note includes data, actions, and client‘s response (DAR)
for the particular client situation.
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Wro. Hanna has developed a fever, 39degree C, 2-days following surgery. The nurse has
auscultated lung sounds and found crackles in the right lower lobe. The client has difficulty
coughing as a result of incisional pain. The nurse repositioned the client, began instruction on
deep breathing exercises.
Focus Note
D- Temp. 39degree C. Lungs auscultated with crackles over R. lower lobe
A- Repositioned client and instructed on deep breathing. Ordered Spirometer
R- Client has difficulty coughing as a result of incisional pain

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Medicines’ Management
It is the nurse‘s responsibility to safely administer the medications to a patient as ordered by
the physician. Nurses should be aware of the desired outcome, dosage, preparation and side
effects of each prescribed medication.
Medication storage
The nurse is responsible to ensure that all medications and medical supplies are stored either
in the central or room cabinet designed for this purpose. Drugs and supplies should not be kept
at bedside. Furthermore, it is the responsibility of the nurse to administer all drugs prescribed
for the patient. Drug administration should not be delegated to the family or any care givers as
long as the patient is in the hospital..
Transcribing the Order:
Medication orders are transcribed by the nurse from the physician order sheet to the
Medication Administration Record. The nurse will document that the order has been
transcribed by putting a signature next to the order.
The nurse is responsible for questioning the physician regarding any medication order or
element of an order that is in his/her judgment an error. The perceived error may be in the
drug ordered, dosage, route, time and/or frequency to be given.
Administration of Medications
The following steps should be followed by the nurse when administering medications. Two
processes are outlined which differ based on whether the medication is stored at the patient‘s
bedside or in a central cabinet. There are three distinct steps to administering medications:
preparation, administration and documentation. Each step requires safety checks to ensure
that the right drug is given to the right patient.
1. Preparation
Medications at the Bedside
 The nurse brings the Medication Administration Record to the patient‘s bedside.
 The nurse checks the prescribed medication from the patient‘s bedside to the
Medication Administration Record three times to ensure that it is the proper
medication:
 When reaching for the container of medication,
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 Immediately prior to the pouring the medication, and

 When returning the container to its proper location.
Medications in a Cabinet
 The nurse brings the Medication Administration Record to the cabinet.
 The nurse checks the prescribed medication from the cabinet to Medication
Administration Record three times to ensure that it is the proper medication:
 When reaching for the container of medication,
 Immediately prior to the pouring the medication, and
 When returning the container to its proper location.
 Medications should be prepared one patient at a time. Each medication for a single
patient should be organized into a group for that individual patient, prior to dispensing
medications for another patient.
 When medications are to be given to more than one patient, the medication
cup/container should be clearly marked with each bed number.
 Before administering medication, the nurse should cross-reference the bed number (on
cup/container) with the bed number and name listed on the Medication Administration
Record.
2. Administration
 The nurse who prepares the medication should always be the nurse who administers
the medication.
 During administration, medications should never be out of the sight of the
administering nurse.
 It is the nurse‘s responsibility to confirm that they are giving the correct drug to the
correct patient. When the nurse arrives at the patient‘s bedside, the nurse must
confirm using two methods that the patient is properly identified.
 Check the name on the Medication Administration Record with the patient‘s posted
name.
 Ask the patient to repeat their name.
 Once the correct patient is verified, administer the medication. If it is an oral
medication do not leave it for the patient to take later. The nurse needs to observe all
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medications being taken to assure that the medication has been adequately
administered.
 If a patient refuses a medication, the physician should be notified and it should be
clearly documented in the medical record.
3. Documentation:
Immediately following the administration of a patient‘s medication, the nurse who
administered the medication must document on the Medication Administration Record that the
medication has been given. The nurse must document the time that each drug was given and
then sign and initial the record.
Medication Errors
Patient safety is fundamental to quality nursing and health care1 and medication errors are the
leading cause of death and disability2. There is a recognition and consensus that patient
safety as primarily a nursing responsibility3 because nurses take a central role in patient safety
and as a result, there is a danger that errors can be attributed to nurses rather than to system
failures. However, evidence shows that nursing vigilance protects patients against unsafe
practices. For example, nurses were responsible for intercepting 86% of all medication errors
made by physicians, pharmacists and others before the error occurred4 and medicines
management is, therefore, a multidisciplinary responsibility.
Why do medication errors happen?
Every step in patient care involves a potential for error and some degree of risk to patient
safety. In a study of prescribing errors5, the most common factors associated with errors
included:
 Using the wrong drug name, dosage form, or abbreviation;
 Mistakes on calculating dosage;
 Atypical or unusual and critical dosage.
Types of Possible Medication Errors
Types Contributing Factors Causes
extra dose Distractions performance deficit
improper dose/quantity workload increase procedure/protocol
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not followed
omission error inexperienced staff knowledge deficit
prescribing error shift change inaccurate or lack of documentation
unauthorized drug agency/temporary staff confusing communication
wrong administration no 24 hour pharmacy inaccurate or omitted transcription
Technique insufficient staffing computer entry
wrong dosage form emergency situation drug distribution system
wrong drug preparation cross coverage inadequate system safeguards
wrong patient code situation illegible or unclear handwriting
wrong route no access to patient
wrong time Information
(Source: Ruth M. Kleinpell, Nursing Spectrum, February 2001. Vol. 2 No. 2. p.39)
Medication errors are preventable, although reducing the error rate significantly will require
multiple interventions and close collaboration between the health team and management.
Types of medication errors
• Omission errors
• Improper dose
• Unauthorized drug errors
• Wrong time error
• Types of medication error…
• Deteriorated drug error
• Wrong dosage form error
• Wrong drug preparation error
• Wrong administration technique
• Monitoring errors
1. Omission error
 Failure to administer an ordered dose to a patient before the next scheduled dose is
considered.
 Omission is not an error
• If there is any medical reason
• When patient cannot take anything by mouth(NPO) prior to a procedure or
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• Patient refuses to take them

3. Improper dose
It occurs when a patient is given a dose that is greater(extra dose error) or less than the
prescribed dose.
Cause: absence of documentation
�Inaccurate measurement of an oral liquid is also an improper dose error.
• Un authorized error
Administration of a medication to a patient without proper authorisation by the prescribers
categorized as an unauthorised drug error
4. Deteriorated drug error
Medications that are dispensed or administered beyond their expiration date may have
lost potency or less effective or ineffective
5. Wrong time error
 Timing of administration is critical to the effectiveness of medications
 Maintaining an adequate blood level of drug is required for effectiveness
 Administering doses too early or too late may effect the drug serum level and
consequently the efficacy of the drug
6. Wrong dosage form error
 Doses administered or dispensed in a different form from that ordered by the
prescriber are classified as wrong dosage form errors
 Depending on the state law and health care facility guidelines, dosage forms
changes may be acceptable to accommodate particular patient needs
For example:
Dispensing a liquid formulation without specific prescription to a patient who has
difficulty swallowing tablets might be an acceptable dosage form change
7. Wrong drug preparation error
Drugs requiring reconstitution, (adding liquid to powdered drug), dilution or special
preparation prior to dispensing or administration of drug
8. Wrong administration technique
Doses that are administered using an inappropriate procedure or incorrect technique are
categorized as wrong administration technique errors
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A subcutaneous injection that is given too deep. An I.V drug that is allowed to infuse via
gravity instead of using an I.V pump. Instilling the eye drops in the wrong eye is another
example
9. Monitoring errors
Monitoring errors result from inadequate drug therapy review. Prescribing an anti
hypertensive agent which lowers blood pressure, and failing to check blood pressure
Error reporting and learning

A good way to learn from medication errors is to establish a reporting system, as voluntary
reporting of adverse events provides data that leads to improved patient safety. However,
because of the ―blame and shame‖ approach in health system, there is generally
underreporting and what is reported is often the tip of the iceberg. A useful approach to use is
the critical incident analysis. This analysis examines adverse events to understand where the
system broke down, why the incident occurred, and the circumstances surrounding the
incident . Analyzing critical incidents, whether or not the event actually leads to a bad
outcome, provides an understanding of the conditions that produced an actual error or the risk
of error as well as the contributing factors.
Feedback and dissemination of information can create an awareness of errors that occur in the
system and improve system design to reduce or eliminate medication errors. Health care
organizations and health professionals should be encouraged to participate in voluntary
reporting systems as an important component of their commitment to patient safety.
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References
i. Bramhall E (2014) Effective communication skills in nursing practice. Nursing
standard/RCN Publishing. vol 29 no 14
ii. Shirly B. and Alec G (2009). Communication and Interpersonal Skills for Nurses.
Learning Matters Ltd
iii. Brian Neese (2015) Effective Communication in Nursing: Theory and Best Practices.
http://online.seu.edu/effective-communication-in -nursing/ Accessed on 17/4/17
iv. International Council of Nurses (2002). ICN Position Statement on Patient Safety. ICN.
v. Institute of Medicine .To Err is Human.
http://books.nap.edu/books/0309090679/html/1.html#pagetop. Accessed on 16/04/10.
vi. Cook, F, A, Guttmannova, K and Clare (2004) An Error by any other name. American
Journal of Nursing. Vol.104, No.6. Pp.32-43.
vii. Leape, et.al (1995) Systems analysis of adverse drug events. JAMA, 274 (1), 35-43.
viii. Lesar et al(1997) Factors Related to Errors in Medication Prescribing. JAMA. 277(4):312–
317.
ix. Kleinpell, R.M (2001) Abstracted in Nursing Spectrum.Vol. 2 No. 2. p.39.
x. Cooper, Jeffrey B, Newbower, Ronald; Long, Charlene, et al(1978) Preventable
xi. Anesthesia Mishaps: A Study of Human Factors. Anesthesiology. 49(6):399–406.
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Module IV: Nursing Process
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Module IV: Nursing Process
Module description
This module is designed to enable trainees to apply nursing process as a framework to provide
quality individualized and holistic nursing care. This module covers all components of nursing
process including nursing assessment, nursing diagnosis, outcome identification, nursing plan
of care, nursing implementation and evaluation.
Module objective
After completing this module the trainees will be able to effectively carry out the nursing
process through assessment of patients, formulation of nursing diagnoses, set-patient centered
outcomes, develop individualized plan of care, carry out nursing interventions and evaluate
outcomes.
Enabling objectives
After completing this module, the trainees will be able to
 Conduct comprehensive assessment of client
 Formulate nursing diagnoses
 Develop holistic nursing care plan
 Carry out nursing instructions
 Evaluate effectiveness and efficiency of nursing care
Module content
The module has seven sessions:
Session 4.1. Introduction to nursing process
Session 4.2. Nursing Assessment
Session 4.3. Nursing diagnosis
Session 4.4. Planning: Outcome Criteria/Identification
Session 4.5. Planning: Nursing Intervention
Session 4.6. Nursing Implementation
Session 4.7. Evaluation
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Session 4.1. Introduction to nursing process
Session Description
This session highlights basics nursing process, which is the tool and methodology of the
provision of nursing care.
Enabling objectives
By the end of this session, trainees will be able to:
 Define concepts of nursing
 Describe nursing process
 Identify the six steps of nursing process
 Explain the characteristics nursing process
 Explain benefits of using the nursing process
 Compare nursing process with medical process
Basic nursing concepts

Nursing is a profession that ensures the successful implementation of interventions that
welcome and nurture life, promotes or restores health, enables the means to a peaceful,
dignified, and pain-free death. American nurses association defined nursing as, the diagnosis
and treatment of human responses to actual and potential health problems or illness (ANA,
1995).
Nurse, is a person who is trained and experienced in nursing profession and interested in care
of sick/well person; has completed a program of basic, generalized nursing education and is
authorized by the appropriate regulatory authority to practice nursing (ICN 1987).
What is the Nursing process and why do we use it?
The nursing process is an organized and systematic process of giving goal oriented,
individualized and humanistic nursing care that is both effective and efficient. It is organized
and systematic in that it consists of six sequential and interrelated steps: assessment,
diagnosis, outcome identification, planning, implementation, and evaluation. Nursing process
is based on the assumptions that professional nursing practice is interpersonal in nature and
professional nurses view human beings as holistic, thereby acknowledging that mind and body
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are not separated but function as a whole. People respond as whole beings. What happens in
one part of the mind or body affects the person as a whole entity.
Given these two assumptions, it would be impossible for a nurse to view a client/patient as
―the hysterectomy in room 201‖ or ―the paranoid in bed 2‖. The woman who has experienced
a hysterectomy may have physiological, spiritual, and psychological health problems, i.e.,
physiological and psychological adjustments due to induced menopause, and spiritual
adjustments if her life style includes a religious orientation related to childbearing. Or the
person with symptoms of paranoia may refuse to eat, causing physiological changes related to
malnutrition. These two assumptions, that nursing is interpersonal in nature and that
professional nurses view human beings as holistic, give guidance and direction to the use of
the nursing process.
In nursing, the client/patient may be an individual, family, or community and the nursing
process has been adapted for use with each type of client/patient.
In order to use the nursing process effectively, nurses need to understand and apply
appropriate concept and theories from nursing, from the biological, physical, and behavioral
sciences, and from the humanities, in order to provide a rationale for decision-making,
judgments, interpersonal relationships, and actions9. These concepts and theories provide the
framework for nursing care.
Historical Perspective and Steps of Nursing Process
In 1955 Lydia Hall, mention the term nursing process for the first time where she introduced
three steps of nursing process: observation, administration of care and validation. Further, in
the late 1950th Johnson and in the early 1960th Orlando and Wiedenbach, introduced three
steps of nursing process that include assessment, planning, and evaluation.
In the late 1960th Yura and Walsh identified four steps in the nursing process: assessment,
planning, implementation, and evaluation. By 1974 the North American Nursing Diagnosis
Association (NANDA), nursing diagnosis was added as a separate and distinct step in the
nursing process. Prior to this, nursing diagnosis had been included as a natural conclusion to
the first step, assessment. Latter in 1991 ANA included outcome identification as a specific
part of the planning phase making the nursing process five steps: assessment, diagnosis,
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outcome identification and planning, implementation, and evaluation (1). Currently the
nursing process consists of six phases (or steps): assessment, diagnosis, planning outcomes,
planning interventions, implementation, and evaluation as shown on Fig 1(2).
Fig 1: The six steps of nursing process

Critical thinking
Critical thinking is the concept central to nursing process. It is the process that allows nurses
to see the big picture (envision the overall perspective) instead of focusing only on details.
It is reasonable reflective thinking that is focused on deciding what to believe or do. Every
day, nurses make decisions that are derived through critical thinking. Making clinical
judgments relies on critical thinking.
Characteristics of critical thinkers:
• Open-minded and curious
• Consciously work in a planning mode
• Proactive instead of reactive
• Flexible
• Organized
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Critical Thinking Skills

Interpretation: Categorize, decode sentences, clarify meanings
Analysis: Examine ideas, identify and analyze arguments
Influence: Query evidence, conjecture alternatives, and draw conclusions
Explanation: State results, justify procedures, present arguments
Evaluation: Assess claims, assess arguments
Characteristics of Nursing Process
Internalizing of the phases of nursing process mentioned above, one could well understand
what the characteristics of this entire process are.
1. Cyclic and dynamic: it is a continuous process throughout the stages of illness and
treatment that ends with the cease of the illness.
2. Goal directed and Client oriented: The nursing process is intended to treat the patient and
is in the best interest of the patient.
3. Interpersonal and Collaborative: This goes to explain the amount of interaction that might
be necessary between nurses, patients of similar illnesses and the health care team. It might
involve group therapy and / or family counseling.
4. Universally applicable: This process is universally standard and applicable in any setting
and for all kinds of clients regardless of their age, type of illness and other conditions. It is
like a common nursing language with common nursing terminology followed universally.
5. Scientific and Systematic: The nursing process is based on the objective format, viz.,
scientific format. Every symptom or sign is a result of a scientific fact that leads to
scientific methods of treatment and follow-ups. It is systematic and goes from step to step
as in the phases mentioned above. It is not based on mere instincts, but outlined within a
framework of set parameters (3-5).
Benefits of the Nursing Process
 Ensures access to quality nursing care
 Ensures continuity of care
 Promotes involvement of clients in their own care
 Speed up diagnosis and treatment of actual and potential health problems, reducing the
incidence of hospital stays;
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 Has precise documentation that improve communication, to prevent errors, omissions,

and unnecessary repetitions;
 Promotes flexibility and independent critical thinking;
 Tailors interventions for the individual responses (not just the disease);
 Helps nurses to gain satisfaction of getting results
 Helps nurses to practice within accepted legal frameworks
 Contributes to the development of nursing profession
Comparison of Nursing Process and Medical Process
Nursing Process Medical Process
Deals with two types of health problems Deals mostly with problems with structure
(1) Human response problems (2) and function of organs or systems
Pathological problems
Uses the six sequential steps which need to Uses medical approach within the scope of
be followed strictly within the scope of medical practice
nursing practice
Considers the whole person, organ and Mainly considers organ and system
system function , as well as, the person‘s function
response to organ/system malfunction
Focuses on teaching individuals or groups Focuses on teaching about how diseases
how to be independent on activities of daily and trauma are treated
living
Involve individuals, their significant others, Mostly involved with individuals,
and with groups in nursing care provision sometimes with groups and families
Summary
Nursing process is a dynamic, systematic, cyclic, client centered and universal process
that encompasses six sequential and interlinked steps (assessment, diagnosis, outcome
identification, planning intervention, implementation, and evaluation) in providing
individualized holistic nursing care.
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Session 4.2. Nursing assessment
Session Description
This session is designed to equip trainees with knowledge and skills of patient assessment.
The trainees will be well accustomed to the 11 Gordon‘s functional health patterns, which is
holistic nursing assessment tool.
Session Objectives
At the end of this session, the trainees will be able to:
 Define nursing assessment
 Describe types of assessment
 Identify the four phases of assessment
 List the sources used for data collection
 Describe how data is collected
 Discriminate between subjective and objective data
 Use the 11 Gordon‘s functional health patterns as nursing assessment tool.
 Describe a method of organizing data that facilitates identifying information that
should be used for nursing diagnosis
Introduction
Assessment can be defined as a systematic collection of subjective and objective data from
patients /family/community with the goal of making clinical judgment about patient, family
and the community.
Nursing assessment is not the duplicate medical assessments, because nursing assessment
focuses on the assessment patients‘ responses, whereas, the medical assessment targets to
investigate pathologic conditions.
Purposes of undertaking nursing assessment
1. To establish baseline information on the client
2. To determine the client‘s normal function, abnormal function, risk for dysfunction and
strengths
3. To provide data for nursing diagnosis
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Types of Nursing Assessment
Types of Nursing Assessment
 Initial assessment- this is performed on initial contact with the patient to gather
information about all aspects of health status of the patient. This information is
also called baseline data, which helps us show the progress of the patient with
our care.
 Time lapsed assessment: this type of assessment is done with the aim of
comparison of client’s current status to baseline obtained previously. It can be
done with certain time interval like at 3r, 6th, 1 year.
 Focus assessment- this is performed to gather detailed information about the

status of a specific condition. It is an ongoing assessment.
 Emergency assessment: this is a type of assessment that is done at any time

identify life-threatening conditions.
Phases of Assessment
Assessment is the first step of the nursing process that is done with the following phases:
 Collection of data (gathering information about the patient or client),
 Validating data (making sure the collected information is accurate),
Organizing data (clustering facts into groups of information that help you identify patterns of
health or illness) and identifying patterns,
 Data interpretation
 Reporting and recording data (reporting and recording abnormalities to expedite
treatment; recording assessment findings to communicate current status.
Collecting Data
Data collection begins when someone first enters the health care system and continues as long
as there is a need for nursing care. The information gathered at this initial contact provides the
basis for determining current health status and establishing an initial plan of care. The
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information gathered on subsequent encounters tells you not only about current health status,
but also about how the person is responding to the plan of care.
What sources do you need to gather the data?
I. Primary source—usual most reliable source
o Patient/client
II. Secondary sources
o Verbal and written consultations
o Family, significant others
o Records of diagnostic studies
o Patient charts including nursing records
o Relevant literatures
Identifying Subjective and Objective Data

Separating these two types of data aids critical thinking because each complements and
clarifies the other.
Subjective Data Objective Data
Relates to what the patient states about their Is what the examiner observes and measures
state of health, feelings or perceptions
Examples: Examples:
 I feel sick  Pulse: Rate 100 bpm, strong and
 I have stomach ache regular
 Nausea  Distended abdomen
 Hemoglobin 9 g/dL
Exercise 2.1 Case study 1. Ato Hailu is 51 years old admitted 2 days ago with chest pain. The physician in
charge ordered the following studies- ECG, and complete blood counts. He states ―I feel much better today,
no more pain. It is a relief to get rid of discomfort‖. You think he appears a little tired, and seems to be
talking slowly and exhale noisily more often than you think. He denies being tired.
V/S: Tep 37oC, PR 74 bpm, RR 20 breaths pm, B/P 140/90 mmHg.
Draw subjective and objective data from the above case history
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Exercise 2.2 Case studies 2:
• W/ro Alem Kebede, 28 years old woman was admitted with a Medical Diagnosis of Acute
Gastroenteritis
Subjective: States…
• ―I am weak and worried about my condition.‖, ―My stool is very watery and frequent‖ and ―I‘m
feeling very feverish‖
Objective:
• Temp = 38.0 C (oral), Pulse = 110 per minute
• Respiration rate = 32 per minute,
• Decreased PaO2 , the nurse observed that the patient had diarrhea x 2-3 times of ½ cup per bout
following admission
• Summarize subjective data from the above case history
•
How data is collected?

• Summarize
Using subjective
these sources data
data should be generated through client interview, doing physical
examination and reviewing charts for other diagnostic findings.
Interviewing
Interviewing is a planned communication or a conversation with a purpose of getting data
from patient. For interviewing one need to have skill in obtaining history.
Interview can be directive interview, which is highly structured and elicits specific
information or nondirective interview or rapport-building interview, in which the nurse allows
the client to control the purpose, subject matter, and pacing.
Phases of interview
Effective interview has four phases:
I. Preparatory phase /pre interaction phase: this phase comes before the nurse meet the
patient that involves pre collection of some information about the patient.
II. Introductory phase/orientation phase: this phase is a phase of establishing rapport with
the patient through clarifying your role. This phase helps to alleviate patient anxiety.
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III. Maintenance phase /working phase: this phase the at which the planned interview is
undertaken
IV. Concluding phase: finalize the interview with concluding the session, for example by
summarizing what have been collected and acknowledging the patient for his/her
cooperation
Interview skills
For effective interview one need to can use the following skills
 Questioning: Using open-ended questions that cannot be answered with a simple ―yes‖ or
―no‘‘
 Facilitation: ―Go on…I am listening.‖ (including non-verbal nodding)
 Direction: ―I understand that many things are bothering you…could we focus on the
diarrhoea for just a minute?‖
 Summarising: ―So, from what I understand, you have had a lot of nausea and some
cramping, you have taken all of the pills each day this week and you want some help with
these symptoms…do I have it all right?‖
Techniques of Physical Examination
The health history provides subjective data for health assessment. The skills used for the
physical examination include:
 Inspection;
 Palpation;
 Percussion and;
 Auscultation.
Inspection
Inspection is concentrated watching. Inspection begins the moment you first meet the
individual and develop a ―general assessment". Start the assessment of each body system with
inspection.
Compare the right and left sides of the body. The two sides are nearly symmetric. Inspection
requires good lighting, adequate exposure, and occasional use of certain instruments
(otoscope, penlight, nasal and vaginal specula).
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Palpation
Palpation follows and often confirms points you noted during inspection. Palpation applies
your sense of touch to assess texture, temperature, moisture, organ location and size, as well
as any swelling, vibration or pulsation, rigidity, crepitation, presence of lumps or masses, and
presence of tenderness or pain.
Different parts of the hands are best suited for assessing different factors.
 Fingertips- best for skin texture, swelling, pulsation, and presence of lumps.
 A grasping action of the fingers- to detect the position, shape, and consistency of an
organ or mass
 The dorsa (backs) of hands and fingers- best for determining temperature because the
skin here is thinner than on the palms.
 Base of the fingers (metacarpophalangeal joints)- or ulna surface for vibration.
Start with light palpation to detect surface characteristics and to accustom the person to being
touched. Then perform deeper palpation, by helping the person use deep breathing. Bimanual
palpation requires the use of both of your hands to get certain organs, such as the kidneys, or
uterus.
Percussion
Percussion is tapping the person's skin with short, sharp strokes in-order to assess underlying
structures. The strokes yield a palpable vibration and a characteristics sound that shows the
location, size and density of the underlying organ. Percussion has the following uses: -
1. Mapping out the location and size of an organ by exploring where the percussion notes
changes - between the borders of an organ and its neighbors
2. Signaling the density (air, fluid, or solid) of a structure
3. Detecting an abnormal mass if it is fairly superficial. The percussion vibration
penetrates about 5 cm deep. A deeper mass would give no change in percussion.
4. Eliciting pain if the underlying structure is inflamed, as with sinus areas or over kidney
or appendix
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Procedure
The stationary hand- Hyperextend the middle finger and place its distal portion, the phalanx
and distal inter-phalangeal joint, firmly against the person's skin. Avoid to percuss the person's
ribs and scapulae. Percussing over a bone yields no data because it always sounds "dull". Lift
the rest of the stationary hand up off the person's skin.
The Striking Hand- Use the middle finger of your dominant hand as the striking finger.
Spread your fingers and bounce your middle finger behind the nail bed. Flex the striking
finger so that its tip, not the finger pad, makes contact.
Table 4. The Five Percussion Notes and Their Characteristics

Percussion Relative Relative Relative Example Location
Notes Intensity Pitch Duration
Flatness Soft High Short Thigh
Dullness Medium Medium Medium Liver
Resonance Loud Low Long Normal lung
Hyperresonance Very loud lower Longer None normally
Tymany Loud High Gastric air bubble or
puffed-out check
Auscultation
Auscultation is listening to sounds produced because of flow of fluid and air. Auscultation can
be done on organs like heart, blood vessels, the lungs, and abdomen. A stethoscope has two-
end pieces- Diaphragm for high-pitched sounds such as breath, bowel, and normal heart
sounds. Hold the diaphragm firmly enough against the person's skin. The bell end piece has a
deep, hollow cup-like shape. It is best for soft, low- pitched sounds such as extra heart sounds
or murmurs. Warm the end piece by rubbing it on your palm.
Equipment needed for physical examination
Items needed for screening physical examination includes: -
 Sphygmomanometer Flexible tape measure
 Stethoscope Reflex hammer
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 Thermometer Sharp object (sterile needle)

 Flashlight Cotton balls
 Tuning fork Bivalve vaginal speculum
 Tongue depressor Clean gloves
 Lubricant
Validating Data
Validation of data is the process through which data are double-checked to make sure the
collected data is accurate, consistent, factual, and complete. If you are not sure about the
validity of the patient information, obtain more data rather than go on to identify problems
based on incorrect or incomplete data that take you to an error in problem identification.
Data verification is done by examining the congruence between subjective and objective data.
For example, a client might exhibit nonverbal expressions of pain (e.g., guarding a part of the
body, facial grimacing) but verbally deny feeling pain.
Strategies for Validating Data
 Be aware that data that can be measured accurately can be accepted as factual (e.g.
height, weight, laboratory study results)
 Keep in mind that data that someone else observes to be factual may or may not be
true. When the information is critical, verify it by directly observing and interviewing
the patient yourself.
 Recheck your own data (e.g. taking B/P in the opposite arm or 10 minutes later)
 Look for factors that may alter the accuracy of your data (e.g. check whether someone
who has an elevated temperature and no other symptoms has just had a hot cup of tea).
 Always double check information that is extremely abnormal or inconsistent with
patient cues. -e.g., repeat a diagnostic study that is extremely high or low.
 Compare your subjective and objective data to see if what the patient is stating is
congruent with what you observe. E.g., compare actual pulse rate with perceptions of
―racing heart‖.
Organizing (Clustering) Data
After data collection is completed and information is validated, the nurse organizes, or
clusters, the information together in-order to identify areas of client strengths and weaknesses.
This process is known as data clustering.
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 Clustering assessment data according to human needs- For example, data that pertain
to physiological needs; data that pertain to safety and security needs.
 Clustering assessment data according to functional health pattern (Gordon) – E.g., data
that pertain to health perception, nutritional, elimination …
 Clustering data according to body systems- E.g., Respiratory system, cardiovascular
system, gastrointestinal system …
Data interpretation
Data interpretation is important to identify cues and reach at inferences, which helps make
clinical judgments about the client.
Identifying Cues and Making Inferences
 Subjective and objective data that you have identified act as cues. Cues are hints, or
reminders, that prompt you to reach a conclusion about a patient needs. Example:
Subjective Data Patient states, “generalized body weakness following three days
of passing loose stool in average four times a day”
Objective Data Dry oral mucosa, PR: 120 bpm, BP: 80/50 mmHg, skin pinch
going back slowly
 The above data give you cues that may lead you to infer (conclusion) that the person is
having dehydration. How you interpret or perceive a cue is called an inference. In this
case you have made an inference about the generalized body weakness following
passage of loose stool and has interpreted as probably having dehydration. Cues and
correct inferences need observational skills, nursing knowledge and your clinical
expertise.
Examples of cues with corresponding inferences
Cue Inference
Letti states, ― I have trouble in sleep that I Letti may have a sleep pattern disturbance
frequently wake and couldn‘t sleep again‖
Recording and Reporting
Accurate and complete recording of assessment data are essential for communicating
information to other health care team members.
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The Eleven Gordon’s Functional Health Patterns

Marjorie Gordon (1987) proposed functional health patterns as a guide for establishing a
comprehensive nursing database. These 11 categories make possible a systematic and
standardized approach to data collection, and enable the nurse to determine the following
aspects of health and human function.
Patient Identifications
Patient identifications may include full name, MRN, age, sex, birth date, and unit/ward. In this
part source of information, source of referral, date of admission and medical diagnoses, need
to be included.
Pattern 1: Health Perception and Health Management

Data collection is focused on the person's perceived level of health and well-being, and on
practices for maintaining health. Habits that may be detrimental to health are also evaluated,
including smoking and alcohol or drug use. Actual or potential problems related to safety and
health management may be identified as well as needs for modifications in the home or needs
for continued care in the home.
Subjective data
 Major reason for seeking health care: addresses reason (s) for seeking health care or
the major concern of the patient right now. It can be changed based on the condition of
the patient as time goes.
 To determine the patients understanding about his/her current health status, his/her
statement about reason of admission should also be sought.
 The statement of significant others about reason for admission may be sought as
required in some cases like diabetes, psychiatric conditions, comatose patients, etc.
 Perceived health rating of the patient, on scale of 1 to 3 or other type of scale how the
patient can rate his/her own health condition can be assessed. For example, general
health can be rated as poor, fair or excellent on scale of three.
Substance use:
 Substances that are used by the patient need to be identified and be described by unit,
amount taken, frequency and its effect on the patient if not taken.
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 Subjectively assess patients for health maintenance practice like regular physical exercise,
healthy eating, regular medical check-ups, history of last immunization and treatment
adherence. Moreover, it is important to assess patient understand regarding the
treatment/medicine he/she is taking by name, dose, frequency, how to take etc.
Objective data
 Under objective data, the health perception and health management of patients can be
assessed by observing his/her general appearance and grooming condition.
Pattern 2: Nutrition and Metabolism
This pattern focuses on the pattern of food and fluid consumption relative to metabolic need.
The adequacy of local nutrient supplies is evaluated. Actual or potential problems related to
fluid balance, tissue integrity, and host defenses may be identified as well as problems with
the gastrointestinal system.
Subjective data
 The subjective data need to address any change in the pattern food and fluid intake which
could be in relation to major meals and snacks. Ask the patient if he/she is taking special
diet because of illness like salt free diet. Gastro intestinal conditions like difficulty of
chewing, dysphagia, sore tongue, sore gums/mouth, dental problem, food
intolerance/preference, nausea and vomiting, appetite/ bulimia nervosa and use of anti-
acids should also be assessed.
 Use of antacids, fever, cold/cold intolerance, abdominal pain and weight loss/gain
Objective data
 Objectively the nutritional and metabolic status can be assessed through anthropometric
measurements that include weight, height, mid-upper arm circumference (MUAC), BMI
and ideal body weight (IBW). BMI is calculated as weight in kg divided by height in
meter square. IBW is calculated as follows:
IBW
 Males: IBW = 50 kg + 2.3 kg for each inch over 5 feet  10%
 Females: IBW = 45.5 kg + 2.3 kg for each inch over 5 feet  10%
Conversion
Skin assessment
1lb = 0.454 kg
 1ft = 0.31 m (5ft = 1.524m)
 1ft = 12 in 155
Assess skin for

 Color changes like cyanosis, pallor, jaundice, petechiae, etc;
 Lesions:
o primary lesions: macule, papule, nodule, vesicle, pustule, etc and
o secondary lesions: scale and crust
 Texture: whether it is rough or smooth
 Moisture: dry like in case of dehydration, wet like in case hyperthyroidism
 Turgor: pinch the skin on abdomen and check whether it‘s going back immediately,
slowly (with in second) or very slowly (took more than 1 and ½ a second)
Hair assessment
 Any scalp lesion
 Distribution: evenly distributed or loss of hair in certain scalp area like in case of
alopecia
 Any color change
Nail assessment
 Color changes: look for any color changes like cyanosis, splinters, etc of nail, which is
normally pink.
 Nail shape: check the nail angle which is normally less than 180o with convex shape
 Tenderness: which is normally non-tender
Assess Oral Mucosa:
 Number of tooth: count the number of teeth and determine missing
 Oral Condition: Color changes, ulcers, white patches, nodules, dental carries, any foul/
bad odor, dryness
 Check gums for color, bleeding, patches
 Tongue: test buds, color, patches
Pattern 3: Elimination
This pattern is focused on excretory patterns (bowel, bladder, skin). Excretory problems such
as incontinence, constipation, diarrhea, and urinary retention may be identified.
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Subjective data
Bladder Habit
 Ask the patient for urinary frequency (voiding multiple times than usual) and nocturia (
unusual increased frequency of voiding during the night)
 Color of urine: any change in color like redness in gross hematuria, cloudy in UTI,
yellowish as in jaundice. Normally the color of urine is amber
 Amount per day: ask the patients whether it‘s increased or decreased or else if possible
monitor intake and output
 Ask for classical manifestations of the other lower urinary tract manifestations like
dysuria (pain/burning on voiding), urgency (desire to pass urine urgently), hesitancy (a
delay between being ready to pass urine and the actual flow of urine)
 Ask for history of urinary incontinence (the inappropriate involuntary passage of urine,
resulting in wetting) and urinary retention (inability to pass urine)
Bowel habit
 Like a bladder habit, ask for bowel habit of frequency, color (which is normally dark
brown), consistency (whether formed, loose or watery) and amount of stool per day
(whether increased or decreased than the usual). Ask also for pain on defecation,
incontinence, constipation, history of colostomy/ileostomy.
Objective data
 Undertake abdominal examination with the order of inspection, auscultation, percussion,
and palpation
Inspection
 Inspect the abdomen for the contour/shape of the abdomen whether it‘s round or flat
(bulging bilaterally or unilaterally); any lesions; umbilicus (drainage, inverted/everted,
redness, etc.), stria (a streak, line or thin band appearing on abdomen); vein (whether
engorged and prominent) and abdominal movement with respiration.
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Auscultation
 Auscultation provides important information about bowel motility. Listen to the
abdomen before performing percussion or palpation, since these maneuvers may alter
the frequency of bowel sounds.
 Listen for bowel sounds and note their frequency and character. Normal sounds consist
of clicks and gurgles, occurring at an estimated frequency of 5 to 30 per minute.
 procedure
1. Diaphragm of stethoscope are used
2. Skin depressed to approximately 1 cm
3. Listening in one spot is usually sufficient
4. Listening for 15-20
5. Bowel sounds cannot be said to be absent unless they are not heard
after listening for 3-5 minutes. (in all quadrants)
Abnormal Findings Related to Bowel Sounds
• Absent/hypoactive
o Listen for 3-5 minutes
o Bowel obstruction, peritonitis, paralytic ileus.
o Low Potassium
o Surgical manipulation
• Increased Bowel sounds/hyperactive
o Increased motility of fluids
o Diarrhea
Percussion
• Percussion helps you to assess the amount and distribution of gas in the abdomen and
to identify possible masses that are solid or fluid filled.
• Percuss the abdomen lightly in all four quadrants to assess the distribution of tympani
and dullness.
A protuberant abdomen that is tympanitic throughout suggests intestinal obstruction
 Using short tapings and percuss the abdomen for tympany (the normal sound noted over
large part of the abdomen) and dullness (which indicates large fluid or mass in the
abdomen). Percussion can also be used to determine organ sizes.
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Liver percussion
 In the right midclavicular line percuss from the lung resonance to liver dullness and
mark. Then percuss from abdominal tympany to the liver dullness and make a mark.
Then measure the distance between the two marks which should be normally 6-12 cm.
In the midsternal line it‘s 4-8 cm.
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Percussing the spleen

The spleenic dullness is located between
9th and 11th intercostal space just behind
the left mid-axillary line and it‘s normally
not wider than 7cm in adults. The
tympanic sound of the spleen, which is the
normal sound, is heard when percussing
the lowest interspace of the left anterior
axillary line and asking the person to

take a deep breath. Normally tympany
remains through a full inspiration. When
the sound changes from tympany to a
dull sound with full inspiration, it is
abnormal. Splenomegally is common in
malaria or hepatic cirrhosis.
Test for shifting dullness
After mapping the borders of tympany and
dullness, ask the patient to turn onto one side.
Percuss and mark the borders again. In a person
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without ascites, the borders between tympany and dullness usually stay relatively constant.
Assessing Kidney Tenderness
Place the ball of one hand in the costovertebral angle (CVA) and strike it
with the ulnar surface of your fist. Use enough force to cause a perceptible
but painless jar or thud in a normal person.
 Pain with pressure or fist percussion suggests pyelonephritis,
but may also have a musculoskeletal cause.
Palpation
 Gently palpate using the pad of fingers for tenderness and increased abdominal muscle
resistance. Using deep palpation examines if there is large masses or enlarged organs.
Techniques of liver palpation
Technique of liver palpation (1)
1. Place your left hand behind the patient, parallel to and supporting the right 11th and
12th ribs and adjacent soft tissues below
2. Press forward by the left hand
3. Place your right hand on the patient‘s right abdomen lateral to the rectus muscle, with
the fingertips well below the lower border of
liver dullness
4. Fingers can point up toward the patient‘s head or
more oblique position
5. Then press gently in and up
6. Ask the patient to take a deep breath
7. Try to feel the liver edge as it comes down to
meet your fingertips. If you feel it, lighten the pressure of your palpating hand slightly
so that the liver can slip under your finger pads and you can feel its anterior surface
8. If palpable a normal liver is soft, sharp, and regular, with smooth and normal liver
may be slightly tender
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Technique of liver palpation (2): Hook method can also be used for the palpation of the
liver.
 Stand to the right of the patient‘s chest
 Place both hands, side by side, on the right abdomen
below the border of liver dullness.
 Press in with your fingers and up toward the costal
margin
 Ask the patient to take a deep breath.
 The liver edge is palpable with the finger pads of both hands
Spleen palpation
Technique of spleen palpation
 With your left hand support and press forward the lower left rib cage and adjacent soft
tissue
 With right hand below the left costal margin, press in toward the spleen
 Ask the patient to take a deep breath
 Try to feel the tip or edge of the spleen as it comes down to meet your fingertips
 Note tenderness, assess the splenic contour, and measure the distance b/n the spleen‘s
lowest point and the left costal margin
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Repeat with the patient lying on the right side with legs somewhat
flexed at hips and knees to bring the spleen forward and to the
right into a palpable location
Palpation of Kidneys
 Kidneys are not usually palpable
Palpation Technique of the Left Kidney
 Move to the patient‘s left side
 Place your right hand behind the patient just below and
parallel to the 12th rib, with your fingertips just reaching
the costovertebral angle (CVA)
 Lift, trying to displace the kidney anteriorly
 Place your left hand gently in left upper quadrant (LUQ),
lateral and parallel to the rectus muscle
 Ask the patient to take a deep breath
 At the peak of inspiration, press your left hand firmly and deeply into the LUQ, just below
the costal margin, and try to ―capture‖ the kidney between your two hands.
 Ask the patient to breathe out and then to stop breathing briefly
 Slowly release the pressure of your left hand, feeling at the same time for the kidney to
slide back into its expiratory position.
 If the kidney is palpable, describe its size, contour, and any tenderness
Palpation Technique of the Right Kidney

 To capture the right kidney, return to the patient‘s right side
 Use your left hand to lift from in back, and your right hand to feel deep in the RUQ
 Proceed as before (palpation of the left kidney)
Other method to palpate left kidney similar to feeling for the spleen
 With your left hand, reach over and around the patient to lift the
left loin, and with your right hand feel deep in the left upper
quadrant
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 Ask the patient to take a deep breath, and feel for a mass
 A normal left kidney is rarely palpable
Rectal examination
 Rectal examination may be done as indicated
 Inspect the rectal mucosa for any lesions, fissure, color, visible masses.
 By using digital rectal examination (DRE) palpate the inside of the rectum giving attention
to prostate in males. Check for any tenderness, roughness, and consistency of the prostate.
Pattern 4: Activity and Exercise

This pattern is focused on the activities of daily living requiring energy expenditure,
including self-care activities, exercise, and leisure activities. The status of major body systems
involved with activity and exercise are evaluated, including the respiratory, cardiovascular,
and musculoskeletal systems.
Subjective data
 Assess the patients‘ level of dependency regarding daily living activities (ADL) on the
scale of: fully independent, need assistance from device/others and fully
dependent/unable to perform ADL. ADL include eating, bathing, dressing, toileting, bed
mobility, transferring, ambulating, cooking, home maintenance and others.
 Ask the patient for dyspnea (laboured or difficult breathing), palpitations (unpleasant
awareness of heart beat), chest pain (characterize by PQRST- Precipitating/aggravating,
Quality, Radiation, Severity/Site and Timing), stiffness of any part of the body,
weakness, cough (characterize), hemoptysis, history of smoking, leisure activities and
occupation. Effect of illness on activities should also be assessed.
Objective data
Vital signs
 For convince purpose all of vital signs should be included under the objective data of
this pattern. Take pulse (with characteristics), temperature (by site), BP (on the right and
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left side at three different positions lying, sitting, and standing) and respiration rate and
depth.
When do we assess vital signs?
 During admission and discharge

 When there is change in client‘s condition
 When ordered by the physicians
 Before and after any interventions that affect vital signs
Blood pressure
 Is a force of blood exerted against the wall of blood vessels.
Systolic BP: The maximum force exerted during contraction of the heart
Diastolic BP: The maximum force exerted during contraction of the heart
Getting Ready To Measure Blood Pressure
 Ideally, ask the patient to avoid smoking or drinking caffeinated beverages for 30
minutes before the blood pressure is taken and to rest for at least 5 minutes.
 Check to make sure the examining room is quiet and comfortably warm.
 Make sure the arm selected is free of clothing. There should be no arteriovenous
fistulas for dialysis, scarring from prior brachial artery cut downs, or signs of
lymphedema (seen after axillary node dissection or radiation therapy).
 Palpate the brachial artery to confirm that it has a viable pulse.
 Position the arm so that the brachial artery, at the antecubital crease, is at heart level—
roughly level with the 4th interspace at its junction with the sternum.
 If the patient is seated, rest the arm on a table a little above the patient‘s waist.
 Standing, try to support the patient‘s arm at the midchest level.
Nursing alert!
. following condition may result in falsely high blood pressure
The
 If the brachial artery is much below heart level.

 The patient‘s own effort to support the arm.
 A loose cuff or a bladder that balloons outside the cuff leads
 Cuffs those are too short or too narrow.
 Using a regular-size cuff on an obese arm.
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Classification of blood pressure for adults ages 18 and older, with recommended follow-
up (for persons not taking antihypertensive drugs and not acutely ill)
Category Systolic (mm Hg) Diastolic(mm Hg) Follow-up recommended
Optimal <120 and <80 Recheck 2 years

Normal <130 and <85 Recheck 2 years
High normal 130–139 or 85–89 Recheck 1year
Hypertension
Stage 1 140–159 90–99 Confirm within 2 months
Stage 2 160–179 100–109 Evaluate within 1 month
Stage 3 180 or higher 110 or higher Evaluate immediately or within 1
week higher
Pulse
 Pulse is a wave of blood created by contraction of the left ventricle of the heart. It
represents the stroke volume output or the amount of blood that enters the arteries with
each ventricular contraction
Heart rate and rhythm
 By examining arterial pulses, you can count the rate of the heart and determine its
rhythm, assess the amplitude and contour of the pulse wave, and sometimes detect
obstructions to blood flow.
Heart Rate. The radial pulse is commonly used to assess the heart rate. With the pads of your
index and middle fingers, compress the radial artery until a maximal pulsation is detected. If
the rhythm is regular and the rate seems normal, count the rate for 15 seconds and multiply by
4. If the rate is unusually fast or slow, however, count it for 60 seconds.
Normal pulse rate for adults is between 60 and 100 beats per minute. Bradycardia is a heart
rate less than 60 beats per minute in an adult. Tachycardia is a heart rate in excess of 100
beats per minute in an adult.
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When the rhythm is irregular, the rate should be evaluated by cardiac auscultation, because
beats that occur earlier than others may not be detected peripherally and the heart rate can thus
be seriously underestimated.
Rhythm. To begin your assessment of rhythm, feel the radial pulse. If there are any
irregularities, check the rhythm again by listening with your stethoscope at the cardiac apex. Is
the rhythm regular or irregular? If irregular, try to identify a pattern: (1) Do early beats appear
in a basically regular rhythm? (2) Does the irregularity vary consistently with respiration? (3)
Is the rhythm totally irregular?
Assessment of the apical pulse is indicated for:

1. Clients whose peripheral pulse is irregular or unavailable.
2. Clients with known cardiovascular, pulmonary, and renal diseases.
3. Newborns, infants, and children up to 2 to 3 years old.
Respiration
Respiratory assessment is the measurement of the breathing pattern. Assessment of
respirations provides clinical data regarding the pH of arterial blood
Observe the rate, rhythm, depth, and effort of breathing. Count the number of respirations in 1
minute either by visual inspection or by subtly listening over the patient‘s trachea with your
stethoscope during your examination of the head and neck or chest.
Characteristics of Normal and Abnormal Breath Sounds
Eupnea refers to easy respirations with a normal rate of breaths per minute that are age-
specific. Bradypnea is a respiratory rate of 12 or fewer breaths per minute. Hypoventilation
is characterized by shallow respirations.
Tachypnea is a respiratory rate greater than 24 breaths per minute. Hyperventilation is
characterized by deep, rapid respirations
NURSING ALERT
Positioning for Dyspneic Clients
Dyspneic clients should never be placed flat in bed; maintain them in a semi-Fowler‘s or
Fowler‘s position. To facilitate maximal lung expansion place the client in a forward-leaning
position over a padded, raised over bed table with arms and head resting on the table
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Temperature
Body temperature is measured during the routine physical examination by using one of the
instruments. Frequent monitoring is required for clients who have or are at risk for infection;
for example, postoperative clients or those with suppressed white blood cell count. Accuracy
of temperature measurement is essential because it guides nursing and medical decision
making and interventions.
Sites
Although the physician may order a specific site to measure the temperature, nursing
judgment usually determines the best site based on the client‘s age and physical and mental
condition. Traditional sites for measuring the body‘s internal (core) temperature are oral (OT),
rectal (RT), and axillary (AT), using either glass or electronic thermometers.
Oral and rectal temperature measurements are higher than axillary because the measuring
device is in contact with the mucous membrane. Rectal measurements are higher than oral
because of the seal created by the anal sphincter, which decreases contact with environmental
air.
With the availability of electronic measuring devices, a glass thermometer should never be
used for oral readings if there is danger that the client will bite and break the thermometer.
The axilla is commonly used as a site for infants and children with disabilities because it is the
safest, even though least accurate, method. Axillary or rectal sites are used for clients who are
uncooperative, comatose, or who have a nasogastric or feeding tube in place.
The average oral temperature, usually quoted at 37°C (98.6°F), fluctuates considerably. In the
early morning hours it may fall as low as 35.8°C (96.4°F), and in the late afternoon or evening
it may raise as high as 37.3°C (99.1°F). Rectal temperatures are higher than oral temperatures
by an average of 0.4 to 0.5°C (0.7 to 0.9°F), but this difference is also quite variable.
(In contrast, axillary temperatures are lower than oral temperatures by approximately 1
degree, but take 5 to 10 minutes to register and are generally considered less accurate than
other measurements.)
Fever or pyrexia refers to an elevated body temperature.

Hyperpyrexia refers to extreme elevation in temperature, above 41.1°C (106°F), while
hypothermia refers to an abnormally low temperature, below 35°C (95°F) rectally.
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Most patients prefer oral to rectal temperatures. However, taking oral temperatures is not
recommended when patients are unconscious, restless, or unable to close their mouths.
Temperature readings may be inaccurate and thermometers may be broken by unexpected
movements of the patient‘s jaws.
 Rapid respiratory rates tend to increase the discrepancy between oral and rectal
temperatures. In this situation, rectal temperatures are more reliable.
NURSING ALERT!
Temperature Measurement Sites
Rectal temperature measurement is contraindicated in clients with cardiovascular
alterations because the thermometer may stimulate the vagus nerve and cause an irregular
cardiac rhythm. It is also contraindicated in leukemia and rectal surgery clients because
the insertion of the thermometer may traumatize the mucosa or incision line, causing
bleeding.
I. Musculoskeletal System Examination

 Observe the patient for gait (steady or unsteady), any musculoskeletal deformity,
swelling of the lower extremities and symmetry of the body. Ask the patient to perform
active range of motions if cannot ask to perform passive range of motion. The major
range of motions include not limited to flexion, extension, abduction, adduction, and
internal and external rotation. Determine whether ROMs are decreased or normal to the
joints.
Gait
Ask the patient to:
• Walk across the room or down the hall, then turn, and come back.
• Observe posture, balance, swinging of the arms, and movements of the legs.
• Normally balance is easy, the arms swing at the sides, and turns are accomplished
smoothly.
 A gait lacking coordination (reeling & instability) is called ataxia
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Determine muscle tone

Technique of muscle tone examination
 This can be assessed best by feeling the muscle‘s resistance to passive stretch.
 Take one hand with yours and, while supporting the elbow, flex and extend the patient‘s
fingers, wrist, and elbow, and put the shoulder through a moderate range of motion.
 On each side, note muscle tone—the resistance offered to your movements
 If you suspect decreased resistance, hold the forearm and shake the hand loosely back and
forth
 Normally the hand moves back and forth freely but is not completely floppy
 Decreased resistance may be caused by disease of the peripheral nervous system,
cerebellar disease, or acute stages of spinal cord injury
 Marked floppiness indicates hypotonic or flaccid muscles
 Increased resistance that is worse at the extremes of the range is called spasticity.
Resistance that persists throughout the range and in both directions is called lead-pipe
rigidity.
Muscle strength
Muscle Strength Examination Technique
 Ask the patient to move actively against your resistance or to resist your movement
 If the muscles are too weak to overcome resistance, test them against gravity alone or with
gravity eliminated
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Muscle strength is graded on a 0 to 5 scale:

0—No muscular contraction detected
1—A barely detectable flicker or trace of contraction
2—Active movement of the body part with gravity eliminated
3—Active movement against gravity
4—Active movement against gravity and some resistance
5—Active movement against full resistance without evident fatigue. This is normal muscle
strength.
Decreased muscle strength
• Paresis: Impaired strength is called weakness
• Paralysis (plegia): Absence of strength
• Hemiparesis: Weakness of one half of the body
• Hemiplegia: Paralysis of one half of the body
• Paraplegia: Paralysis of the legs
• Quadriplegia: Paralysis of all four limbs
II. Respiratory system assessment

For respiratory assessment first do inspection, palpation, percussion, and auscultation of the
posterior chest. With the same mechanism inspect, palpate, percuss, and auscultate the
anterior chest.
The posterior chest:
Inspect the posterior chest.
 Note the shape and configuration of the chest wall. The spinous processes should
appear in a straight line. The thorax is symmetric. The scapulae are placed
symmetrically.
 Shape of chest which should be normally the anteroposterior diameter is
approximately half of the transverse diameter
 Antero-posterior = transverse diameter or ―barrel chest ―in chronic obstructive
pulmonary disease.
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Palpation
 Palpate the chest for tenderness, masses, lesions, respiratory excursion, and vocal
fremitus
Testing chest expansion (Respiratory excursion)
Technique of respiratory excursion examination
 Thoracic expansion at 10th rib: place thumbs close to client‘s spine and
spread hands over thorax
 Note divergence of thumbs, feel for range and symmetry of movement
during deep inhalation and full exhalation
Cause of unilateral decrease or delay of respiratory excursion:
 Pleural effusion
 Lobar pneumonia
 Pneumothorax
 Unilateral bronchial obstruction
Cause of bilateral decrease or delay of respiratory excursion:
 When alveoli do not fully expand
 Emphysema
 Pleurisy
Tactile Fremitus
 Used to detect sound vibration generated by the larynx traveling distally along the
bronchial tree
Technique
 Place ulnar aspect of your open hand at right apex of lung and place the hand
at each location on the chest (as shown on pictures)
 Instruct client to say ―99‖ or ―1-1-1‖ or ―44‖ in Amharic
 Use one hand or both
 Note areas of increased or decreased fremitus
 An increase in solid tissue per unit volume of lung will enhance fremitus
 An increase in air per unit volume of lung will impede sound
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Percussion
 Percuss between the scapulae of the posterior chest.
 Percussion Notes
 Have the patient keeps both arms crossed in front of the chest
 When percussing the lower posterior chest, stand somewhat to the side
rather than directly behind the patient
 When comparing two areas, use the same percussion technique in both areas
 Learn to identify five percussion notes
Pathologic Examples
 Flatness may indicate large pleural effusion
 Dullness --fluid or solid tissue replaces air-containing lung or occupies the pleural space
beneath percussing fingers.
 Examples include: lobar pneumonia, pleural effusion, hemothorax, empyema, fibrous
tissue, or tumor
 Hyperresonance  Emphysema, pneumothorax
 Tympany  Large pneumothorax
Auscultation
Evaluate the presence and quality of normal breath sounds. The person is sitting, leaning
forward slightly, with arms across the lap. Instruct the person to breath through the mouth, a
little bit deeper than usual. Use the flat diaphragm end-piece of the stethoscope and hold it
firmly on the person's chest wall. Listen to at least one full respiration in each location. Side to
side comparison is most important.
While standing behind the person listen posterior from the apex at C7 to the base (around
T10), and laterally from the axilla down to the seventh or eighth rib. Decreased or absent
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breath sounds occur when the bronchial tree is obstructed by secretions or foreign body, in
lungs such as pleurisy or pneumothorax.
 Auscultate between the scapulae of the posterior chest.

 Auscultation is used to assess airflow through the tracheobronchial tree
 Auscultation involves
1. Listening to the sounds generated by breathing
2. Listening for any adventitious (added) sounds
3. If abnormalities are suspected, listening to the sounds of the patient‘s spoken or
whispered voice as they are transmitted through the chest wall
Techniques of chest auscultation
 Listen to the chest anteriorly and laterally as the patient breathes deeply with mouth open
 Compare symmetric areas of the lungs
 Listen to the breath sounds, noting their intensity and identifying any variations from
normal vesicular breathing
 Identify any adventitious sounds
 Listen for transmitted voice sounds
Breath Sounds (Lung Sounds)

 Are known by their normal location
Duration of sounds Intensity of Pitch of Location where
expiratory expiratory heard normally
sound sound
Vesicular Inspiratory sounds Soft Relatively low Over most of both
last longer than lungs
expiratory ones
Broncho- Inspiratory and Intermediate Intermediate Often in the 1st and
vesicular expiratory sounds are 2nd interspaces
about equal anteriorly and
between scapulae
Bronchial Expiratory sounds Loud Relatively high Over the
last longer than manubrium, if
inspiratory ones heard at all
Tracheal Inspiratory and Very loud Relatively low Over the trachea in
expiratory sounds are the neck
about equal
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Adventitious sounds and pathologic examples

Adventitious sounds Pathologic examples
Crackles Lung fibrosis, Early CHF, Chronic bronchitis, Asthma
Pleural Rub Inflamed and roughened pleural surface
Stridor Partial obstruction of the larynx or trachea
Wheezes Asthma, Chronic bronchitis, COPD, CHF (cardiac asthma)
The Anterior Chest
Inspection
 Inspect the anterior chest for the shape, symmetry, facial expression, level of
consciousness and quality of respiration.
 Shape of chest which should be normally the

anteroposterior diameter is approximately half of the
transverse diameter
 Respiratory rate and rhythm
 Signs of respiratory difficulty: cyanosis signals
hypoxia, use of accessory muscles, chest indrawing
and clubbing of the nails
Abnormal: - Barrel chest, restlessness (hypoxia), noisy breathing (asthma), unequal chest
expansion with pneumonia or obstruction, tachypnea or bradypnea.
Palpating the anterior chest

Palpate the symmetric expansion of the chest by placing your hands on the antero-lateral wall
with thumbs along the coastal margins and pointing toward the xiphoid process. Ask the
person to take deep breath and watch your thumbs move apart symmetrically, and note smooth
chest expansion with your fingers.
Abnormal: - Failure in expansion occurs in pneumonia and palpable

grating sensation with breathing indicates pleural fremitus.
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Assess tactile fremitus- Begin palpating over the lung apex in the supra-clavicular areas.
Compare vibrations from one side to the other as the person repeats " Arba-Arat". Note skin
temperature and moisture.
Percussing the anterior chest

Begin percussing the apex in the supra-clavicular areas and then with the inter-
space and comparing one side to the other, moving down to the anterior chest. Do
not percuss directly over female breast tissue because it produces dull note. Note
the borders of cardiac dullness normally found on the anterior chest and do not
confuse these with suspected lung pathology. In the right, the upper border of
liver dullness is located in the 5th inter-costal space in the right mid-clavicular line. On the
left, tympani is evident over the gastric space.
Auscultate the Anterior chest
Auscultate the lung fields over the anterior chest from the apex in the supraclvicular areas
down to the sixth rib. Progress from side to side as you move downward, and listen to one full
respiration in each location. Do not place your stethoscope directly over the female breast.
Displace the breast and listen directly over the chest wall.
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III. Cardiovascular assessment

Inspection
Jugular vein distension
 Elevating the head of the bed to 30-45o,
observe for the distension of the jugular vein,
which is not usually appearing.
Heaves and lifts
 Look at the apex of the heart at 5th ICS MCL
for heaves and lifts and on the abdomen for
any visible blood vessels.
Palpation
 Palpate pulse at different body sites like carotid, apical, radial, and femoral and dorsalis
pedis.
Palpate the carotid artery
 The carotid pulse provides valuable information about cardiac function
and is especially useful for detecting stenosis or insufficiency of the
aortic valve.
 Take the time to assess the quality of the carotid upstroke, its amplitude
and contour, and presence or absence of any overlying thrills or bruits.
 Character and Volume: best checked on carotid arteries.
 Place fingers behind the patient's neck and compress the carotid on one side
 The amplitude of the pulse.
 The contour of the pulse wave.
 Variations in amplitude from beat
 to beat or with respiration
 During palpation of the carotid artery, you may detect humming vibrations, or thrills,
that feel like the throat of a purring cat.
 At the apex of the heart, the pulse could also be palpable.
 For pulsation & thrill (vibration) in all areas of the pericardium
 Apical area
 palpate apical impulse (PMI)
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 If pulsation present determine its size, diameter, location & time it

pulsates within cardiac cycle.
 Normally no pulsation palpable over the aortic and pulmonic areas but
at the PMI
Assess For Jugular Venous Pressure (JVP)
Steps for Assessing the Jugular Venous Pressure (JVP)
A. Make the patient comfortable
B. Raise the head slightly on a pillow to relax
the sternomastoid muscles
C. Raise the head of the bed or examining
table to about 30°
D. Turn the patient’s head slightly away from
the side you are inspecting
E. Use tangential lighting and examine both
sides of the neck
F. Identify the external jugular vein on each side, then find the internal jugular venous
pulsations
G. If necessary, raise or lower the head of the bed until you can see the oscillation point or
meniscus of the internal jugular venous pulsations in the lower half of the neck
H. Focus on the right internal jugular vein. Look for pulsations in the suprasternal notch,
between the attachments of the sternomastoid muscle on the sternum and clavicle, or just
posterior to the sternomastoid
I. Identify the highest point of pulsation in the right internal jugular vein
J. Extend a long rectangular object or card horizontally from this point and a centimeter
ruler vertically from the sternal angle, making an exact right angle
K. Measure the vertical distance in centimeters above the sternal angle where the horizontal
object crosses the ruler
L. This distance, measured in centimeters above the sternal angle or the atrium, is the JVP
JVP elevated if measured at greater than:
 3 cm or possibly 4 cm above the sternal angle, or
 8 cm or 9 cm in total distance above the right atrium
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NB: The sternal angle usually remains about 5 cm above the right atrium
Increased JVP suggests:
 Right sided heart failure
 Constrictive pericarditis (less common)
 Tricuspid stenosis
 Superior vena cava obstruction
 Obstructive lung disease
• May appear on expiration only
• The veins collapse on inspiration
• This does not indicate congestive heart failure
Percussion
 Percussion is used to determine heart size, especially in case of cardiomegaly.
Auscultation
 Auscultate for the heart sound (S1, S2, murmur and gallop) at the following sites
Use of stethoscope
 The diaphragm is better for picking up the relatively high-pitched sounds of S1 and S2,
the murmurs of aortic and mitral regurgitation, and pericardial friction rubs by pressing
the diaphragm firmly against the chest.
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 The bell is more sensitive to the low-pitched sounds of S3 and S4 and the murmur of
mitral stenosis. Apply the bell lightly, with just enough pressure to produce an air seal
with its full rim.
Auscultation sequence
 For auscultation you can start with diaphragm auscultating on the 2nd right sternal border
intercostal space, then ask the patient to breath normally and continue to auscultate on
the 2nd left sternal border intercostal space, 3rd left sternal border interspace, 4th left
sternal border interspace, 5th left sternal border interspace and then at the apex. This
sequence is usually helps to hear heart sound 1 and heart sound 2.
 By changing to the bell of the stethoscope start to auscultate at the apex, then to 5th left
sternal border interspace and 4th left sternal border interspace. This sequence is for
identification of S3, S4 and murmur.
S3
 S3 occurs immediately after S2
 A physiologic third heart sound is heard
frequently in children and may persist in young
adults to the age of 35 or 40. It is common during
the last trimester of pregnancy.
o It is heard best at the apex in the left lateral decubitus position.
o The bell of the stethoscope should be used with very light pressure.
 A pathologic S3 or ventricular gallop sounds just like a physiologic S3. An S3 in a
person over age 40 (possibly a little older in women) is almost certainly pathologic.
o Causes include decreased myocardial contractility, myocardial failure, and volume
overloading of a ventricle, as in mitral or tricuspid regurgitation.
o On the left side best heard at typically at the apex in the left lateral position and a
right-sided S3 is usually heard along the lower left sternal border or below the
xiphoid with the patient supine.
S4
 An S4 (atrial sound or atrial gallop) occurs just before S1.
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 An S4 is heard occasionally in an apparently normal person, especially in trained

athletes and older age groups.
 More commonly, it is due to increased resistance to ventricular filling following atrial
contraction.
 Causes of a left-sided S4 include hypertensive heart disease, coronary artery disease,
aortic stenosis, and cardiomyopathy.
 A left-sided S4 is heard best at the apex in the left lateral position and the right-sided S4
is heard along the lower left sternal border or below the xiphoid.
 Causes of a right-sided S4 include pulmonary hypertension and pulmonic stenosis.
Pattern 5: Sleep and Rest Pattern

This pattern is focused on the person's sleep, rest, and relaxation practices. Dysfunctional
sleep patterns, fatigue, and responses to sleep deprivation may be identified.
Subjective data
Ask the patient in any change of sleep in relation to the illness. This may include:
 Change in sleep time: what was the usual sleeping time and change in sleep time, is
there waking up early than usual, onset problems/difficulty falling asleep and difficulty
remaining asleep.
 Ask also history of use of sleep aids, problems of readiness for work after sleep and
history of dreams and nightmares.
 What the patient perceives that hinder and facilitate sleep.
Objective data
 Observe the patient whether he/she seems had adequate sleep (appearance), yawning
frequently, irritable and have short attention span. Are there dark circles and puffiness
around the eyes?
Pattern 6: Cognitive - Sensory-Perceptual Pattern
This pattern is focused on the ability to comprehend and use information and on the sensory
functions. Data pertaining to neurologic functions are collected to aid this process. Sensory
experiences such as pain and altered sensory input may be identified and further evaluated.
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I. Cognitive
Subjective data
 Ask the patient how his/her memory is changed because of the illness (if any) like
experiencing loss of memories.
 Ability of speaking, reading and writing and educational status and performance should
also be asked as a measure of cognitive function.
 Hearing problem Yes No explain _________
 Aid for hearing: Yes No
 Taste problem Yes No explain ________________
 Smelling problem Yes No explain _______
 Problem in sensation(skin)Yes No explain
 Pain assessed by PQRST/COLDSPA
Descriptions of pain
 Precipitating/aggravating,
 Quality,
 Radiation,
 Severity/Site
 Timing, including: onset, duration, and frequency
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Objective data
 Determine level of consciousness using Glasgow Coma Scale.
 Orientation to TPP:
 Glasgow coma scale :
• Ability to speak Yes No
• Ability articulate words Yes No
• The Glasgow coma scale for adults and older children is available below
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Glasgow coma scale
Response Score
Eyes open:
 Spontaneously 4
 To speech 3
 To pain 2
 Never 1
Best verbal response:

 Orientated 5
 Confused, disoriented 4
 Inappropriate words 3
 Incomprehensible sounds 2
 None 1
Best motor response:

 Obeys commands 6
 Localizes pain 5
 Withdraws (flexion) 4
 Abnormal Flexion posturing 3
 Extension posturing 2
 None 1
TOTAL 3-15
A total score
A. Score 3 or 4: patients have an 85% of chance of dying or remaining vegetative
B. Score <7: State of coma
C. Score <10: Semi-coma
D. Score above 11: patients have only a 5 to 10% likelihood of death or vegetative state and
85 % of chance of moderate disability or good recovery
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Mood assessment
 Observe the patient for the status of his mood, is he/she happy/pleasant, euphoric (feels
great joy, excitement, or well-being), depressed/sad, irritable (easily annoyed), labile
(frequently changing mood) or flat (no interest or excitement)?
Memory test
 Test the patient for short term and long-term memories. For short-term memory test, you
can tell him/her your name, back after 10 or 30 minutes, and ask him/her your name. For
long-term memory test by asking the patient something important event in his/her life in
the past one year. If the patient can remember either in short term or long term memory
test, his/her memory is intact otherwise not intact.
II. Sensory function

Subjective data
 Ask the patient history of visual problems, use of vision aids, hearing problems, use of
hearing aids, taste problems and smell problems.
Objective data
Examination of the eye
 Ask the patient to stand at 20ft (6m) away from
Snellen‘s chart. Using the Snell‘s chart examine
visual acuity of the right eye (OD), left eye (OS)
and both eyes (OU).
 If the patient cannot read Snell‘s chart ask him/her
to count finger and if cannot count, ask if he/she if
he/she can see hand motion. If the patient cannot
identify hand motion, flash light to check the
ability of the patient to distinguish light from dark
site. The higher the lower figure the poor the visual acuity of the eye. For example,
20/100 is to mean what a healthy eye is reading well at 100ft this patient‘s eye is reading
at 20ft.
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Visual field assessment

Visual field screening
 Ask the patient to look with both eyes into your eyes.
While you return the patient‘s gaze, place your hands
about 2 feet apart, lateral to the patient‘s ears.
Instruct the patient to point to your fingers as soon as
they are seen. Then slowly move the wiggling
fingers of both your hands along the imaginary bowl
and toward the line of gaze until the patient identifies
them. Repeat this pattern in the upper and lower
temporal quadrants.
 Normally, a person sees both sets of fingers at the
same time. If so, fields are usually normal.
Further visual field testing
 If you suspect a temporal defect in the left visual field,
for example, ask the patient to cover the right eye and,
with the left one, to look into your eye directly opposite.
Then slowly move your wiggling fingers from the
defective area toward the better vision, noting where the
patient first responds. Repeat this at several levels to
define the border.
Extra ocular muscle examination
 The movement of each eye is
controlled by the coordinated
action of six muscles, the four
rectus and two oblique muscles.
You can test the function of each
muscle and the nerve that
supplies it by asking the patient
to move the eye in the direction
controlled by that muscle. Ask
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the patient to look at these six different directions as shown on the following figure.
 If one of the six muscles is paralyzed, the eye will deviate from its normal position in
that direction of gaze and the eyes will no longer appear conjugate, or parallel.
Pupil examination
 Using pen light shine on one of the eyes to check for PERRLA (pupil equal, round, and
reactive to light and accommodation); normally both pupils should be equal in size,
round and reactive to light and accommodation.
 Further examination of the eye can be done with ophthalmoscope.
Examination of the Ear

 Auricle: inspect the auricle for any deformities, lumps, skin lesions and discharge.
Palpate for any tenderness.
Ear canal and drum

 Using otoscope inspect the ear canal and drum by straightening the ear canal, by
grasping the auricle firmly but gently and pull it upward, backward,
and slightly away from the head.
 Inspect the ear canal, noting any discharge, foreign bodies, redness
of the skin, or swelling. Cerumen, which can be yellow, flaky or
brown in color and sticky or even to dark and hard, which may
wholly or partly obscure your view in consistency.
 Swollen, narrowed, moist, pale, tender and reddened canal may be because acute otitis
externa.
Inspect the eardrum, noting its color and contour.
 Red bulging drum may be caused by acute purulent otitis media, and amber drum may
be of a serous effusion
Auditory acuity
 Test one ear at a time by asking the patient to occlude one ear with a finger or, better
still, occlude it yourself.
 Stand at 1 or 2 feet away, exhale fully (so as to minimize the intensity of your voice) and
whisper softly toward the unoccluded ear. Choose numbers or other words with two
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equally accented syllables, such as ―nine-four,‖ or ―baseball.‖ If necessary, increase the

intensity of your voice can be increased. To make sure the patient does not read your
lips, cover your mouth or obstruct the patient‘s vision.
Air and Bone Conduction
 If hearing is diminished, try to distinguish between conductive and sensorineural hearing
loss. Prepare a quiet room and a tuning folk with the frequency in the range of human
speech 300 Hz to 3000 Hz (usually 512Hz or 1024Hz).
Test for lateralization (Weber test).
 Place the base of the lightly vibrating tuning fork firmly on top of the patient‘s head
 Normally the sound is heard in the midline or equally in both ears.
 In unilateral conductive hearing loss, sound is heard in (lateralized to)
the impaired ear. May indicate
 acute otitis media,
 perforation of the eardrum, and
 obstruction of the ear canal, as by cerumen
 In unilateral sensorineural hearing loss, sound is heard in the good ear
Compare air conduction (AC) and bone conduction (BC) (Rinne test).
 Place the base of a lightly vibrating tuning fork on the mastoid bone,
behind the ear and level with the canal.
 When the patient can no longer hear the sound, quickly place the fork
close to the ear canal (facing the ‗U‘ of tuning fork forward) and ascertain
whether the sound can be heard again
 Normally the sound is heard longer through air than through bone
(AC > BC)
• Conductive hearing loss: BC = AC or BC > AC
• Sensorineural hearing loss: AC >BC
III. Pain
Subjective Data
 Does the patient complain any pain/discomfort, if so characterize by PQRST. For
severity a 10 point pain assessment scale can be used.
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Objective data
 If the patient has an acute pain, PR may be increased and there may be diaphoresis,
change in body position, grimacing, guarding, refusal to move body part and rubbing
body.
 However, if the patient has a chronic pain he/she may has flat facial expression, dull eye
appearance, crying, moaning or yelling.
Pattern 7: Self-Perception and Self-Concept

This pattern is focused on the person's attitudes toward self, including identity, body image,
and sense of self-worth. The person's level of self-esteem and response to threats to his or her
self-concept may be identified.
Subjective Data
 Try to determine the concern of the patient related to his/her health. Ask the patient to
describe oneself and to describe his/her feeling differently because of illness.
Objective Data
 How is the eye contact of the patient? Is he/she well confident to look at people around
and you? Is he well groomed or not? How is his mood? Is he well to control his
emotion? Is his/her tone of voice appropriate for the situation? Is his/her speech pattern
appropriate/coherent?
Pattern 8: Roles and Relationships

This pattern is focused on the person's roles in the country, community, work area or home
and relationships with others. Satisfaction with roles, role strain, or dysfunctional relationships
may be further evaluated.
Subjective data
 Ask the patient about employment status, weather actively working, retired or
unemployed.
 Does he/she have any disability?
 What is his/her primary role at home? At work? In the community?
 What is the effect of illness on his/her role?
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 What is his/her living arrangement? Living alone or with whom?

 Does he/she have any source of help?
 Are there problems affecting his/her health at work or home?
 History of possible genetic related diseases, like diabetes, hypertension, cancer, asthma
and others
Objective data
 Observe the interaction with family members and significant others. How is the flow of
visitors as per the local culture?
Pattern 9: Sexuality and Reproduction

This pattern is focused on the person's satisfaction or dissatisfaction with sexuality patterns
and reproductive functions. Concerns with sexuality may he identified. Objectively the
reproductive organ system should be undertaken as indicated.
Subjective Data
Female
 Ask her menstruation specific questions like date began, last cycle, length (how long it
bleeds), any problems associated with the period?
 Ask her also number of gravida, para, abortions and stillbirth. Is she fertile and pregnant
now?
 Does she usually perform breast self-examination (BSE) with certain time interval?
Male-Female
 Ask history of contraception use, undesirable side effects of the contraception method,
any problems associated with sexual activities (like pain/discomfort, burning), and effect
of illness on sexual activities. Address also history of STDs and any discharge.
Objective Data
Breasts:
 Examine breast for shape, symmetry, nipples condition, any discharge, palpable masses
and lymph nodes.
Male genitalia
 As indicated, perform testicular exam feel for any mass, swelling and texture.
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 Do penile exam for any masses, growth condition, lesions, foreskin retraction and
urethral opening. Pinching the glans penis examine for color and urethral discharge.
Inspect and palpate for inguinal masses and lymph nodes.
Female genitalia
 Inspect the labia for color, swelling and symmetry. Open the labia and inspect for color,
lesion and urethral discharge. Inspect also the vaginal opening for lesion, discharge,
hymen and signs of inflammation.
Pattern 10: Coping and Stress Tolerance

Assessment is focused on the person's perception of stress and on his or her coping strategies.
Support systems are evaluated, and symptoms of stress are noted. The effectiveness of a
person's coping strategies in terms of stress tolerance may be further evaluated.
Subjective Data
 Ask the patient any big changes/crisis in his/her life in last one or two years and how
overcome the crisis (coping mechanisms). Also, ask him/her the most helpful person,
common stressors in his life and experience of resent stress.
Objective data
 If the stress is acute, there might be sympathetic stimulation whereby, PR and BP are
increased and the patient become diaphoretic.
Pattern 11: Values and Belief
Assessment is focused on the person's values and beliefs (including spiritual beliefs), or on the
goals that guide his or her choices or decisions
Subjective Data
 Ask the patient what he/she values most and any change because of the illness. What is
also the goal of the patient in his/her life? Identify source of hope/strength for the patient
and significant religious persons in contact with the patient.
 What religious practices he/she usually undertake? Any alteration because of the illness?
 What is the perception of the patient regarding his/her relationship with God/Allah?
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Objective Data
 Observe the surrounding of the patient for the presence of religious articles, for the
practices of religious activities and visits from clergy.
Session Summary
Nursing assessment is the first step of nursing process, which has to be done for all patients on
admission to hospital. It involves the systematic collection of subjective and objective data with
the aim formulating nursing diagnoses.
The 11 Gordon‘s functional health patterns is holistic nursing assessment tool that is used by
nurses in patient assessment. Each of the pattern incorporated both subjective and objective
data.
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Session 4.3 Nursing Diagnoses

Session Description
This session is designed to equip trainees with knowledge and skills of constructing nursing
diagnoses. The trainees will be able to formulate various nursing diagnoses based on holistic
nursing assessment data.
Session Objectives
After completing this session, the trainees will be able to
 Describe nursing diagnoses
 Distinguish nursing diagnoses from medical diagnoses
 Describe the five types of nursing diagnoses
 Explain components of nursing diagnoses by type
 Identify collaborative problems
 Construct various kinds of nursing diagnoses
Introduction
 Transition from assessment to nursing diagnoses
Data Data Organizing Making

collection validation data in inferences
cluster
Writing nursing Consulting

diagnostic statement NANDA
list
During assessment, you gather, validate, organize data and finally you record and report
abnormal findings. In nursing diagnosis, you further analyze and synthesize (put together) the
information and come to some specific clinical judgment; you identify areas of positive
functioning, areas where there may be risk of problems and areas problems are existing.
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Definition of Nursing Diagnosis

Diagnosis means reaching at a definite conclusion regarding the patient‘s strengths and
human responses through utilization of nurses critical thinking .
Nursing diagnoses is a clinical judgment about individual, family, or community responses to

actual or potential health problems/life processes. (NANDA-North American Nursing
Diagnoses Association, 1996, p. 8).
 Nursing diagnoses provide the basis for selection of nursing interventions to achieve
outcomes for which the nurse is accountable.
 For the identified nursing diagnoses, nurses can legally prescribe definitive
interventions independently.
Nursing diagnosis versus Medical diagnosis
Exercise 3.1
What are similarities and differences between nursing diagnosis and medical diagnosis?
 Nursing diagnosis is the terminology used for a clinical judgment by nurses that
identifies the client‘s actual, risk, wellness, or syndrome responses to a health status.
 Medical diagnosis is the terminology used for a clinical judgment by physicians that
identifies or determines specific pathologic conditions.
Similarities of nursing diagnoses and medical diagnoses
1. Both are diagnostic process Need professionals cognitive, interpersonal, and
psychomotor skills;
2. Involve critically analysis of assessment data;
Table 5. Comparison of nursing diagnoses and medical diagnoses
Nursing diagnosis Medical diagnosis
 Within the scope of nursing practice  Within the scope of medical practice
 Identify responses to health and illness  Focuses on curing pathology
 Can change from day to day  Stays the same as long as the disease
is present
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Types of nursing diagnoses

There are five types of nursing diagnoses:
1. Actual nursing diagnosis
2. Risk nursing diagnosis
3. Possible nursing diagnosis
4. Wellness nursing diagnosis
5. Syndrome nursing diagnosis
1. Actual
An actual nursing diagnosis indicates that a problem exists, and is composed of the diagnostic
label, related factors, and signs and symptoms.
Example: Impaired Skin Integrity related to prolonged pressure on bony prominence as
manifested by (AMB) Stage II pressure ulcer over coccyx, 3 cm in diameter.
2. Risk and High-Risk Diagnoses
A risk or / and high risk diagnoses is defined as ―a clinical judgment that an individual,
family, or community is more vulnerable to develop the problem than others in the same or
similar situation. A risk diagnosis is one that is likely to develop if you do not intervene to
prevent it.
Example: Risk for Impaired Skin Integrity related to inability to turn self from side to side in
bed.
3. Possible Nursing Diagnosis
―Possible nursing diagnoses are statements that describe a suspected problem requiring
additional data. A possible diagnosis may state a ―hunch‖ or intuition by the nurse that cannot
be confirmed or eliminated until more data have been collected. A possible diagnosis is
composed of the diagnostic label and related factors.
Example: Possible Self-Esteem Disturbance related to recent retirement and relocation.
4. Wellness Diagnoses
A wellness diagnoses is described as ―a clinical judgment about an individual, group, or
community in transition from a specific level of wellness to a higher level of wellness
proceeded by the phrase ‗potential for enhanced‘.‖ These types of diagnostic statements do
not contain related factors, but rather contain the label only.
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For example a client who is neither overweight nor underweight tells the nurse that she knows
she could improve her diet in some ways. She states that she eats only a small number of
vegetables and fruits and thinks that the fat content of her diet is probably high. She expresses
a desire to know more about how to improve her diet. The nurse would make a wellness
diagnosis as follows
Example. Readiness (Potential) for Enhanced Nutrition.
5. Syndrome Diagnoses
The Syndrome diagnoses ―comprise a cluster of predicted actual or high risk nursing
diagnoses related to a certain event of situation.‖ (Carpenito-Moyet, 2010, p. 18). This type of
diagnostic statements only contain the label (no related to or m/b).
NANDA list has syndrome diagnoses:
Examples. Rape Trauma Syndrome, Disuse Syndrome, Post-Trauma Syndrome, and Impaired
Environmental Interpretation Syndrome.
Components of nursing diagnosis
1. Diagnostic label which contains diagnostic focus and descriptive words
The diagnostic focus and judgment/modifier are essential components of a nursing diagnosis.
The Diagnostic Focus
The diagnostic focus is the principal element or the fundamental and essential part, the root, of the
diagnostic concept. It describes the ―human response‖ that is the core of the diagnosis. The diagnostic
focus may consist of one or more nouns. When more than one noun is used (for example, Activity
intolerance), each one contributes a unique meaning to the diagnostic focus, as if the two were a single
noun; the meaning of the combined term, however, is different from when the nouns are stated
separately. Frequently, an adjective (Spiritual) may be used with a noun (Distress) to denote the
diagnostic focus Spiritual Distress.
Modifier
A descriptor or modifier limits or specifies the meaning of the diagnostic focus. The diagnostic focus
together with the nurse‘s judgment about it forms the diagnosis. Modifiers may include impaired,
altered, decreased, possible, ineffective, and high risk.
Examples
Modifiers Diagnostic Focus
Ineffective Airway clearance
Risk for Overweight
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Readiness for enhanced Knowledge

Impaired Memory
Ineffective Coping
Each nursing diagnosis has a label with a clear definition. It is important to state that merely
having a label or a list of labels is insufficient. It is critical that nurses know the definitions of
the diagnoses they most commonly use. In addition, they need to know the ―diagnostic
indicators‖ – the data that are used to diagnose and to differentiate one diagnosis from
another.
These diagnostic indicators include defining characteristics and related factors or risk factors.
2. Etiology/ Related factors
Related factors are an integral component of all problem-focused nursing diagnoses. Related
factors are etiologies, circumstances, facts, or influences that have some type of patterned
relationship with the nursing diagnosis (e.g., cause, contributing factor). Risk factors are
influences that increase the vulnerability of an individual, family, group, or community to an
unhealthy event (e.g., environmental, psychological, genetic).
o The related cause or contributor to the problem can be:
• Pathophysiological,
• Treatment related
• Maturational
o Related factor is joined to the next part by the phrase related to related to ―r/t‖
3. Defining characteristics:
Defining characteristics are observable cues/inferences that cluster as manifestations
of a diagnosis (e.g., signs or symptoms). An assessment that identifies the presence of
a number of defining characteristics lends support to the accuracy of the nursing
diagnosis
• Defining characteristics joined to the first components with the connecting phrase ―as
evidenced by‖ (AEB).
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Rules for Writing Diagnostic Statements for Actual and Risk Nursing Diagnoses
1. For Actual Diagnoses- Use a three part statement using the PRS format (address the Problem,
Related factors (cause), and Signs and Symptoms. Use the words ―related to‖ to link the problem and
the related factor. Add, ―As evidenced by‖ to state the evidence that supports that diagnosis is present.
Component Label related Related AEB Defining characteristics
s to (r/t) factors
Example Activity r/t immobility AEB report of fatigue or
intolerance weakness and exertional
dyspnea
2. For High Risk Nursing Diagnoses- Use a two-part statement, using ―related to‖ to link the
potential problem with the risk factors present.
Components Label related to etiology/ related factors
(r/t)
Example Risk for Activity intolerance r/t immobility
High risk for impaired skin r/t confinement to bed
integrity
Avoiding Errors When Writing Diagnostic Statements

 Don‘t write the diagnostic statement in such a way that it may be legally incriminating.
For example: Incorrect- High risk for injury related to lack of side rails on bed.
Correct- High risk for injury related to disorientation.
 Don‘t state the nursing diagnosis using medical diagnostic terminology; focus on the
person‘s response to the medical problems.
For example: Incorrect- Mastectomy related to cancer.
Correct- High Risk for Self-concept Disturbance related to effects of
mastectomy.
 Don‘t rename a medical problem to make it sound like a nursing diagnosis.
For Example: Incorrect: Alteration in Haemodynamics related to hypovolemia.
 Don‘t state the nursing diagnosis based on a value judgment.
For example: Incorrect- Spiritual Distress related to atheism as evidenced by
statements that she has never believed in God.
 Don‘t state two problems at the same time.
For example: Incorrect- Pain and Fear related to diagnostic procedures.
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Group Activities
Exercise 3.2: Identifying correctly stated nursing diagnosis

A. Put a ―C‖ in front of each nursing diagnosis that is stated correctly.
1.______High risk for constipation related to confinement to bed.
2.______High risk for impaired skin integrity related to lack of .positioning by nurses.
3.______Pain and anxiety related to surgery.
4.______Hopelessness related to progressive disease process.
5.______Spiritual distress related to atheism
6.______Mastectomy related to cancer
7.______Impaired skin integrity related to heel pressure and rubbing on sheets
8.______Altered haemodynamics related to hemorrhage
9.______Impaired physical mobility related to joint pain as evidenced by reports of pain
limiting movement of joints.
10._____Imbalanced nutrition: less than body requirements related to inability to take food
by mouth as evidenced by patient‘s BMI = 16Kg/m2.
Collaborative problems
Nurses do also make collaborative diagnoses. Collaborative problems are defined as

physiologic complications monitored by nurses to assess changes in client status.
Collaborative problems are managed through the use of interventions prescribed by other
health care practitioners and/or nurses. Usually collaborative problems involve alterations in
organ and/or system function or structure (e.g., myocardial infarction, duodenal ulcer).
Collaborative problems begin with the label Potential Complication (PC) followed by the
situation—for example, Potential Complication: Hemorrhage.
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Group Activities
Exercise 3.3: – Differentiating nursing Diagnoses from Collaborative Problems
Instruction: Place ―N‖ in front of nursing diagnoses and place ―C‖ in front of the
collaborative problem.
1. _____ Potential complication: hemorrhage related to clotting problems

2. _____ Ineffective airway clearance related to copious secretions as evidenced by crackle
sound on auscultation over the left lower lobe of the lung.
3. _____ High risk for injury related to generalized weakness.
4. _____ Fluid volume deficit related to insufficient fluid intake due to sore throat as
evidenced by dry oral mucosa and patient verbalization of weakness.
5. _____ Impaired skin integrity related to unrelieved pressure point as evidenced by ulcer
on the right heal which is 3cm in length.
6. _____ Potential complication: cardiac arrhythmias related to hyperkalemia
7. _____ Risk for activity intolerance related to prescribed prolonged bed rest.
8. _____Potential complication: Increased intra-cranial pressure related to concussion
Summary
There are five major types of nursing diagnoses. The actual nursing diagnoses and the risk nursing
diagnoses are the most widely identified diagnoses by nurses. The actual has three parts
incorporating PES formats, whereas the risk nursing diagnoses is two part nursing diagnoses. Nurses
do also have identifying collaborative problems.
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Session 4.4. Planning: Outcome Identification
Session Description
This session is designed to equip trainees with knowledge and skills of developing plan of
care through priority setting, goal setting, and identification of expected outcomes.
Sessions Objectives
By the end of this presentation trainees will be able to:
 Define planning and outcome identification
 Prioritize nursing diagnoses
 Set goal for identified nursing diagnoses
 Write statement of client centered and SMART expected outcomes
 Develop individualized plan of nursing care for a patient
Introduction
Planning is a set of actions that the nurse will implement to resolve existing and potential
health problems identified through nursing assessment and formulation of nursing diagnosis.
It is one of the critical steps of the nursing process.
It is about ―What are we going to do about it?‖, ―What is the best strategy?‖, and ―What do we
want to happen?‖
Is a record of nursing interventions that will address the identified problems; it‘s a legal
document that identifies the care to be given, and it shows who planned and gave that care, it
aids continuity of care, it is a logical and systematic flow of ideas from the initial assessment
to the final evaluation (Rush and Fergy, 1996).
Types of planning
 Initial planning: comprehensive plan of care on admission assessment
 Ongoing planning: continuous updating of the client‘s plan of care.
 Discharge planning: critical anticipation and planning for the client‘s needs after
discharge
Major activities in planning
1. Setting priorities
2. Setting goals
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 Globally written statement describing the intended change in the client‘s behavior,
response, or outcome
3. Outcome identification
4. Determining nursing interventions
5. Recording the plan of care
Establishing Nursing Priorities

After formulating specific nursing diagnoses, the nurse should establish the priorities of the
diagnoses by reviewing
 What problems need immediate attention, ranking them in order of importance and
urgency of the problems (it is about analysis of the identified nursing diagnoses of
what problems need immediate attention)
 What problems have simple solutions
 What problems must be done by nurses or referred
Guidelines for Setting or establishing Nursing Diagnoses Priorities:
o Use the principle of ABC‘s (airway, breathing, circulation)
o Use Maslow‘s hierarchy of needs (here physiological needs are of greatest priority and
must be met first. Once they are met, the client is more willing and able to seek
fulfillment of higher- level needs.)
o Take in to account the concern of the patient
o Usually actual problems take precedence over potential concerns.
o Priorities of the nursing diagnosis by ranking them in order of implication (importance
and urgency) can be
 High ( emergency, life-threatening )
 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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Table 6. Prioritizing Nursing Diagnoses with Accompanying Nursing Implications

(Importance or Urgency)
Priority Diagnoses Nursing implications
High Ineffective breathing pattern  Assess breath sounds
 Auscultate lungs
 Monitor vital signs
 Reposition client
Moderate Risk for impaired skin  Perform comprehensive skin assessment
integrity  Keep skin clean and dry
 Provide turning schedule
Low Ineffective coping  Assist to identify problem
 Encourage keeping daily journal
 Teach client strategies for expressing
feelings
Breakout
If you have someone with the following problems, which problem would you need to treat
immediately?
A. Diarrhea related to gastrointestinal irritation as evidenced by passage of loose stool 3-4
times/day
B. Ineffective breathing pattern related to respiratory muscle fatigue as evidenced by use of
accessory muscles to breathe
C. High risk for fluid volume deficit related to persistent loss of loose stool.
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Fig 4.4.1. Maslow‘s Hierarchy of Human Needs (as one method for setting priority)
Table 7. Ranking Nursing Diagnoses, Using Maslow’s Hierarchy of Human needs

Nursing Diagnosis Maslow’s hierarchy of Rank
needs
Anxiety related to Safety and security Moderate
hospitalization
Ineffective coping Self-esteem Low
Ineffective airway clearance Physiologic High
related to excessive secretion
Setting Goals
Goal is a broad statement derived using the problem statement in the nursing diagnoses. It
should indicate the identified health problem has been resolved or prevented. Goals establish
appropriate evaluation criteria to measure the effectiveness of nursing interventions for the
resolution of the client‘s individual nursing diagnoses.
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The purpose of writing goals and expected outcomes:

• Provides direction for individualized nursing interventions
• Assist the patient in resolving the diagnosed problems
• Promote client involvement
• Evaluate the effects of nursing care as a part of health care
• Establish evaluation criteria to measure the effectiveness of the nursing care plan (as,
goal is an aim, intent, or an end).
• Write client-centered goals instead of nursing goals has been recognized as an
effective method of writing goal statements
Examples of goals
• Reducing anxiety before undergoing surgery
• Maintenance of a patent airway
• Relief of pain
Identify Patient Expected Outcomes

Outcome identification describes the specific data that tell the nurse that the broad goal has
been achieved and is the basis of evidence that tells patient problems have been prevented,
corrected, or controlled.
Writing client-centered goals (what the client is expected to achieve) instead of nursing goals
(what the nurse aims to achieve) has been recognized as an effective method of writing goal
statements.
Well-identified outcomes help to determine specific interventions and to evaluate
effectiveness of care.
Types of expected outcomes
Goals should be established to meet the immediate, as well as long-term prevention and
rehabilitation, needs of the client.
1. Short-term outcome (STO):- are those that can be met relatively quickly, often in less
than a week, or in a short period. It is usually focused on the etiology.
2. Long term outcome (LTO):- are those that are to be achieved over a longer period of
time, often weeks or months. requires more time. LTOs usually focused on the problem.
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Often you will set several short-term goals in order to reach a long-term goal. Long-term
goals may also include goals that are ongoing (i.e., goals that are to be accomplished
every day). These types of long-term goals are usually stated by using the words ―every
day‖ or ―will maintain.‖ Note the examples below:
 ― Tigist will dress herself every morning.‖
 ―Ato Daniel will maintain a fluid intake of 2000 mL a day.‖
Example of STOs and LTOs
Nursing diagnoses: Constipation related to confinement to bed as evidenced by client‘s
verbalization of evacuation of scanty, hard stool less frequently than the usual.
Short-Term Outcome Long-Term Outcome
――Fatuma will demonstrate how to hold her ―Fatuma will demonstrate how to dress, feed,
newborn infant by tomorrow (6/7).‖ and bathe her newborn infant by discharge
(15/7).‖
―Ato Hailu will turn and reposition himself ―Ato Hailu will maintain good skin integrity
from side to side every 2 hours. while he is on bed rest.‖
―Ato Sium will demonstrate how to change ―Ato Sium will demonstrate how to give
his colostomy bag within 2 days (by 7/7).‖ complete colostomy care according to
Hospital standards by discharge (by 7/21).‖
―Tekle will walk with crutches with ―Tekle will walk unassisted with a crutch by
assistance by 3 days after surgery (by 7/28).‖ discharge (by 8/10)/‖
Components of expected outcomes

 Subject: the person expected to achieve the outcome
 Verb: actions that the person must take to achieve the outcome
 Choosing verbs that measure progress will avoid ambiguity and focuses on the
behavior that will measure progress.
 Use measurable verbs in order to be a specific. Verbs like -identify, describe,
perform, relate, state, list, verbalize, hold, demonstrate, share, express, has an
increase in, has a decrease in, has an absence of, exercise, communicate, cough,
walk, discuss, etc.
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 Non Measurable Verbs (Do not Use) include -know, understand, appreciate, think,
accept, and feel.
 Condition: circumstances under which the person performs the actions
 Performance criteria: how well is the person to perform the actions
 Target time: by when is the person expected to able to perform the actions,
Example: Ato Hailu will walk with a crutch at least to the end of the hall and back by Friday
(May 5, 2017)
Subject: Ato Hailu Verb: will walk Condition: with a crutch
Criteria: at least to the end of the hall and back Specific time- by May 5, 2017
Guidelines of writing nursing expected outcomes

 Be realistic in establishing goals: when establishing realistic goals, one must know the
resources of the health care facilities available to reach expected outcomes in a timely
manner.
 Whenever possible, set outcomes mutually with the client and others involved in his/her
health care. It ensures agreeable goals to all key players in the plan.
 Be sure that the outcomes describe a client behavior or action that demonstrates the
desired improvement, control, or resolution of the identified nursing diagnoses.
o One expected outcome should address only one behavioral response
 Follow the rules for writing outcome statements.
 Using measurable, observable verbs to describe actions or behaviors that you expect to
see
Writing more than one outcome statements

Sometimes there may be more than one outcome criteria to prevent, control, or resolve a
problem. In these cases, the outcomes probably relate to the causes, or related factors, of the
problem rather than to the problem itself. However, make sure at least one of the outcomes
should demonstrate resolution, improvement, or control of the nursing diagnosis.
Example
Nursing Diagnosis: Obesity related to poor eating habits and minimal physical activity as
evidenced by BMI of 32 kg/m2.
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Goal: LTG: The client will attain a normal BMI.

Outcome #1: Client will verbalize his feelings about changing eating habits a week after
counseling session.
 This outcome relates to the problem of ―poor eating habits, which is a causative factor
Outcome # 2: Client will attend daily exercise classes beginning from May 6, 2017.
 This outcome relates to the problem of ―minimal physical activity,‖ which is a
causative factor.
Outcome #3: Client will lose half kilo per week beginning May 20, 2017 until he weighs
between 60 and 70 Kg.
 This outcome demonstrates a direct resolution of the problem of obesity
Steps in identifying Outcomes from Nursing Diagnoses

1. Look at first part of the nursing diagnoses itself or problem statement (the word or words
before ―related to‖)
Example- High risk for impaired skin integrity related to immobility.
Now restate the first part in a statement that describes improvement, control, or absence of
the problem.
Example- The person will demonstrate no signs of skin irritation or breakdown.
2. In modifiable related factors, identify outcomes that state the related factor (s) is/are
resolved, prevented or controlled.
Example: The patient will use safety and comfort devises (pillow, cotton ring, air ring)
over bony prominence areas as of tomorrow.
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Exercise
Instruction: Choose the outcomes that are written correctly below and state what is
wrong with the statements that are written incorrectly.
1. Tesfaye will know the four basic food groups by Tahsas 1, 2009.
2. Wrt. Saba will demonstrate how to use her walker unassisted within 3 days.
3. Ato Lemma will improve his appetite by Meskerm 11, 2010
4. Tullu will list the equipment needed to change sterile dressing by 09/05/2009 EC.
5. David will walk independently in the hall the day after surgery.
6. Wrt. Genet will understand the importance of maintaining a salt-free diet.
7. Wrt. Tadeletch will appreciate the importance of exercise for pt. with diabetes.
8. Ato Sium will feel less pain by Thursday (Jan 10, 2012).
Summary
In the plan of care nurses should prioritize list of nursing diagnoses, set goals and expected
outcomes.
Goals are broad statements that states what the client will attain at the end. Whereas,
outcomes are action-oriented specific statements that the patient is expected to attain after an
implementation of nursing interventions.
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Session 4.5. Planning: nursing intervention/instruction
Session description
This session is the continuation part of care plan that focuses on nursing intervention with
nursing orders/instructions.
Enabling objectives
By the end of this session, trainees will be able
 Describe nursing intervention
 Describe types of nursing intervention
 Write nursing instructions/orders
Introduction
A nursing intervention is an action planned by a nurse that helps the client to achieve the
results specified by the goals and expected outcome. It is important to identify as many
nursing interventions as possible so that if one proves to be unsuitable, others are readily
available.
The interventions are prioritized according to the order in which they will be implemented.
Nursing intervention also facilitates communication between care givers and actively involves
the client and family.
Nursing interventions could be carried out through assessing, teaching, counseling, consulting,
and determining problem specific interventions.
The three categories of nursing interventions are:
1. Independent interventions: interventions that require no supervision or directions
from others
Example: Demonstrating client about insulin self-injection. This intervention do not
require any physicians order
2. Interdependent interventions: are type of interventions that are implemented in a
collaborative manner by the nurse with other health care professionals
Example: Nursing interventions in operation theatre with other health care team.
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3. Dependent interventions: - are based on the interaction or written orders by other

health care provider.
Example: Administering a medication, preparing a client for different procedure …
Nursing Instructions/Orders
After setting the goals and planning the appropriate nursing interventions, the nurse writes
nursing orders to communicate the exact nursing interventions that are to be implemented for
the client. A nursing order is a statement written by the nurse that is within the realm of
nursing practice to plan and initiate. These statements specify direction and individualize the
client‘s plan of care.
Consider the following when writing nursing instructions:
 What to look for (assessing, or seeing)
 What to do
 What to teach or counsel
 What to record
Elements of nursing order/instruction

 Date: the date on which the order is written. This information is updated to reflect
review and revision.
 Action Verb: directs the nurses‘ action. Example: Explain, demonstrate, auscultate
 Detailed description: precisely clarifies what the nurse‘s action will be. This phrase
explains what, when, where, and how.
 Time frame: Describes when, how often, and how long the nursing order is to be
performed.
 Signature: Indicates the nurse who writes the order. This element implies legal and
ethical accountability.
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Examples of nursing interventions and instructions

Nursing Action Nursing instructions
Ambulate patient  Ambulate patient the length of the hall using the
walker 3 times a day
 Monitor ability to use walker appropriately and record
response daily on flow sheet.
Provide for periods of  Do not wake up the patient from midnight to 7 am
uninterrupted rest  Allow the patient to rest from 1 pm to 3 pm (no
visitors)
 Record the patient‘s perception of hours slept
SESSION SUMMARY
Nursing intervention is a part of nursing care plan. For ease execution nursing interventions need to be
written in nursing instruction or order forms using action verbs, dated and signed.
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Session 4.6. Implementation
Session Description
This session is designed to equip trainees with knowledge; skill and the right attitude that will
enable them implement nursing care effectively and efficiently according to predetermined
plan of care
Sessions Objectives
By the end of this presentation trainees will be able to:
• Define implementation of nursing care
• Put plan of care in to action using various implementation methods
• Record the actual implementation
Introduction
Describes the nursing behavior in which the actions necessary for achieving the goals and
expected outcomes of the nursing care are initiated and completed.
It is the fifth step in the nursing process is 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.
 To complete implementation effectively, the nurse must be knowledgeable about:
1. Types of interventions,
2. Specific implementation method and
3. Implementation process
The nurse carries out the nursing care plan by using several implementation methods
to achieve the goals of nursing care. The nurse is responsible for knowing when one of
these methods is preferred over another.
The nurse is responsible to know and determine the preferred method
1. Assisting with ADLs
2. Counseling- to use problem solving process and manage problems
3. Teaching- used to present correct principles, procedures, and techniques of health care
to clients, to inform clients about their health status and refer clients to social resources
4. Preventing Adverse Reactions- when providing care and applying correct techniques
in administering care and preparing the client for special procedures.
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5. Compensating for Adverse Reactions- Nursing actions that compensate for adverse
reactions reduce or counteract the reaction
Ex. Understanding the known potential side effects of the drug, Assessing the client
side effects, or initiation life saving measures
Implementation process
i. Reassessing the client
ii. Delegating interventions
iii. Direct care
iv. Supervising the delegated care
v. Documenting nursing activities
Implementation of nursing interventions include-

 Performing, assisting or directing the performance of objective of daily Living
(ADL). These include activities performed in the course of a normal day that
include ambulating, eating, dressing, bathing, brushing the teeth, grooming and
toileting , .
 Coordinate activities of patient, family, significant others, nursing team members,
and other health team members.
 Delegate specific nursing interventions to other members of the nursing team as
appropriate.
o Consider the capabilities and limitations of the members of the nursing team.
o Supervise the performance of the nursing interventions.
 Counseling and teaching the client or family
 Providing direct care.
 Delegating, supervising and evaluating the work of staff members
 Record and exchange relevant information of the patient's responses to the nursing
interventions for the client‘s continued care precisely and concisely.
To implement nursing interventions clinical decision making (requires knowledge),
interpersonal (communication), and psychomotor skills are necessary. Nursing interventions
are written in the nursing care or communicated orally and following implementation, the
214
nurse documents the interventions and the client‘s response to the treatment on the appropriate
record.
SESSION SUMMARY
Implementation is the fifth step in nursing process that puts plan of nursing care in to action. The nurse
uses psychomotor, interpersonal and critical thinking skills during implementation of nursing care.
Implementation also involves reporting and documentation.
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Session 4.7. Nursing evaluation

Session description
This session is designed to equip trainees to evaluate plan of care with the aim of determining
whether goal has met, partially met, or not met.
Sessions Objectives
By the end of this presentation participants will be able to:
• Collect necessary data for verification of attainability of the goals
• Rate whether the stated goals were met, or needs of changes
• Compare the relationship between expected outcomes and goals of care
• Assess the function evaluation plays in improving the quality of client care
• Analyze evaluation as a continual process.
• Evaluate the overall interrelated components of nursing process
Introduction
Determines the patient‘s responses to the nursing interventions and the extent to which the
outcomes have been achieved. or the measurement of how well the patient achieved the
outcomes specified in the plan of care.
Is the regular review of the effect of nursing interventions and the treatment regimen on the
patient‘s health status and expected health outcomes, or a systematic measures the client‘s
response to nursing actions and the client‘s progress toward achieving the goals and expected
outcomes (consideration of reviewing ADOPI ―Did it work? Why didn‘t it work?‖, ―Did we
end up where we wanted to?‖, and ―Are we done or is there more? What‘s the problem?‖)
The purpose of the nursing care evaluation is:
 Assist the client in minimizing or resolving actual health problems
 Preventing the occurrence of potential problems, and
 Promoting the maintenance of a healthy state
 Measure how well the patient has achieved desired outcomes
 Identify factors contributing to the patient`s success or failure
 Modify the plan of care, if indicated.
Evaluation is done primarily to determine whether a client is progressing—that is,
experiencing an improvement in health status. It is not an end to the nursing process, but
rather an ongoing mechanism that assures quality interventions.
216
Evaluation of the goals of care determines whether this purpose was accomplished. There are
different degrees of goals attainment. If the client‘s response matches or exceeds the expected
outcome, the goal is met. If the client‘s behavior begins to show change but does not yet met
criteria set, the goal is partially met. If there is no progress, the goal is not met.
Steps used to objectively evaluate the degree of success in achieving a goal:-

1. Examine the goal statement and identify the client behavior or response
2. Assess the client for the presence of that behavior or response
3. Compare the established expected outcome with the behavior or response
4. Judge the degree of agreement between expected outcome and the behavior or
response
a. Goal is Met- if the client‘s response matches or exceeds the outcome criteria.
b. Goal is partially Met- If the client‘s behavior begins to show changes, but
does not yet meet specified criteria.
c. Goal is Not Met - If there is no progress
5. Ask questions if there is no agreement.
N.B. When goals have been partially met or when goals have not been met, two conclusions
may be drawn:
• The care plan may need to be revised, since the problem is only partially resolved OR
• The care plan does not need revision, because the client merely needs more time to
achieve the previously established goals. So the nurse must reassess why the goals are
not being partially achieved.
During evaluation, the following questions should be considered:
• Have the goals of the nursing care plan been achieved, If not, why not
• Were the goals realistic
• Was the patient committed to the goals
• Was there enough time to achieve the goals
• Did other problems arise that impeded progress
• Were interventions consistently performed as prescribed
• Have any new problems developed that have not been addressed
217
Example
Nursing Diagnosis: - Knowledge deficit regarding insulin therapy related to inexperience
Goals: client will self- administer insulin by 12/18
Outcome criteria
 Client prepares insulin dosage in syringe by 12/17
 Client demonstrates self – injection by 12/18
Evaluation finding (Client response)
 Client prepared accurate dosage in syringe on 12/17
 Client administered morning insulin dosage; self – injection was correctly performed on
12/18
Judgment: Goal achieved, no need to revise this part of care plan
Methods of Documentation
SESSION SUMMARY
Evaluation is the final step of nursing process whereby the implemented nursing care is
measured against the pre-determined goal and expected outcomes. Based on which judgment
can be made as goal is met, partially mate or unmet.
218
References
1. DeLaune SC, K.Ladner P. Fundamentals of Nursing: Standards and Practice
Delmar/Thomson Learning; 2002.
2. Wilkinson JM, Treas LS, Barnett K, Smith MH. Fundamentals of Nursing.
Philadelphia: E.A. Davis Company; 2016.
3. Characteristics of the Nursing Process Nursing Process: Act for Libraries; 2017.
Available from: http://www.actforlibraries.org/characteristics-of-the-nursing-process-
nursing-process/.
4. Wikipedia. Nursing Process. Available from:
https://en.wikipedia.org/wiki/Nursing_process#cite_note-8.
5. Berman A, Snyder SJ, Kozier B, Erb G. Fundamentals of Nursing: Concepts, Process,
and Practice Julie Levin Alexander; 2008.
6. Bate's B. A guide to physical examination and history taking.
7. Berman A, Snyder SJ, Kozier B, Erb G. Fundamentals of Nursing: Concepts, Process, and
Practice Julie Levin Alexander; 2008.
8. DeLaune SC, K.Ladner P. Fundamentals of Nursing: Standards and Practice
Delmar/Thomson Learning; 2002.
9. Cox‘s Clinical applications of nursing diagnosis. Suzan A newfield
10. Fundamentals of Nursing. Standards and practice, 2nd edition. Sue C. DeLaune and
Patricia K. Ladner
11. Nursing Process. Hammoud Hospital University Medical Center Staff Development
Department. Mrs. Rana Kachouh, BSN, DESSS taff Development Coordinator
12. Mrs. Rana Kachouh, BSN, DESS Staff Development coordinatorhammoud Hospital
University Medical Center Staff Development Department
13. NANDA. Nursing diagnoses. Definitions and classification , 2015-2017
14. Fundamentals of nursing. 2nd edition , Carpenito-Moyet, 2010.
219
Annexes
Annex 1. Example of nursing service managerial structure
Hospital Board
Chief Executive
Director
Nursing
Director
vice nurse vice nurse

vice nurse director
director director
Emergency
Inpatient Outpatient
Head Nurse A Head Nurse B Head Nurse A Head Nurse B Head Nurse B Head Nurse B
Shift Leader A Shift leader A Shift Leader A Shift Leader A Shift Leader A Shift Leader A
Staff Nurse Staff Nurse Staff Nurse Staff Nurse Staff Nurse Staff Nurse
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Annex 2: Nurse Director Job description
Job Title: - Nurse Director
Department: -
Report to: - Chief Executive Director
Employment type: - Regular
Education level: - Degree/Master/PHD
Summary of service: the matron is responsible for setting the direction for the delivery of high
quality, cost efficient nursing care, which includes the nursing overseeing the nurse service‘s
fiscal management and patient care units. As the leader of a nursing service, the matron, also
known as the nurse director, is the link between nursing and hospital administration, physician
leadership and the human resource department. The nurse director participates in senior level
decision-making and the strategic planning of the hospital in order to ensure that hospital
initiatives are implemented across the patient care units.
Essential job responsibilities
Leadership
- Establishes a model of nursing practice, guided by comprehensive knowledge of current
nursing theory and practice, and ensures its successful implementation to improve nursing
services.
- Provides visible leadership in a continuous manner to improve learning, performance and
quality, while also promoting a clear sense of direction in accordance with the mission and
objectives of the hospital.
- Is responsible for creating a work environment within the nursing service that inspires high
morale, encourages teamwork, stimulates innovation, provides quality care, and increases
staff retention.
- Attends hospital meetings and effectively communicates patient care issues to the senior
management level of the hospital.
- Demonstrates knowledge and skills in strategic planning and uses these skills to advance the
quality of nursing services and to integrate the hospital‘s goals and objectives into the
nursing service goals.
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Quality and process implement

- Demonstrates knowledge and skill in quality improvement and uses these concepts to
administer best practices across the nursing service.
- Reviews and develops systems which optimize department efficiency and improve patient
care.
- Collaborates effectively with other departments within the hospital to develop systems that
solve issues or problems which are identified by the management team or are raised by the
nursing staff.
- Establishes standards of care and nursing policies to ensure that nursing protocols and
procedures are appropriate and evidence-based.
- Ensures that all regulatory standards are met across the nursing service.
- Approve all food, laundry and cleaning quality of service.
Staff management and development
- Ensures that policies and procedures are in place to hire, orient, develop, reward and
discipline staff.
- Ensures that nursing directors and nurse managers are aware of the policies and that they are
implemented fairly.
- Develops the nursing management staff to ensure that they have the skills to function at a
level necessary for the efficient operation of the hospital.
- Act as a role model.
- Assists in the development of teaching and training materials for all nursing care staff.
Fiscal management
- Demonstrates knowledge and skill in developing and operating capital budgets.
- Monitors budgetary performance to ensure that all patient care units are within budget.
- Develops and implements manpower planning strategies, including creating guidelines for
the use of agency nurses and other external assistance as needed.
Supervise to: nurse supervisor
Benefit package’
1. Monthly salary; Based on the government policy
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2. Other payments;
3. To facilitate the work done by matron:
4. Position allowance:
Name of Nurse_______________ Signature __________date __________________
Annex 3. Head nurse job description
Job Title: - Head nurse
Department:-
Report/accountable to: - Nurse Director
Employment type: - Regular
Educational level: - Degree/Master
Summary of jobs: - head nurses direct the performance of nursing functions on their unit,
consistent with the philosophy, goals, objectives, and standards of care in the nursing Service.
They structure their activities to anticipate and respond to events, in order to ensure that the
patients on their unit receive optimum care. Each manager is responsible for a defined area and
must collaborate with others to achieve the best care for their patients. In order to achieve the
hospital‘s goals, nurse managers are a direct link between the hospital‘s strategic objectives and
the staff on their unit.
Essential job responsibilities
Leadership
- Provides direction and leadership to nursing staff, ensuring quality and patient-
focused care.
- Establishes systems/processes that ensure effective unit operations.
- Demonstrates a positive, supportive attitude toward patients, families and staff.
- Attends all departmental and committee meetings and activities to share the unit‘s
perspective.
- Acts as a liaison between staff, the matron and the hospital.
Fiscal management
- Manages the unit‘s budget by staffing within budgeted employee levels while
maintaining staff to patient ratios. Creates staff work schedules based on the budget.
- Responsible to the cost effective utilization of supplies and equipment.
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- Maintains ward statistics pertaining to the unit‘s admissions, discharges, mortality
and staffing.
- Ensure all food, laundry and cleaning quality and availabilities of service.
219
Unit objectives
- Responsible for ensuring that the unit is clean and orderly.
- Establishes systems to ensure effective utilization and availabilities of equipment and
supplies.
- Ensures adequate staffing on all shifts, verifying that all patients have an assigned
nurse.
- Ensures that nurses and students are assigned appropriate patients.
- Manages the flow of patients by coordinating admissions, and transfers in a time
manner.
- Makes rounds on the unit to assess the adequacy of staff assignments and the
availability of adequate equipment and supplies.
- Maintains an inventory of supplies and equipment for the unit.
- Ensures adequate stock levels, and makes timely requisitions or repairs.
Human resource management

- Holds all staff accountable for achieving high levels of performance.
- Ensures that duties and responsibilities of staff nurses and students are carried out
efficiently.
- Monitors the productivity of staff through performance appraisals.
- Regularly meets with staff receives education, so that they remain current in the latest
treatments and technology.
- Supports nursing students to ensure that students get the desired learning experience.
- Organizes orientation and training programs for new staff.
- Make sure that all members of the team have annual leave program and used based on
the program.
- Make sure that all the nurses, students and other staff in the ward wear their uniforms
and have a badge that bears their name and profession.
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Standard compliance
- Understands and communicates all relevant regulatory standards to staff, ensuring
that the standards are met or exceeded.
- Ensures that all staff complies with standards of performance, including those related
to infection controls and staff and patient safety practise in the hospital.
- Initiates the development of standard operating procedures for all new procedures and
nursing interventions.
Benefit packages
1. Monthly salary: Based on government scale
2. Other payments:
3. To facilitate the work done by head nurse:
4. Position allowance:
5. Annual leave: Based on program
Name of Nurse_____________________ Signature ___________________Date_________
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Annexes 4: Pain Assessment Scale
Pain assessment scale for adults chart
Pain assessment scale for pediatrics chart: FLACC Pain Rating Scale for infants to 7 years
age
222
Annex 5: LOC for pediatrics
223
Annex 6: Nursing process format
Nursing/Midwifery Comprehensive Client Assessment Format

Please Complete or Affix Label ________________HOSPITAL
Full Name:_________________________________
Age:_____ Sex:____ MRN:
Ward: ___________
Address:- City: Sub city:
Bed No.: _______
Kebele: House no. -
Medical diagnosis:____________________
Date of admission: ___________________
Tel. No.:__________________________________
Time of admission: ___________________
Source of information:____________________
Source of referral: ________________________
Personal Details
Marital Status: Nationality: Ethnic group:

Language:
Single Widowed  Religion:
Married Living common law Occupation(previous and current):
Divorced
Patient’s support
1. Name: 2. Name:
Relationship: Relationship:
Address: Tel No.: Address: Tel No.:
City: Sub city: City: Sub city:
Kebele: House no. Kebele: House no.
1. Health perception and Management pattern

Subjective data
Client‘s statement about reason of admission: ________________
__________________________________________________
__________________________________________________
Significant others‘ statement about reason of admission:
____________________________________________________
Substance use
Type Unit /measurement Frequency Effect if not taken Remark
Alcohol
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Khat
Tobacco
Others
Health maintenance practice:_______________________________________________
___________________________________________________
Past medical history
Measures taken for the problem
Understanding of Medication(what, how and why) Patient is taking before admission (incl. “over the count”
Drug name Dose Freq. Drug name Dose Freq.
**Known allergies for medication: ____food:____Others: ____ Specify: ________
Last immunization (type and date): ________________
2. Nutrition and Metabolism pattern

Subjective data Objective data
Pattern of food intake Wt: ______Ht:______BMI: ______MUAC ___
Breakfast:Lunch:  Skin
 Color: jaundice Pallor Erythema 
Dinner: Snacks: 
Central cyanosisPetechiae Other ______
Others_____________________  Lesion: Macule Papule  Vesicle
Special diet NodulePostuleWheal  Ulcer Creast scale
Other________
_______________________________  Texture: Smooth and Soft Rough Thick 
Appetite: Normal Increased Decreased   Temperature: WarmExtremely warm 
 Extremely cool  other____
Average Fluid intake per day in ml: ______  Moisture: Dry  Wet Oily
Difficulty in chewing: Yes No  Turgor/skin pinch: Immediately Slowly
Very Slow 
Sore tongue: Yes No  Any visible Wound Yes  No 
Difficulty in swallowing: Yes No If yes type of wound ______________
225
Nausea: Yes No Vomiting: Yes No Location:________ length in cm:___width in cm:
___
Abdominal pain: Yes No
Discharge Yes No
Antacid: Yes No If yes colour: ___________________
Odour: ___________________
Wt. gain: Yes No
 Bilateral pitting edema Yes No
Wt. losing: Yes No  Oral cavity
History of weight gain:Yes No  Mucosa: Intact Yes NoPink Yes No
 Moist Yes  No Dry Yes  No
Cold intolerance: Yes No  Lesion Yes NoOthers ________
Hot intolerance: Yes No  Teeth: malformation Yes NoDenture Yes
No
 Dental caries Yes No Other __________
 Tongue: PinkPale  Dry Moist 
Lesions  Intact
3. Elimination pattern
Subjective Objective
Bowel habits Abdomen
Frequency: _____Color ________________ Contour/shape: Rounded  FlatDistended
Pain: Yes No Scaphoid
Consistency_________ Laxative: Yes No Abdominal detention
Enema: Yes No Umbilicus: ProtrusionInflamed Drainage 
Hx of Bowel surgery Vein: Engorged and Prominent Vein : Yes No
 Colostomy Yes No Bowel sound:<5/m5-30/m>31/m
 Illeostomy Yes No Abdominal Tenderness: Yes No
Bladder habit Characterize___________
Frequency _______Amt____ml
Color: ____
Pain:Yes No
Hematuria:Yes No
Incotinenance: Yes No
Nocturia: Yes No
Retention: Yes No
Urinary Catheter: Yes NoType_______
4. Activity and exercise pattern

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Daily Activities (any difficulties with :) Musculoskeletal:
Hygiene: Yes No cooking: Yes No Grooming ________________________
House work: Yes No shopping: Yes Gait: Steady/Balanced  Unsteady/Unbalanced
No 
Eating Yes No toileting Yes No Posture:____________
Dyspnea: Yes No During Minor activity Extremity swelling:Yes NoSymmetrical:
During vigorous activity  Yes No
Chest pain:Yes No Range of motion : Normal for all joint
Stiffness: Yes No Decreased 
Weakness: Yes No Crepitus: Yes NoTone: Strong Weak
Aching:Yes No Respiratory
Effect of illness on activity of daily Thorax Shape: Normal funnel Barrel
living:_____________________________ pigeon
Symmetry: equal unequal
____________________________________________ Intercostals space: even and relaxed Bulging
____________________________________________ Retracting
____ Tenderness: Yes No
Breathing
 Pattern: regular irregular
 Difficulty:Yes No
 Respiratory rate________________
Objective data  Depth: Normal Deep shallow
 Adventitious sound_________________________
Scor Level of dependence Cardiovascular
e Jugular vein distension Yes No
0 Fully independent in personal care Heart sound: S1:YesNoS2:Yes No
1 Requires minimal intervention Murmurs_____________
2 Requires moderate intervention Blood pressure : Rt arm :______ Lt arm
3 Requires intensive intervention :______
4 Requires intensive intervention(fully Pulse
Rate : ____
dependent)
Rhythm : regular  irregular 
Bilaterally equal Yes No
Temperature(in 0C): Axilary___
Oral_____Rectal___
5. Rest and sleep pattern

Sleep time___________ Adequacy: Yes No Yawning: Yes No
Difficulty falling sleep: Yes No Short attention span: : Yes No
227
Sleep aid: Yes No Irritability : Yes No
Sleep medications: Yes No
Change in sleeping pattern: Yes No
Difficulty remaining sleep: Yes No
What facilitate
sleep________________________________
What hinders sleep
________________________________
6. Sexuality and reproductive pattern

Female Menstruation Breast:
Date began: Shape___________Symmetry___________
_______Lastcycle_________Length______ Nipple: erected flatInvertedDischarge:Yes
Gravida: ____ Para____ Abortion___ still No
birth______ Masses: Present  No mass 
Current Pregnancy:Yes No Lymph node: Enlarged: Yes NoTenderness: Yes
LNMP:_________EDD--------GA--------- No
Fertility: Fertileinfertile Testicular exam
Male/Female Masses:Yes NoSwelling:Yes No
Contraception: Yes No Penile exam
Undesirable side effects of contraceptives Mass: Yes No Growth: Yes No
:_____________ Lesion:_________ Discharge: Yes No
Problem with Sexual Female Genetalia
activities:_____________ Swelling:Yes No Symmetry: symmetrical
____________________________________ asymmetrical 
Discharge: Yes No Characterize
Effect of illness on Sexual __________________
activities:________ Vaginal opening: Lesion
__________________________________ _______Discharge_______Inflammation: Yes No
STD/STI:
__________________________________
Pain during intercourse: Yes No
Burning during intercourse: Yes No
Discomfort during intercourse: Yes No
7. Cognitive and perceptual

Educational status:______________________________  Ability to speak Yes No
Able to read __________Write __________________  Ability articulate words Yes No
Primary language:__________________________  Level of consciousness :
Visual problemYes No explain Glasgow coma scale : _____________
____________________________  Orientation to TPP:_____________________
228
Aids for vision: Yes No  Hearing :
Hearing problemYes No explain Tympanic Membrane: Intact
__________________________ Ruptured
Aid for hearing:Yes No whisper test: respond unable to
Taste problem Yes No explain respond
______________________________  Visual acuity:
Smelling problemYes No explain OD_________OS:___________OU:____________
__________________________  PERRLA: intact Bilaterally Non intact
Problem in sensation(skin)Yes No explain  Skin : Sensations: Superficial: +Ve –V 
___________________________________________________ o Deep Pressure: +Ve –V 
Pain(any):Yes No Characterize if yes o 2 Point discrimination: +Ve –V 
____________
Ability to recall: Remote: Yes NoRecent: Yes
No
Ability to make decisions: Yes No
Expression of feelings: ______________________
8. Self-Perception and Self-concept pattern
What do you feel differently about yourself? Appearance(dressing and Hygiene):__________________

__________________________ _______________________________________________________
Perception of abilities:__________________________ Mood(expression): Nervous ____ relaxed ____
Things frequently make you angry ,fearful or anxious ______________________________________________________________
:____________________________________________________________________ Speech: Pace of conversation:
___________________________________________________________________ Appropriate inappropriate
Tone of voice:
Appropriate to the situations
Inappropriate to situations
9. Role and relationship
Discharge Arrangements and Other Social Details
Role in Communication between family members:____
family:_________________________________________________ ____________________________________________________________
Responsibility: ____________________________________________________________
________________________________________________ Family visits: Yes No
Work role:________________________________________________
Social role:_________________________________________________  Yes No  Comments:
Level of __________________________________________
 Yes No  Comments:
satisfaction:__________________________________________ __________________________________________
229
Effect of illness on  Yes No  Comments:
_________________________________________
roles:_____________________________________
Lives alone?
Employee?
Self-employee?
Ability to pay:  YesNo Comments:____________
10. Coping and stress tolerance pattern
Subjective
Any big change that can Cause Stressor:________________
_______________________________________________________
Coping methods: _________________________________
______________________________________________________
Support system: __________________________________
11. Value and belief

Subjective
 Cultural practice :Yes  No
 Religious practice Yes  No 
 Familial traditions (yes  no )
 Would you like your religious leader to be contacted? Yes 
No 
Additional information: Clinical Data

S.No Date Investigations/procedures Specimen Result Reference value
230
231
Summary of subjective and objective data
Summary subjective data Summary objective data
Signature and initial of admitting nurse: _____________________ Date:______________
232
233
Date :________________
Nursing Problem Index List

Please Complete or Affix Label Hospital_________________
Name:___________________________ Father Name: _________________________
Ward:____________
Address: City:_____________________ Sub city: ____________________________
Kebele:___________________________ House No: _________________ Bed No.: ____________
MRN:____________________ Age:_____________ Tel. No.:_________________
Date Prob Date
Signature & Signature &
Identified lem Problem/Nursing Diagnosis Resolved &
Designation Designation
& Time No Time
234
Nursing Care Plan

Please Complete or Affix Label Hospital______________
Name:___________________________ Father Name: _________________________ Ward:____________
Address: City:_____________________ Sub city: ____________________________
Kebele:___________________________ House No: _________________
MRN:____________________ Age:_____________ Tel. No.:_________________ Bed No.: ____________
Date
Prioritized Signature &
and Goals Expected outcomes Instructions
Problem No Initial
Time
235
Implementation
Full name___________________________________ Age __ Sex____

MRN:__________________ Tel. No.: __________________ Ward: __________________ Bed No.:______________
Date Proble
Identified and m Implementations Signature and Designation
Time No
236
Progress Note (SOAP)

Progress Report No: ___________ Shift: Morning  Afternoon  Night 
Date: ___________ Time: ___________ Signature: _____________
Evaluation Judgment: ________________________________________________________________
Subjective Data: _____________________________________________________________________
_ ___________________________________________________________________________________
Objective Data: ______________________________________________________________________
_ ___________________________________________________________________________________
Analysis/Assessment: ______ ___________________________________________________________
____________________________________________________________________________________
Plan:____ ___________________________________________________________________________
_ _____________________________________________________________________________
Subjective Data: _____________________________________________________________________
_ ___________________________________________________________________________________
Objective Data: ______________________________________________________________________
_ ___________________________________________________________________________________
____________________________________________________________________________________
Plan:____ ___________________________________________________________________________
_ _____________________________________________________________________________
Subjective Data: _____________________________________________________________________
_ ___________________________________________________________________________________
Objective Data: ______________________________________________________________________
_ ___________________________________________________________________________________
____________________________________________________________________________________
Plan:____ ___________________________________________________________________________
237
Annex 7. Trainee assessment check list. Blood pressure
S.N TASKS
The trainee SCORE
Yes No
1 Prepared setting for measurement that was quiet and free of interruptions.
2 Asked patient about eating, drinking caffeine, smoking or exercising 30 minutes before
measurement. Measurement was delayed if there were any "Yes" answers.
3 Seated patient with feet flat on floor, back supported for a period of rest.
4 Positioned patient‘s bared arm on a hard surface, with midpoint of upper arm at level
of heart.
5 Used appropriate cuff size, determined by measuring patient‘s arm using 80/40 rule.
6 Located brachial artery by palpation.
7 Centered bladder of the cuff over brachial artery.
8 Wrapped cuff smoothly and snugly around patient‘s arm, with the lower edge one inch
above bend in elbow.
9 Placed aneroid dial at eye level and easily visible.
10 Checked cuff tubing for obstruction.
11 Placed first and second fingers firmly over patient‘s radial pulse.
12 Inflated cuff to approximately 70 mm Hg.
13 Inflated cuff at 10 mm Hg increments until the patient‘s pulse disappears.
14 Deflated cuff completely.
15 Waited 15 seconds before continuing with technique.
16 Placed earpieces in ears so they were angled forward.
17 Placed stethoscope head in bell position.
18 Placed bell side of stethoscope over brachial artery.
19 Inflated cuff quickly to a level 20–30 mm Hg over palpate estimate.
20 Deflated cuff at a steady rate of 2–3 mm Hg/second.
238
21 Obtained systolic (Phase 1) and diastolic (Phase 5, or 4 if no Phase 5) blood pressure.
21 Deflated cuff at least an additional 10 mm Hg after Phase 4, then quickly deflated completely.
22 Recorded systolic and diastolic blood pressure.
23 Recorded cuff size, arm used and patient‘s position (if not seated).
24 Waited one to two minutes before recheck.
25 Waited one to two minutes before recheck.
26 Recorded both measurements.
27 Performed measurement on same arm as previous measurement.
28 Explained measurements to patient and discussed recommended follow-up.
239
240
Annex 8. Competency Checklist for Radial Pulse
S.N Did the trainee Yes No

1 Gather Equipment/Supplies: Gather Equipment/Supplies:
2 Perform hand hygiene and don gloves.

3 Select the appropriate peripheral site based on assessment data and move the patient‘s
clothing to expose only the site chosen.
4 Place your first, second, and third fingers over the artery. Lightly compress the artery so
pulsations can be felt and counted
5 Using a watch with a second hand, count the number of pulsations felt for 30 seconds.
Multiply this number by 2 to calculate the rate for 1 minute.
6 If the rate, rhythm, or amplitude of the pulse is abnormal in any way, palpate and count the
pulse for 1 minute.
7 Note the rhythm and amplitude of the pulse.
8 When measurement is completed cover the patient and help him or her to a position of
comfort
241
Annex 9. Competency Checklist for body temperature
Did the trainee Ye No

s
1 Select appropriate site and thermometer type. ―Zeroes‖ or shakes down glass thermometer
as needed.
2 Insert thermometer in sheath or uses thermometer designated only for the patient.
3 Insert in chosen route/site.
a. Oral: Place thermometer tip under the tongue in the posterior sublingual pocket (right or
left of frenulum).
Asks patient to keep lips closed.
b. Rectal: Lubricate thermometer; uses rectal thermometer; inserts 1 to 1.5 inches (2.5–3.7
cm) in an adult; 0.9 inches (2.5 cm) for a child, and 0.5 inch (1.5 cm) for infant.
c. Axillary: Dries axilla; Place thermometer tip in the middle of the axilla; lowers patient‘s
arm.
d. Tympanic membrane: Position the patient‘s head to one side and straighten the ear canal.
1) For an adult, pulls the pinna up and back.
2) For a child, pull the pinna down and back
4 Leave glass thermometer recommended time (oral 3–5 min, rectal 2 min, axillary 6–8 min).
5 Hold rectal thermometer securely in places; does not leave patient unattended
6 Leave electronic thermometer until it beeps.
7 Read temperature. Holds glass thermometer at eye level to read.
8 Shake down (as needed) and cleans or stores thermometer.
242
ANNEX-10 Competency Checklist for assessment of respiration
S.N Trainee did Yes No

1 Place your hand over client‘s wrist and observe one complete respiratory cycle.
2 Start to count with first inspiration while looking at second hand sweep of watch.
• Infants and children: count a full minute.
• Adults: count for 30 seconds and multiply by 2.
If an irregular rate or rhythm is present, count for a full minute.
3 Observe depth of respirations by degree of chest wall movement and rhythm of cycle
(regular or interrupted).
4 Replace client‘s gown.
5 Record rate and character of respirations.
243
ANNEX 11. NANDA-APPROVED NURSING DIAGNOSES 2015-2017
Indicates new diagnosis for 2015-2017—25 total
Indicates revised diagnosis for 2015-2017- 14 total
(Retired Diagnoses at bottom of list—7 total)
1. Activity Intolerance
2. Activity Intolerance, Risk for
3. Activity Planning, Ineffective
4. Activity Planning, Risk for Ineffective
5. Adaptive Capacity, Decreased Intracranial
6. Airway Clearance, Ineffective
7. Allergy Response, Risk for
8. Anxiety
9. Aspiration, Risk for
10. Attachment, Risk for Impaired
11. Autonomic Dysreflexia
12. Autonomic Dysreflexia, Risk for
13. Behavior, Disorganized Infant
14. Behavior, Readiness for Enhanced Organized Infant
15. Behavior, Risk for Disorganized Infant
16. Bleeding, Risk for
17. Blood Glucose Level, Risk for Unstable
18. Body Image, Disturbed
19. Body Temperature, Risk for Imbalanced
20. Breastfeeding, Readiness for enhanced
21. Breastfeeding, Ineffective
22. Breastfeeding, Interrupted
23. Breast Milk, Insufficient
24. Breathing Pattern, Ineffective
25. Cardiac Output, Decreased
26. Cardiac Output, Risk for Decreased
244
27. Cardiovascular Function, Risk for Impaired
28. Childbearing Process, Ineffective
29. Childbearing Process, Readiness for Enhanced
30. Childbearing Process, Risk for Ineffective
31. Comfort, Impaired
32. Comfort, Readiness for Enhanced
33. Communication, Readiness for Enhanced
34. Confusion, Acute
35. Confusion, Chronic
36. Confusion, Risk for Acute
37. Constipation
38. Constipation, Perceived
39. Constipation, Risk for
40. Constipation, Chronic Functional
41. Constipation, Risk for Chronic Functional
42. Contamination
43. Contamination, Risk for
44. Coping, Compromised Family
45. Coping, Defensive
46. Coping, Disabled Family
47. Coping, Ineffective
48. Coping, Ineffective Community
49. Coping, Readiness for Enhanced
50. Coping, Readiness for Enhanced Community
51. Coping, Readiness for Enhanced Family
52. Death Anxiety
53. Decision-Making, Readiness for Enhanced
54. Decisional Conflict
55. Denial, Ineffective
56. Dentition, Impaired
245
57. Development, Risk for Delayed
58. Diarrhea
59. Disuse Syndrome, Risk for
60. Diversional Activity, Deficient
61. Dry Eye, Risk for
62. Electrolyte Imbalance, Risk for
63. Elimination, Impaired Urinary
64. Elimination, Readiness for Enhanced Urinary
65. Emancipated Decision Making, Impaired
66. Emancipated Decision Making, Readiness for Enhanced
67. Emancipated Decision Making, Risk for Impaired
68. Emotional Control, Labile
69. Falls, Risk for
70. Family Processes, Dysfunctional
71. Family Processes, Interrupted
72. Family Processes, Readiness for Enhanced
73. Fatigue
74. Fear
75. Feeding Pattern, Ineffective Infant
76. Fluid Balance, Readiness for Enhanced
77. Fluid Volume, Deficient
78. Fluid Volume, Excess
79. Fluid Volume, Risk for Deficient
80. Fluid Volume, Risk for Imbalanced
81. Frail Elderly Syndrome
82. Frail Elderly Syndrome, Risk for
83. Gas Exchange, Impaired
84. Gastrointestinal Motility, Dysfunctional
85. Gastrointestinal Motility, Risk for Dysfunctional
86. Gastrointestinal Perfusion, Risk for Ineffective
246
133. Mobility, Impaired Wheelchair
134. Mood Regulation, Impaired
135. Moral Distress
136. Nausea
137. Noncompliance
138. Nutrition, Imbalanced: Less than Body Requirements
139. Nutrition, Readiness for Enhanced
140. Obesity
141. Oral Mucous Membrane, Impaired
142. Oral Mucous Membrane, Risk for Impaired
143. Other-Directed Violence, Risk for
144. Overweight
145. Overweight, Risk for
146. Pain, Acute
147. Pain, Chronic
148. Pain, Labor
149. Pain Syndrome, Chronic
150. Parenting, Impaired
151. Parenting, Readiness for Enhanced
152. Parenting, Risk for Impaired
153. Peripheral Neurovascular Dysfunction, Risk for
154. Personal Identity, Disturbed
155. Personal Identity, Risk for Disturbed
156. Poisoning, Risk for
157. Post-Trauma Syndrome
158. Post-Trauma Syndrome, Risk for
159. Power, Readiness for Enhanced
160. Powerlessness
161. Powerlessness, Risk for
162. Pressure Ulcer, Risk for
247
163. Protection, Ineffective
164. Rape-Trauma Syndrome
165. Reaction to Iodinated Contrast Media, Risk for
166. Relationship, Ineffective
167. Relationship, Risk for Ineffective
168. Relationship, Readiness for Enhanced
169. Religiosity, Impaired
170. Religiosity, Readiness for Enhanced
171. Religiosity, Risk for Impaired
172. Relocation Stress Syndrome
173. Relocation Stress Syndrome, Risk for
174. Renal Perfusion, Risk for Ineffective
175. Resilience, Impaired
176. Resilience, Readiness for Enhanced
177. Resilience, Risk for Impaired
178. Role Conflict, Parental
179. Role Performance, Ineffective
180. Role Strain, Caregiver
181. Role Strain, Risk for Caregiver
182. Self-Care, Readiness for Enhanced
183. Self-Care Deficit, Bathing
184. Self-Care Deficit, Dressing
185. Self-Care Deficit, Feeding
186. Self-Care Deficit, Toileting
187. Self-Concept, Readiness for Enhanced
188. Self-Directed Violence, Risk For
189. Self-Esteem, Chronic Low
190. Self-Esteem, Risk for Chronic Low
191. Self-Esteem, Situational Low
192. Self-Esteem, Risk for Situational Low
248
193. Self-Mutilation
194. Self-Mutilation, Risk for
195. Self-Neglect
196. Sexual Dysfunction
197. Sexuality Pattern, Ineffective
198. Shock, Risk for
199. Sitting, Impaired
200. Skin Integrity, Impaired
201. Skin Integrity, Risk for Impaired
202. Sleep, Readiness for Enhanced
203. Sleep Deprivation
204. Sleep Pattern, Disturbed
205. Social Interaction, Impaired
206. Social Isolation
207. Sorrow, Chronic
208. Spiritual Distress
209. Spiritual Distress, Risk for
210. Spiritual Well-Being, Readiness for Enhanced
211. Spontaneous Ventilation, Impaired
212. Standing, Impaired
213. Stress Overload
214. Sudden Infant Death Syndrome, Risk for
215. Suffocation, Risk for
216. Suicide, Risk for
217. Surgical Recovery, Delayed
218. Surgical Recovery, Risk for Delayed
219. Swallowing, Impaired
220. Thermoregulation, Ineffective
221. Tissue Integrity, Impaired
222. Tissue Integrity, Risk for Impaired
249
223. Tissue Perfusion, Ineffective Peripheral
224. Tissue Perfusion, Risk for Ineffective Peripheral
225. Tissue Perfusion, Risk for Decreased Cardiac
226. Tissue Perfusion, Risk for Ineffective Cerebral
227. Transfer Ability, Impaired
228. Trauma, Risk for
229. Vascular Trauma, Risk for
230. Unilateral Neglect
231. Urinary Retention
232. Ventilatory Weaning Response, Dysfunctional
233. Verbal Communication, Impaired
234. Walking, Impaired
235. Wandering
RETIRED DIAGNOSES
Energy Field, Disturbed
Failure to Thrive, Adult
Immunization Status, Readiness for Enhanced
Nutrition, Imbalanced: More than Body Requirements
Nutrition, Risk for Imbalanced: More than Body Requirements
Environmental Interpretation Syndrome, Impaired
Growth and Development, Delayed
250
ANNEX 12. SAMPLE NURSING PROCESS
ON A PATIENT WITH FIBULAR FRACTURE SECONDARY TO CAR ACCIDENT
1. PT IDENTIFICATION
Name: Mengistu Father Name: Zenebe
Address:- City: Debrebirhan Sub city: Kebele: Bakelo House no. -

MRN: 004567 Age: 43yrs Tel.No.:
Ward: Surgical ward Bed No.: 7
Medical Dx : Fibular # secondary to car accident Nationality: Ethiopian
Ethnic group: Amhara Language: Amharic Religion: orthodox Occupation: farmer
Marital Status: Married
2. SUMMARY OF SUBJECTIVE AND OBJECTIVE DATA

SUBJECTIVE DATA OBJECTIVE DATA
The client verbalized pain in response to • V/S=To=36.5Oc,BP=100/70mmHg,PR=82bpm

movement of the Rt leg, consumption of food RR=20/min
low in fiber(white bread, egg, milk products, • Bowel sound=2/min(hypoactive)
pasta and white rice) evacuation of scanty • Limited ROM in the Rt leg
amount of hard stool every other day (usual • Visible wound of 5cm in width and 12cm in
bowel habit was once in a day) and inability length on the right leg.
to bath and go to toilet by himself. • Visible devitalized tissues around the wound
 Observed that he was un able to wash and dry
his body, unable to go, sit on and rise from
toilet
251
3. NURSING DIAGNOSES
S. N PROBDLEM (NURSING DIAGNOSES)
1 ACUTE PAIN related to physical injury to the bone and soft tissue as evidenced by patient‘s verbalization of
pain on the right leg.
2 CONSTIPATION related to consumption of diet low in fiber, low fluid intake and confinement to bed as
evidenced by patient‘s verbalization of evacuation of scanty hard stool less frequent than the usual(qod)
3 BATHING SELF CARE DEFICIT related to immobility and weight bearing limitation as evidenced by in
ability to gather supply for bath ,wash and dry his body .
4 TOILETING SELF CARE DEFICIT related to immobility and weight bearing limitation as evidenced by
in ability to go to toilet, sit on or rise from toilet .
5 IMPAIRED SKIN INTEGRITY related to physical injury to the soft tissue as manifested by visible wound
of 5cm in width and 12cmin length on the right leg
6 RISK FOR INFECTION related to loss of skin barrier and disruption of bone unity
S. N PROBLEM (NURSING DIAGNOSES)
1 ACUTE PAIN related to physical injury to the bone and soft tissue as evidenced by patient‘s verbalization of
pain on the right leg.
2 CONSTIPATION related to consumption of diet low in fiber, low fluid intake and confinement to bed as
evidenced by patient‘s verbalization of evacuation of scanty hard stool less frequent than the usual(qod)
3 BATHING SELF CARE DEFICIT related to immobility and weight bearing limitation as evidenced by in
ability to gather supply for bath, wash and dry his body.
252
4. NURSING CARE PLAN
S.N GOAL EXPECTED OUTCOMES INTERVENTIONS/INSTRACTIONS
1 The client will be relieved 1.1 Ato Mengesha will 1.1 Administer parenteral analgesics
from pain verbalize relief from pain 1hr after consulting the physician
after administering analgesic as
after consulting physician
2 The client will achieve 2.1 Ato Mengesha will report 2.1 Administer oil enema with 300ml of
normal bowel elimination temporary relief from olive oil every day until normal bowl
constipation 30 min after elimination returns.
administering oil enema 2.2 Counsel the client about consuming
2.2 The client will describe diet with high fibers(vegetables, fruits
different food items and and beans) , high fluid intake on a daily
amount of fluid consumed basis.
every day to combat 2.3 Monitor bowel elimination pattern
constipation an hour after daily by asking the patient about
counseling session frequency of bowel habit, consistency
2.3 Ato Mengesha will of the stool and auscultation of bowl
consume food rich in fiber and sound.
more than 2liters of oral fluid
per day beginning from
December 20,2011.
2.3 Ato Mengesha will
verbalize return of usual bowel
evacuation (QD) from
December 23, 2011 onwards.
3 The client will demonstrate 3.1 The client will perform 3.1 Offer bed pan to the patient as soon
performance of ADL (self toileting and bathing everyday as his/her urge to defecation comes
care) with assistance 3.2, 4.3 encourage and assist the client
3.2 The client will ambulate with isometric exercise of the lower
after a month without extremities 3 times a day.
253
assistance . 3.3 Ambulate patient the length of the
3.3 The client will perform hall using the walker 3 times a day
toileting and bathing being 3.4 Monitor ability to use walker
unassisted after a month appropriately and record response daily
on flow sheet.
4 The client‘s skin will restore The client will attain normal 4.1 advise the client about
normal integrity skin texture ,color and consumption of diet rich in protein,
intactness a month later vitamin C
5 Infection will be prevented 5.1 The client‘s wound will 5.1.1 Clean the wound using aseptic
remain free from signs of technique with antiseptic solutions QD.
infection(foul smelling, pus 5.1.2 administer topical and parenteral
from the site ,Temperature antibiotics as prescribed
below 37.5 oc) throughout his 5.1.3 remove devitalized tissue with
hospital stay scalpel
254

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Standards of Nursing Practice Course- Participant Manual

LIST OF ACRONYMS AND ABBREVIATION

ANA American Nursing Association HSTP Health Sector Transformational Plan

CU- ICAP Colombia University, International ICN International Council of Nursing

CNA Canadian Nurse Association ISTC In Service Training Center

CPD Continuing Professional Development KPI Key Performance Indicator

EHMI Ethiopian Hospital Management NNTWG National Nursing Technical Working

EHRIG Ethiopian Hospital Reform NOCI Nursing Outcome Identification

EHAQ Ethiopian Hospital Alliance for RN Registered Nurse

EHSTG Ethiopian Hospital Service SMT Senior Management Team

ENA Ethiopian Nurses Association SOAP Subjective data, Objective data,

FHP Functional Health Pattern SOP Standard Operating Procedures

FMHACA Food, Medicine, Health care

SESSION 4.1. INTRODUCTION TO NURSING PROCESS .......................................... 140

ANNEX 2: NURSE DIRECTOR JOB DESCRIPTION .............................................................. 216

ABOUT THIS MANUAL

CORE COMPETENCIES FOR TRAINEES

TRAINING COURSE SYLLABUS

Suggested class size

Days Time Topics Facilitator

11:30-12:30 AM Presentation and discussion:

10:45AM– 11:15PM Group Activity on case studies

11:30 -12:30 PM Presentation and discussion:

cognitive and perceptual

3:45-4:45 PM Presentation and discussion

2:00-3:30 PM Group activity:

8:30-10:00 AM Planning (Nursing

10:00-10: 30AM Implementation and evaluation

10:45-12:30 PM Group Presentation: developing nursing

OVERVIEW OF HOSPITAL SERVICES

Situation of Hospital Services in Ethiopia before 2006

 Inefficient &inaccessible services

2006 2010 2012

2008 2011 2014

 2006 : Ethiopian Hospital management initiative

Rational for EHRIG revision

Module I: Operational Standards of Nursing Practice

Session 1.1 : Operational Standards of Nursing Practice

1.1.2 Operational Standards

1.1.3 Operational standard for nursing practice

Session 1.2. Implementation Guideline/Handout

1.2.1 Organizational Support for Nursing/Midwifery Function

1.2.2 Organizational structure of the Nursing and Midwifery Service

Types of organizational structures:

Advantages of an organizational chart:

1.2.3 Job description

1.2.4 Team Work

- Collaborate with the patient and their caregivers,

1.2.5 Clinical supervision and delegation

Model of Clinical Supervision

A supervisory relationship can also be described as one of ‗monitoring, development and

Application of Clinical Supervision within Nursing

Clinical supervisor recruitment

The provision of clinical supervision

Confidentiality and Professional Responsibility and Accountability

1.2.6 Nursing/Midwifery Workforce Plan

There should be a minimum of a registered professional nurse/midwife in-charge of

1.2.7 CPD and Professional Portfolio

Nurses need to maintain a professional Portfolio because it: